AMA Federal Council elections

Several vacancies on the AMA Federal Council will be put to the vote following the receipt of rival nominations.

The Returning Officer, Anne Trimmer, has announced that electronic ballots will be held for each of five contested positions on the Council, which is the AMA’s peak policy making body.

A ballot of members in relevant Federal Voting Groups or Areas will be held for the following positions next month:

Contested vacancies

Area Representatives

VICTORIA:

· Dr Anthony Bartone
· Dr Umberto Boffa

QUEENSLAND:

· Dr Wayne Herdy
· Dr Richard Kidd

Specialty Groups

GENERAL PRACTITIONERS:

· Dr Anthony Bartone
· Dr Richard Kidd

PAEDIATRICIANS:

· Dr Paul Bauert
· Dr Kathryn Browning Carmo

PSYCHIATRISTS:

· Dr Steve Kisely
· A/Professor Robert Parker

Filled vacancies

Fifteen other positions on the Council have been filled without contest, and Ms Trimmer has declared the following members elected:

Area Representatives

NSW/ACT: A/Professor Saxon Smith

SA/NT: Dr Christopher Moy

TAS: Dr Helen McArdle

WA: Dr Michael Gannon

Specialty Groups

ANAESTHETISTS: Dr Andrew Mulcahy

DERMATOLOGIST: Dr Andrew Miller

EMERGENCY PHYSICIANS: Dr David Mountain

OBSTETRICIANS AND GYNAECOLOGISTS: Dr Gino Pecoraro

ORTHOPAEDIC SURGEONS: Dr Omar Khorshid

PATHOLOGISTS: Dr Beverley Rowbotham

PHYSICIANS: A/Professor Robyn Langham

RADIOLOGISTS: Professor Makhan (Mark) Khangure

SURGEONS: A/Professor Susan Neuhaus

Special Interest Groups

DOCTORS IN TRAINING: Dr John Zorbas

PUBLIC HOSPITAL PRACTICE: Dr Roderick McRae

Open vacancies

Nominations were not received for three positions, and Ms Trimmer has called for expressions of interest from members. The positions are:

Private Specialist Practice
Rural Doctors
Ophthalmology

Members interested in filling these vacancies are asked to contact Ms Trimmer at: atrimmer@ama.com.au

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Focus on health wins, Northern Territory News, 20 February 2015

AMA President Professor Brian Owler visited health facilities in Alice Springs, as well as the Indigenous communities of Utopia, Ampilatwatja, and Kintore. Professor Owler said Indigenous health gains might be slow, but it is important successes are not lost in a sea of depressing statistics.

Angry medicos urge action over plight of detainees, Sydney Morning Herald, 22 February 2016

AMA President Professor Brian Owler has savaged the Department of Immigration and Border Protection for what he says has been its intimidation of doctors who speak out about the plight of asylum seekers.

Row stymies e-health rollout, AFR Weekend, 27 February 2016

Pharmacists and doctors are feuding over the Federal Government’s struggling electronic My Health Record system. AMA President Professor Brian Owler said the organisation backed e-health records as a way of controlling health costs, but the Government had failed to ask medical specialists what they needed to make My Health Record work.

Hangover cure no miracle as clinic closes, Sun Herald, 28 February 2016

NSW health authorities have launched an investigation into a national chain of hydration clinics after a Sydney woman was hospitalised following an intravenous vitamin infusion sold as a miracle hangover cure. AMA Vice President Dr Stephen Parnis has accused those behind the IV infusion trend of bringing the medical profession into disrepute.

Patients to feel pain as cuts bite, Adelaide Advertiser, 11 March 2016

Across Australia, public hospitals will lose more than a $1 billion in federal funding next year. AMA President Professor Brian Owler said as hospital capacity shrinks, doctors won’t be able to get their patients into hospital or keep them there to receive the critical care they require.

AMA warns of hospital funding crisis as cuts bite, Sydney Morning Herald, 11 March 2016

Hospitals are limiting surgery hours and forcing patients to wait longer for elective procedures as an economic disaster looms. AMA president Brian Owler said patients with life-threatening conditions such as cancer would wait longer for surgery, while emergency departments would struggle to treat half their sickest patients within 30 minutes.

