Implementation and Evaluation of a Surgical Rapid Assessment Unit – Improving Emergency Department Flow with Timely Surgical Care

Emergency Departments (EDs) in Queensland hospitals are often overcrowded, leading to long wait times and reduced patient satisfaction. At Logan Hospital, patients with surgical problems currently go through a full ED assessment before seeing a surgical specialist, causing unnecessary delays. To address this, we’re creating a Surgical Rapid Assessment Unit (SRAU). This unit will be open on weekdays from 8 am to 4 pm and will directly assess stable patients with surgical issues, bypassing the usual ED process. This means patients will be seen faster by the right specialist.

Our research aims to evaluate how well the SRAU works. We’ll look at:
1. How it affects patient wait times and overall hospital stay
2. Patient safety
3. Whether it’s cost-effective
4. Challenges in implementation

This project is innovative because it fundamentally changes the patient journey, allowing direct surgical assessment without the usual step of ED evaluation. This approach could improve care quality and use hospital resources more efficiently. If successful, the SRAU model could significantly reduce ED congestion and improve patient flow. This model of care could be applied statewide and nationally to other Australian hospitals facing similar challenges.

We’ll use multiple research methods, including comparing data before and after SRAU implementation, surveying patients and staff, and analysing costs. The results will provide strong evidence on whether this model works and how it could be adopted by other Queensland hospitals, potentially leading to widespread improvements in emergency surgical care across the state.

Acceptability, feasibility and efficacy of the Activity Level and Flow Report – Emergency Department (ALFRED) tool. Measurement of capacity, overcrowding and escalation reporting in a tertiary paediatric emergency department

Emergency department (ED) overcrowding and subsequent impacts on patient safety and quality of care is a global public health challenge. Capacity measurement and risk assessment tools play a vital role in capturing and communicating ED overcrowding to trigger escalation strategies, mitigate risk and facilitate patient safety and flow. Currently, there is no universal definition of ED crowding and tools developed to measure crowding and quality of care in paediatric EDs are largely based on research undertaken in the adult setting.

The Queensland Children’s Hospital (QCH) ED currently use the Staffing Acuity Physical Transfer/Disposition Environment (SAPhTE) tool, manually calculated by the Emergency Flow Coordinator (EFC) and designed to assess and escalate ED capacity, access block and departmental risk. Audits and staff surveys have identified challenges in the SAPhTE tool including timely completion especially during peak ED activity, inter-operator variability in interpretation and scoring, limited central visibility and poor shared understanding around escalation. QCH ED have co-designed the Acuity Level and Flow Report - Emergency Department (ALFRED) dashboard which provides near real-time capacity metrics from FirstNet to provide an automated and visual report of ED capacity, patient flow challenges and risk assessment. As a measure of overcrowding, ALFRED incorporates the single-site validated Pediatric Emergency Department Overcrowding Scale (PEDOCS). Further research is required to evaluate the acceptability, feasibility and efficacy of the ALFRED tool in a paediatric ED. This will facilitate potential translation to other pediatric centers and mixed emergency departments to promote a proactive approach to capacity risk assessment and improve patient flow.

Exploring Effective Communication Strategies for Children and their Caregivers in a Paediatric Emergency Department Waiting Room

Optimising communication in the Emergency Department (ED) waiting room is the best means of improving paediatric patient and caregiver satisfaction of their acute hospital experience. There are many different approaches to addressing this matter across Australian EDs, however, there is limited research assessing the effectiveness of individual strategies on improving patient and caregiver experience.

This study will aim to address this gap in literature through the following:
(1) A systematic literature review on effective communication strategies used in emergency department waiting rooms globally, and
(2) A qualitative approach, cross sectional single-centre study in the Queensland Children’s Hospital Paediatric ED waiting room to ascertain paediatric patient and caregiver perspectives and satisfaction regarding different communication strategies implemented.

Drug Overdose with Reduced Consciousness: Patient and Staff Perspectives. A Mixed Methods Study

Drug overdoses are a common reasons for Emergency Department (ED) presentation. Overdoses may be intentional (self-harm), recreational, or accidental and often lead to reduced consciousness. Patients often need extra attention to their airway and breathing. They can be managed conservatively with oxygen, observation and regular nursing assessments. However, some require intubation: insertion of a breathing tube under sedation.