Porn turning kids into predators, The Australian, 29 February 2016

Online pornography is turning children into copycat sexual predators, doctors and child abuse experts warned. AMA Vice President Dr Stephen Parnis said the internet was exposing children to sexually explicit content that taught sex was about use and abuse.

Radio

Professor Brian Owler, Radio National, 22 February 2016

AMA President Professor Brian Owler discussed calling for the immediate removal of infants and children from immigration detention centres, and for all asylum seekers to have access to quality health care.

Dr Stephen Parnis, 2HD Newcastle, 22 February 2016

AMA Vice President Dr Stephen Parnis discussed Turnbull Government plans for asylum seeker Baby Asha and her family to be returned to Nauru once medical and legal process are complete. Dr Parnis said doctors were in an untenable situation in treating patients with serious physical and mental health issues, particularly the children, who were under threat of return to conditions that will only exacerbate their health problems.

Dr Stephen Parnis, 5AA Adelaide, 28 February 2016

AMA Vice President Dr Stephen Parnis talked about hangover clinics. He said clinics which claim to cure hangovers through intravenous infusions have no benefit and could put lives at risk.

Professor Brian Owler, 2UE Sydney, 11 March 2015

AMA President Professor Brian Owler talked about public hospital funding. Professor Owler said Australia has one of the best health care systems in the world, but it relies on having adequate funding.

Television

Professor Brian Owler, ABC Melbourne, 21 February 2016

Federal Immigration Minister, Peter Dutton, says that asylum seeker baby Asha and her family will moved to community detention, and not immediately sent to Nauru. The AMA reiterated its call for all children to be immediately released from detention

Dr Stephen Parnis, ABC Melbourne, 2 February 2016

A new report warns that Australia isn’t properly prepared for health problems triggered by an increase in heat waves over the next 40 years. AMA Vice President Dr Stephen Parnis said hundreds of people could die every year if nothing is done to tackle climate change.

Dr Stephen Parnis, Channel 10, 8 March 2015

An official submission to the Government proposes increasing the tax on alcohol. AMA Vice President Dr Stephen Parnis is supportive of increasing the price.

Professor Brian Owler, Prime 7, 10 March 2016

AMA President Professor Brian Owler warns regional communities they will be worst hit when the Federal Government’s hospital cuts take effect from next year. AMA urges the Government to prioritise health when it lays down the budget in May.

Professor Brian Owler, Sky News, 10 March 2016

AMA President Professor Brian Owler talks about the No Jab, No Pay laws coming into force on March 18, when parents who don’t ensure their child’s immunisation is up-to-date stand to lose childcare benefits.

Our drivers deserve the best: Owler

AMA President Professor Brian Owler has called for tougher vehicle safety standards, improved road user education and the development of a national road trauma database as part of efforts to reduce death and injury on the country’s roads.

Professor Owler told a Senate inquiry into road safety that there was much that can and should be done to reduce traffic trauma, including the adoption of world-leading design rules and technologies, such as autonomous emergency braking.

“I do not see why an Australian life should be worth any less than the life of a European or US or Japanese citizen,” he said. “I think our vehicles should be rated to the highest standards. It makes good sense.”

Cars equipped with autonomous emergency braking can detect the threat of an imminent collision and apply the brakes, either avoiding an accident or significantly reducing its severity.

Professor Owler said it was not just about preventing fatalities. He said people involved in simple accidents like rear-end collisions can suffer injuries such as whiplash that can have serious lifelong consequences.

He told the committee he had seen “many young people” who had lost their job and their partner after suffering whiplash and subsequently developing a dependence on opioids while trying to manage the pain.

Often, calls to tighten design and safety standards are resisted on the grounds that will add to production costs.

But Professor Owler said the marginal increase to the cost of a vehicle was more than offset by the huge savings to be made from preventing deaths and injuries that, over a lifetime, might cost millions of dollars in care.

One of the biggest blank spots in efforts to cut down the road toll was the lack of a national road trauma database, he said.

Though road deaths were recorded and shared across state borders, this did not extend to traffic accident injuries, hampering efforts to come to grips with the scale of the issue and how it could best be tackled.

“The number of deaths is only a fraction of the number of injuries that occur,” Professor Owler said. “While some of those injuries might heal…there are many injuries that are very devastating or at least result in significant time off work, loss of income, disruption to families. Being able to record that information is a very basic step that we need to take in order to be able to assess how we are going to make roads and cars safer.”

“It would provide a platform for being able to assess any investment [in road safety] that is made. But it will also allow us to determine where the problems are occurring”.

Professor Owler said while this was important, the most significant action governments should take would be to improve driver behaviour through education – particularly aimed at young people learning how to drive.

He said there was “a lot of positive feedback” regarding programs that aimed to educate those about to get their driver’s licences about speed, driving conditions, distractions and the role of passengers.

“People will make mistakes, and that is why education is so important, particularly for young drivers,” the AMA President said.

Adrian Rollins

Rural practice the prize for Australian Medicine reader survey winner

Caption: Australian Medicine reader survey winner Jezreel Blanco receives her Apple iPad Pro from AMA President Professor Brian Owler

As she prepares to embark on a career as a rural GP, Australian Medicine reader survey winner Jezreel Blanco’s one concern about winning the latest generation Apple iPad Pro is that it will out-match the speed of bush internet connections.

Adelaide-based Jezreel won the iPad after her name was randomly selected from more than 1500 readers who took part in the Australian Medicine survey, and was excited to receive the prize from AMA President Professor Brian Owler earlier this week.

The GP trainee is currently a resident at Flinders Medical Centre and is busily accruing the skills and experience she thinks will be vital to working as a general practitioner in a rural practice. She has already spent some time in obstetrics and paediatrics, and is currently working in an emergency department, where she hopes to gain experience in trauma care.

It is quite a shift in focus from Jezreel’s initial career as a medical scientist. Following a four-year degree at Sydney University, she worked in a coordinating centre for neonatal research, which she found to be too removed from the frontline of care for her liking.

“We were doing research on neonatal illnesses, but I never got to meet the families who were effected,” Jezreel said. “I was very interested in meeting with them and working them.”

It was this realisation that spurred her to undertake a medical degree, and to soon become a rural GP – even if the internet access isn’t great.

Adrian Rollins

[Clinical Picture] Clonal heterogeneity in plasma cell myeloma

A 52-year-old man presented to the emergency department with fevers and chills in December, 2014, and was admitted with a diagnosis of pneumonia. CT to exclude pulmonary embolus showed diffuse osseous lytic lesions, and he was also found to have anaemia and an IgG kappa monoclonal protein of 55·8 g/L on protein electrophoresis (a single band). After a bone marrow biopsy he was given a diagnosis of plasma cell myeloma and was treated with four cycles of CyBorD chemotherapy (cyclophosphamide, bortezomib, and dexamethasone) in preparation for an autologous stem cell transplantation.

[Correspondence] PEPFAR: is 90-90-90 magical thinking?

The President’s Emergency Plan for AIDS Relief (PEPFAR) 3.0 has embarked on an important refocusing to achieve epidemic control through 90-90-90 (90% of HIV-positive individuals knowing their status, 90% of those receiving antiretroviral therapy, and 90% of those achieving viral suppression).1,2 Despite good intentions, the implementation is creating health-system disruption. For example, in Zimbabwe, a voluntary medical male circumcision programme will now serve ten instead of 21 districts. Ambassador Birx, referring to these programme cuts as “efficiencies”, touted that funds will be freed up “for the greatest impact.

[Correspondence] Utilising additional sources of information on microcephaly

When the Zika virus outbreak was declared a Public Health Emergency of International Concern on Feb 1, 2016, the WHO International Health Regulations Emergency Committee made several recommendations. One of them was for increased research into the aetiology of clusters of microcephaly and its link to Zika virus.1 Quantification of microcephaly incidence is now a pressing requirement to estimate the proportion of cases that might be attributable to Zika virus infection. However, most countries that are at risk of Zika virus transmission because of the presence of Aedes mosquitoes have weak health-care systems and even weaker surveillance systems.

The sick will pay heavy price for Govt cuts

Patients are likely to face blow outs in emergency care and elective surgery waiting times from next year, and may even miss out on care altogether, unless the Federal Government acts immediately to unwind massive Commonwealth public hospital spending cuts.