There is practice variation between doctors as to which overdose patients require intubation. Thus, the patient’s perspective becomes paramount, as their experiences influence management. We also need to understand clinician thought processes to ensure that care is standardised where possible.

This qualitative research is innovative in being the first to assess the patient experience around airway and breathing management for drug overdose with reduced consciousness, and assessing clinician attitudes. This will be done through patient and clinician questionnaires and semi-structured interviews.

AIM 1: To investigate the patient experience for an ED presentation with drug overdose and reduced conscious level. To understand the impact that interventions such as intubation can have on patients.

AIM 2: Explore clinician attitudes to the management of airway and breathing for these patients. Barriers to a conservative approach, triggers for intubation, departmental pressures and existing frameworks of care.

The research will provide insight into how this vulnerable patient population experience their care, and how clinicians reach critical decisions. It will inform development of a pathway of care to be used in the ED assessment of airway and breathing management for patients with drug overdose and reduced consciousness.

Most clinical staff working in the ED are clinical facing, allowing little to no time to develop research or their skills in research. The primary aim of the CBG is to support, develop, and undertake research of importance for Robina ED with Robina ED staff, HHS Executives, and consumers.

Our strategic vision for the CBG is to have research an integral part of clinical practice and education at Robina ED and that guidelines and policies are informed by our research. It will be guided by the GCH ED Research Strategy which has 4 goals: 1) Organise emergency care research; 2) Build and streamline research capacity; 3) Promote excellence, relevance, and impact of research; and 4) Develop, strengthen, and sustain research partnerships.

Structure: To build research capacity specifically for Robina ED staff, the structure will involve the employment of a Robina-based ED Research Fellow (part-time) and Research Nurse (part-time), as well as consultancy from a consumer advisor, and health economist/statistician (see budget); Engagement of health service executives, local and international university academics, collaborators from other agencies; and specific mentorship from other ED research leaders using tested frameworks (NASEM, 2019).

Expected benefits of the CBG include: active research engagement and collaboration leading to partnerships between Robina ED clinicians, researchers, HHS Executive, consumers and external collaborators in the development of 2 projects led by staff at Robina with support from researchers; the development and sustainment of capacity building mechanisms for: research involvement opportunities for Robina ED clinicians, dissemination of research updates and findings, and research mentorship.

Improved Respiratory Support in Remote Settings for Children: A Paediatric Acute Respiratory Intervention Study (PARIS), PARIS on Country

The next phase of studies, titled "Paris on Country," represents a continuation of efforts in Australia and New Zealand to enhance care for infants and children presenting with acute respiratory issues in emergency departments. Through these studies, we have successfully implemented changes in treatment protocols, aimed at alleviating respiratory distress and reducing anxiety for both patients and their parents.
In rural and remote areas of Queensland, approximately 38 percent of the state's total population resides. However, access to healthcare and emergency services in these areas can significantly differ from urban regions. The primary goal of this project is to elevate the standard of care for children experiencing acute respiratory distress in remote and regional settings to match the level of care available in larger cities.

Does a Vascular Access Specialist Model in the Emergency Department (VAS-ED) improve peripheral intravenous catheter outcomes? A Randomised Controlled Trial

More than 6 million peripheral intravenous catheters (PIVCs) are inserted in patients' veins in Australian emergency departments (EDs) annually. These devices can be challenging to insert, and over half will fail before the treatment is finished. Although ED clinicians regularly insert PIVCs, most inserters are junior medical or nursing staff who often default to short PIVCs because that is what they were trained to insert. These “generalist” inserters often don’t have the skills or knowledge to select alternate vascular access devices appropriate to the patient's needs. In contrast, Vascular Access Specialists (VAS) are experts with advanced assessment and expertise in inserting and managing vascular access devices, a model that has proven successful in inpatient wards, but hasn’t yet been tested in the ED setting.

In this study, we will compare the effectiveness and cost of using VAS specialists versus generalist inserters for peripheral IV device selection and insertion. In total, 320 ED patients will be recruited and randomly allocated to receive either a VAS or generalist inserter (standard care). We will compare outcomes including first-time insertion success, device failure rates, complications, patient satisfaction, and cost between the two groups. Additionally, we will interview clinicians to better understand the barriers and facilitators to implementing and using a VAS model.