AMA analysis shows a huge shortfall in Federal funding for hospitals will rapidly open up from mid-2017 as a lower indexation arrangement kicks in, creating a gap in resourcing that State and Territory governments are unlikely to be able to cover.

AMA President Professor Owler said the states and territories were facing an “economic disaster” unless the Federal Government urgently restored its funding, and warned patients would be forced to wait longer for vital health care and may, in some cases, miss out altogether.

“As hospital capacity shrinks, doctors won’t be able to get their patients into hospital or keep them there to receive the critical care they require,” Professor Owler said. “Doctors will always do the best they can by their patients, but these cuts mean the system as a whole simply won’t be able to meet the demand.”

His warnings came amid mounting speculation the Commonwealth will provide emergency funds to avert a pre-election crunch in public hospital finances – though it is expected to make little dent in the long-term shortfall, which is projected to reach $57 billion by the middle of next decade.

Expectations are increasing that Prime Minister Malcolm Turnbull will use a rare joint meeting with the nation’s premiers and treasurers scheduled for 1 April to clear the decks on a range of contentious issues in the lead-up to the Federal election, not least massive cuts to Commonwealth support for public hospitals unveiled in the Government’s disastrous 2014-15 Budget.

The Prime Minister has reportedly already offered New South Wales Premier Mike Baird an emergency $7 billion cash injection to tide the State’s public hospital and education systems through till after the election, which could come as early as July or as late as November, and other premiers are now lining up to demand similar assistance.

Professor Owler said such handouts would help relieve pressure on hard-pressed public hospitals in the short-term, but if a financial crisis for the nation’s public hospitals was to be averted there needed to be an overhaul of Commonwealth-State arrangements to ensure hospitals were supported by a reliable long-term source of funding that grew in step with the increase in demand for their services.

“It is clear there is a crisis in public hospital funding and an immediate commitment is required, but a quick fix will not solve the long-term capacity problems for public hospitals or ease the economic burden on State budgets,” he said.

There is mounting evidence that the performance of hospitals is already being hurt by a squeeze on their finances, even before massive cuts detailed in the controversial 2014-15 Budget come into effect.

The human cost

The AMA’s annual Public Hospital Report Card, released earlier this year, showed that hospital performance is already beginning to suffer as the flow of Commonwealth funds slows.

In emergency departments, the proportion of urgent Category 3 patients seen within the clinically recommended 30 minutes fell back to 68 per cent in 2014-15 – a two percentage point decline from the previous year, ending four years of unbroken improvement.

Meanwhile, improvements in elective surgery waiting times have stalled – the median delay in 2014-15 was 35 days, six days longer than a decade earlier.

Professor Owler said there was a real human cost to be paid for such a deterioration in performance.

“For a patient requiring urgent attention for abdominal pain, this could mean they are seen one to two hours after they present to the ED,” he said. “Their symptoms could be consistent with indigestion, or could be a perforated bowel. The quicker a doctor can see them and make a diagnosis, then the quicker they can receive relief from their pain, and their condition can be prevented from deteriorating, potentially to a very serious situation.”

In the Budget, the Coalition announced it would renege on hospital funding guarantees to the states, saving $1.8 billion over four years, while a further $57 billion would be would be saved by 2024-25 by downgrading the indexation of Commonwealth hospital funding to inflation plus population growth.

Increasing the squeeze, the Independent Hospital Pricing Authority has set the National Efficient Price – which determines how much the Commonwealth pays for hospital services – at 1.8 per cent lower than the amount that was set last year, locking in hospital underfunding.

States under pressure

The massive Commonwealth cuts have outraged the states, which have warned of a significant reduction in hospital services unless another stream of funding is found.

The savings appeared to be part of a broader Commonwealth strategy to dump most of the funding responsibility for health services onto the states and directly on to patients, and occurred in the context of a renewed debate about taxation and the structure of the Federation.

Two premiers, Mr Baird and South Australia’s Jay Weatherill, had championed changes to the GST and income tax arrangements to give states access to a more robust stream of revenue to fund hospitals and schools, but they were undercut when Mr Turnbull dismissed any talk of changing the consumption tax.

The resistance of Canberra to calls for more funds has been stiffened by the fact that all the states are currently in surplus, while the Commonwealth expects a deficit of $37.4 billion this financial year, and no return to surplus over the next four years.

But, while Treasurer Scott Morrison has continued to talk tough, telling the states to sort out their hospital funding problems themselves, behind the scenes Mr Turnbull has reportedly been approaching some premiers to discuss a possible deal.

Professor Owler discussed the looming crisis in a meeting with Mr Weatherill earlier this month, and the SA Premier echoed his concerns.

Any short-term deal offered by Mr Turnbull would only “kick the can down the road”, he told ABC radio.

But he indicated the states were likely to accept any injection of funds offered.

“Mike Baird and I have been pushing for a much bigger solution – a 15-year solution – but we have to be realistic, we’re on the shadows of an election, and it’s an urgent problem,” Mr Weatherill said.

Adrian Rollins

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations

Alcohol-related presentations are common in emergency departments (EDs) throughout Australia and New Zealand. Two point prevalence surveys indicate that one in eight presentations to EDs are alcohol-related.1,2

ED clinicians are at the forefront of responding to the consequences of alcohol-related harm. Verbal and physical violence and aggression are common in EDs, with adverse effects on staff wellbeing and job satisfaction.3 As little is known about this problem in the local context, our study surveyed perceptions of clinical staff of alcohol-related presentations to Australasian EDs. The study had two main objectives: to quantify the scale of the problem of alcohol-related violence experienced by ED staff, and to assess their perceptions of the effects of alcohol-related presentations on the functioning of the ED.

Methods

A mixed methods, cross-sectional online survey was developed after undertaking a literature search, and refined by the consensus of an expert steering committee. Definitions for verbal and physical aggression were taken from the Medicine in Australia: Balancing Employment and Life (MABEL) Longitudinal Survey (http://mabel.org.au/) (Appendix 1). Free-text items were included for qualitative analysis. The survey was piloted, leading to minor modifications of its wording.

The survey was conducted from 30 May to 7 July 2014. Participation was anonymous, voluntary, and consent implied by completion of the survey. The survey link was distributed by email to 156 directors of emergency medicine at EDs accredited by the Australasian College for Emergency Medicine (ACEM). Directors were asked to forward the survey link to all clinical staff in their ED to encourage participation. The ACEM e-bulletin and social media channels were also used to promote the survey. The College for Emergency Nursing Australasia (CENA) also distributed the survey. These distribution channels ensured the survey was targeted at clinicians working in Australasian EDs. At the time of its distribution, 1575 emergency registrars and 1270 emergency physicians were working in ACEM-accredited EDs, together with an average of eight nurses per physician.

The survey distribution methodology meant that a response rate could not be determined. A small number of responses were received from ED staff who were not doctors or nurses; these were excluded from analysis.

Statistical analysis

Quantitative data was analysed using SPSS Statistics for Windows 22.0 (IBM). Proportions with 95% confidence intervals (CIs) were calculated, cross-tabulated by clinician role, and compared in χ² tests; P < 0.05 was defined as statistically significant. When analysing Likert scale data, “positive” and “very positive” responses were combined, as were “negative” and “very negative” responses. When assessing how frequently alcohol-related aggression was experienced, “frequently” and “often” responses were pooled, as were the responses “occasionally”’ and “infrequently”. Qualitative data were categorised according to thematic keywords derived from the free-text responses, and then analysed by the frequency distribution method.

Ethics approval

Ethics approval was provided by the Monash Health and Monash University Human Research and Ethics Committees (reference, MUHREC-CF14/1691-2014000782).

Results

Responses to the survey were received from 2002 clinicians (emergency physicians, ED registrars, resident medical officers, interns, and ED nurses) working in EDs in Australia and New Zealand (Box 1).

Alcohol-related verbal aggression from a patient had been experienced by 97.9% of respondents (1899 of 1940) in the past year, and physical aggression by 92.2% (1784 of 1935) (Box 2). Appendix 2 breaks downs the frequency of alcohol-related verbal or physical aggression experienced during the past year according to clinician type. Eighty-seven per cent of respondents (1682 of 1929) had felt unsafe in the presence of an alcohol-affected patient. Nursing staff were more likely than other ED staff to have felt unsafe (Box 3).