We expect that patients who have a peripheral IV device inserted by a VAS will have higher first-time insertion success, and be more satisfied with their care than patients allocated to the generalist group.

The feasibility of point-of-care ultrasound conducted by physiotherapists for the diagnosis of ankle syndesmosis injuries in the acute care setting: A diagnostic study and budget impact analysis study

Syndesmosis injuries, also known as a high ankle sprain, due to ligamentous injury are relatively uncommon but can have devastating outcomes when missed. This includes chronic pain, instability and osteoarthritis. Early surgical fixation of these injuries is recommended in some cases. Magnetic Resonance Imaging (MRI) is the most accurate way to diagnose these, but not ordered in the emergency department (ED) due to its cost and poor availability. Although clinical tests can help to narrow down who needs an MRI, they are often inaccurate in the acute phase. Ultrasound performed by sonographers can visualise ligament to components of the syndesmosis complex to streamline MRI referrals but is under demand during the day and not available afterhours. Point of Care Ultrasound (POCUS) performed by clinicians is an alternative option for imaging.

Emergency physiotherapy practitioners (EPP) typically manage patients with musculoskeletal injuries in the ED and are well placed to perform musculoskeletal POCUS. This study will evaluate the feasibility and accuracy of ED physiotherapist-performed POCUS for the diagnosis of ligament injury in the ED, indicative of a syndesmosis injury, against radiology-performed ultrasound. This could guide MRI patient selection to allow for earlier detection of unstable ankle injuries and expedite outpatient orthopaedic expert review and management. If POCUS by ED physiotherapists is demonstrated to be feasible and accurate for these syndesmosis injuries, the results of this study could inform the development of a diagnostic pathway that could be implemented in EDs locally and throughout Australia.

A structures, process and outcome evaluation of the Residential Aged care District Assessment and Referral Rapid Response (RADAR RR) model

Older persons from residential aged care homes (RACF) have unique needs that are often overlooked in our traditional emergency departments (EDs). This can lead to under triage, prolonged length of ED stays, unnecessary investigations and iatrogenic hospital acquired complications (1). The Residential Aged Care District Assessment and Referral Rapid Response (RADAR RR) model is a pre-hospital Queensland Ambulance Service (QAS) co-responder model providing ED equivalent care in the resident’s home for acute illness and injury. RADAR RR model operates between 0800 and 2000, 7 days a week. We hope to evaluate the clinical and cost outcomes of the RADAR RR model and determine if it is equivalent to the care provided by traditional ED models of care in an urban setting. We will also review the structures and processes required for effective service delivery which will in turn guide the development of a toolkit to assist other hospitals in adopting the RADAR RR model if appropriate for their area. Finally, given increasing pressure for high value models of care we will undertake an economic evaluation to determine if the RADAR RR model is more economically efficient than the traditional ED model of care.

Suspected Pulmonary Embolism Exclusion with D-dimers in Emergency Departments (SPEED-ED)

Pulmonary embolism (PE) refers to blood clots in the lung. They can cause sudden death, collapse, chest pain, shortness of breath yet sometimes they cause no symptoms at all and are discovered incidentally. As they can be severe, they have become regarded as a not-to-miss diagnosis. As they can present with a variety of symptoms, emergency clinicians consider the possibility of PE on a frequent basis.

When considering whether a patient has a PE, the clinician may confirm or exclude the diagnosis directly with definitive chest scans. However, these scans are time consuming, costly and have other side effects including exposure to radiation and to chemical contrast agents. When patients are assessed to be less likely of having a PE, it is often possible to safely exclude PE by applying a set of clinical decision rules or doing a blood test called a D-dimer. If the level of D-dimer is below a certain threshold, then PE can be excluded.

We aim to safely exclude PE without scans where possible. Evidence has been building that employing a higher D-dimer threshold is reasonable, yet uptake of this newer approach is limited. We hope to demonstrate that a higher threshold can work in Australia without compromising safety. This will be a large study that answers this question and if shown to be the case, then patient care can be improved while using less resources in busy emergency departments.