Sixty-eight per cent of respondents (1311 of 1940) reported having experienced verbal aggression often (a few times per month) or frequently (one or more times a week); 42% (807 of 1935) had often or frequently experienced physical aggression from alcohol-affected patients in the past year. Third party aggression (from patients’ relatives and carers) was also common. Although most staff had experienced alcohol-related verbal and physical aggression from patients and verbal aggression from a relative or carer in the past 12 months, nursing staff were more likely to have experienced this problem than non-nursing staff (χ² test, P < 0.001) (Appendix 2).

Forty-eight per cent of respondents (931 of 1931) reported routine screening for alcohol consumption of patients presenting to their ED, and 44% (850 of 1928) reported screening, brief intervention and referral to treatment for patients at risk of alcohol harm.

Thematic analysis of qualitative responses (selected examples: Box 4) showed that alcohol-related aggression was a daily occurrence, as reflected in 24% of free-text comments on this theme (44 of 186). Respondents also commented that such behaviour should not be acceptable in the workplace.

Men and women reported similar frequencies of verbal and physical aggression from patients, but women were more likely to report verbal or physical aggression from relatives or carers (χ² test, P = 0.01) (Appendix 3).

Alcohol-related presentations were perceived to have a negative impact on waiting times, other patients in the waiting room, and the care of other patients (summary: Box 5; full results: Appendix 4). Alcohol-related presentations were also widely viewed as having a negative or very negative impact on the workload, wellbeing and job satisfaction of ED staff (summary: Box 5; full results: Appendix 5).

Free-text responses about the impact of these presentations on ED functioning confirmed this. Sixty per cent of respondents (1191 of 2002) provided a comment about the effect of alcohol-related presentations on other patients attending the ED. Most described negative effects, with 48% (569 of 1191) commenting that other patients experienced distress and felt unsafe if an alcohol-affected patient displayed loud, aggressive, violent or antisocial behaviour. Seventeen per cent (201 of 1191) commented that this distress was heightened in vulnerable patients, including children, the elderly, and in those who were mentally unwell.

Twenty-three per cent of these respondents (272 of 1191) also commented that alcohol-affected patients caused increased waiting times for other patients because they often were treated as a priority. Alcohol-affected patients were perceived to affect other patients by diverting resources (17% of respondents; 205 of 1191) and clinicians (15%; 182 of 1191), and by generally compromising the quality of care that other ED patients received (16%; 188 of 1191).

Discussion

Our study found that more than 90% of ED clinicians had in the past year experienced physical aggression from a patient affected by alcohol, with 42% experiencing this aggression weekly or monthly. This frequency of physical aggression from a single cause is disturbing, particularly compared with a large survey of Australian general practitioners and hospital doctors in which 32.3% reported experiencing physical aggression in the past year.4

Verbal aggression from patients affected by alcohol was an ever-present part of clinical life for ED staff. This compares with 70.6% of a more general cohort of doctors reporting that they had experienced verbal or physical aggression.4 While all ED clinician types experience violence and aggression, it is more frequently experienced by ED nurses,5 and it has been suggested that nurses see violence and aggression as an inescapable part of their job.6,7

We also found that ED clinicians frequently experience both physical and verbal violence and aggression from alcohol-affected patients’ relatives and carers. While this third party aggression has been reported before, comments made by respondents suggest that accompanying persons were often also affected by alcohol, and this may explain the high rate of aggression. Although there was no difference in their experience of violence and aggression from the patients themselves, female staff were more likely to experience violence and aggression from the carers of alcohol-affected patients. Previous research did not find this gender difference for either doctors or nurses.8,9

Adverse impacts of alcohol-affected patients on other patients and the effective operation of the ED is concerning. The need to divert resources disrupts or delays care for other patients. Effects on the welfare of and care for other patients, particularly vulnerable groups, are further exacerbated by the disruptive and antisocial behaviours of alcohol-affected people in EDs.

Violence and aggression had a negative effect on respondents’ perceptions of their wellbeing and job satisfaction. This has been previously reported,8 and it has been suggested that this affects the quality of care beyond its obvious effects on workload. Patient aggression and violence has a profound impact on patients, clinicians and the therapeutic relationship.10 It can also affect staff retention and recruitment, and this highlights the importance of community education about alcohol-related harms and of changing the culture of unacceptable behaviour.9

The MABEL study found that medical practitioners were less likely to experience aggression in workplaces where strategies to reduce aggression had been implemented.11 Environmental and human factors should be taken into account to reduce the risk of workplace violence, while resources that enable appropriate medical care and access to safe sobering-up facilities will assist EDs to manage alcohol-affected patients.

Study limitations

Selection and non-responder bias inevitably affects voluntary surveys. ED clinicians who have recently experienced aggression and violence from alcohol-affected patients may be more likely to respond. Further, as the survey was anonymous, it was difficult to ensure that respondents did not complete the survey several times. However, our review of respondents’ IP addresses and their demographic data suggests that this was unlikely. More than half the respondents worked in major referral hospitals, suggesting that this group was over-represented. Recall bias was minimised by asking respondents only about the past 12 months. Definitions of violence and aggression were provided in the survey to limit misclassification of events by respondents. Misclassification may, however, have resulted in some respondents confounding alcohol-related presentations with those related to other drug use, or to a combination of alcohol and drug use.

Conclusions

Alcohol-related verbal aggression was commonplace for the clinicians who responded to this survey. Physical violence was experienced by a large majority. This violence and aggression has a negative impact on the care of other patients and on the wellbeing of clinicians. Managers of health services must ensure a safe working environment for staff. More importantly, however, a comprehensive public health approach to changing the prevailing culture that tolerates alcohol-induced unacceptable behaviour is required.

Box 1 –
Workplace characteristics of the 2002 emergency department staff who responded to the survey

	Number	Percentage

Gender
Men	700	35.0%
Women	1285	64.2%
Not stated	17	0.8%
Staff role
ED nurse	904	45.2%
EM physician	507	25.3%
EM registrar	373	18.6%
Medical officer	136	6.8%
Other	67	3.3%
Not stated	15	0.7%
Location
Victoria	408	20.4%
Queensland	367	18.3%
Western Australia	300	15.0%
New South Wales	298	14.9%
South Australia	211	10.5%
Tasmania	46	2.3%
Northern Territory	29	1.4%
Australian Capital Territory	11	0.5%
Australia (total)	1670	83.4%
New Zealand	313	15.6%
Not stated	19	0.9%
Role delineation of ED
Major referral	1035	51.7%
Urban district	566	28.3%
Regional/rural	379	18.9%
Not stated	22	1.1%

ED = emergency department; EM = emergency medicine.

Box 2 –
Frequency of alcohol-related verbal or physical aggression experienced by respondents within the past 12 months (summary)*

Number of responses

Often/frequently

Occasionally/infrequently

Not at all

Verbal aggression from a patient

1940

67.6% (65.5–69.7%)

30.3% (28.3–32.3%)

2.1% (1.6–2.9%)

Physical aggression from a patient

1935

41.7% (39.5–43.9%)

50.5% (48.3–52.7%)

7.8% (6.7–9.1%)

Verbal aggression from a relative or carer

1923

30.8% (28.8–32.9%)

58.7% (56.5–60.9%)

10.5% (9.2–11.9%)

Physical aggression from a relative or carer

1930

18.9% (17.2–20.7%)

58.0% (55.8–60.2%)

23.1% (21.3–25.0%)

Data are presented as the percentage of received responses, with the 95% confidence intervals in parentheses. * For full results and breakdown by clinician group, see Appendix 2.

Box 3 –
Emergency department staff reporting that they have felt unsafe because of the presence of an alcohol-affected patient in their emergency department*

Staff role

Number

% (95% CI)

Emergency department nurses

863

91.8% (89.8–93.4%)

Emergency department registrars

360

88.6% (84.9–91.5%)

Emergency department physicians

499

82.6% (79.0–85.0%)

Emergency department medical officers

133

72.2% (64.0–79.1%)

Other/unknown

85.1% (75.3–91.5%)

* P < 0.001 (χ² test).

Box 4 –
Selected qualitative responses to the survey

Alcohol-related aggression and violence in the emergency department (ED)

Verbal abuse is an hourly occurrence. One or two people removed for physical aggression each shift, a staff member injured severely enough to have days off every few months, patients restrained by security/code black every two to four hours. Serious property damage (window/wall broken) every one or two months. [ED doctor, female]
Staff are regularly faced with physical/verbal aggression due to alcohol presentations; several members of staff have had chairs thrown at them, one underwent a shoulder reconstruction after sustaining a dislocation from a patient and we are constantly abused. [ED nurse, male]
If I am out of uniform I do not have to tolerate these behaviours and have a course of action; if I am in uniform, I am fair game! [ED nurse, female]
I was assaulted and knocked unconscious by a patient. I was put in my own resus[citation] room with concussion and vomiting. I had residual effects for several weeks following. The patient was arrested in the ED. When asked why he hit the doctor, his reply was: “because no-one brought me a **** sandwich.” [ED doctor, male]
I was obviously pregnant and was threatened by a patient (in front of his kids and wife) that he was going to punch me in the stomach. [ED nurse, female]

The impact of alcohol-related presentations on patient care

They can feel threatened and intimidated in an environment where they should feel safe. They are often shocked and offended by what they see or hear. [ED nurse, female]
I always feel terrible when there is a parent with a sick kid and they are exposed to behaviour and language and sometimes violence or even police presence; it’s very unfair towards them. [ED doctor, female]
A woman and her 4-year-old daughter in a cubicle had a drunk man open the curtain and urinate over the bed thinking he was in the toilet. Distressing for mum and child. [ED nurse, female]
Other patients in the ED often have delayed care because of intoxicated patients, and sometimes even important tests or observations are missed or forgotten because the intoxicated patient is taking up so much of our time — either vomiting, abusing staff or other patients, creating a scene, or generally being unsafe. [ED nurse, female]
They use resources that may otherwise go to another case. If you have one remaining bed and two patients, and one of them is highly intoxicated, they will get preference over the patient who may be quite ill but is able to sit in the waiting room. [ED nurse, female]

Box 5 –
The impact of alcohol-related presentations on emergency department function and care of other patients* and on emergency department staff^† (summary)

Number of responses

Positive/very positive

Neutral

Negative/very negative

Don’t know

On patients

On waiting times

1980

0.5% (0.3–0.9%)

13.7% (12.3–15.3%)

85.5% (83.8–86.9%)

0.4% (0.2–0.7%)

On other patients in the waiting room

1980

0.4% (0.2–0.8%)

4.4% (3.6–5.4%)

94.4% (93.3–95.3%)

0.8% (0.5–1.3%)

On the care of other patients

1982

0.6% (0.4–1.1%)

10.9% (9.6–12.4%)

88.3% (86.8–89.6%)

0.2% (0.1–0.5%)

On emergency department staff

On staff workload

1991

0.8% (0.5–1.3%)

4.7% (3.8–5.7%)

94.2% (93.1–95.2%)

0.3% (0.1–0.7%)

On staff wellness

1981

0.7% (0.4–1.2%)

24.6% (22.7–26.5%)

74.1% (72.1–76.0%)

0.6% (0.4–1.1%)

On staff job satisfaction

1983

1.3% (0.9–1.9%)

17.4% (15.8–19.1%)

80.9% (79.2–82.6%)

0.4% (0.2–0.8%)

Data are presented as the percentage of received responses, with the 95% confidence intervals in parentheses. * For full results and breakdown by clinician group, see Appendix 4. † For full results and breakdown by clinician group, see Appendix 5.

[Comment] Zika virus and microcephaly in Brazil: a scientific agenda

Since 1981, the Brazilian population has had dengue fever epidemics and all control efforts have been unsuccessful.1 In 2014, chikungunya fever was reported for the first time in the country.2 In 2015, the occurrence of Zika virus was also reported,3 along with an increase of microcephaly and brain damage in newborn babies.4,5 The mosquito Aedes aegypti is the most conventional vector of these three viral infections and is widely disseminated in a great part of urban Brazil. Brazilian public health authorities declared a National Public Health Emergency on Nov 11, 2015, and intensified the vector control campaign to tackle the epidemic.