Results for Princess Alexandra Hospital


Fibrinogen Early In Severe Trauma in children studY (FEISTY Junior)

Traumatic injuries in children are a leading cause of death and disability in Australia. In high income countries, 40% of child deaths are because of traumatic injuries. Fibrinogen is one of the key clotting factors that need to be replaced in severe traumatic bleeding.

Currently, fibrinogen is replaced using cryoprecipitate; a blood product obtained from healthy volunteer donors. This is a precious resource that is stored frozen in the blood bank; it can take a long time to administer and place significant strain on blood banks. Fibrinogen concentrate (FC) is an alternative product used to assist in blood clotting. It is a product that is derived from blood plasma but stored in powder form and can be reconstituted at the bedside and given quickly. The study will investigate whether it is quicker to administer FC than cryoprecipitate, which may reduce haemorrhage and improve outcomes.

This study will enrol 30 children from three major paediatric trauma centres in Queensland admitted with severe traumatic bleeding. Time to administration of fibrinogen replacement and the effect of fibrinogen levels will be measured.

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FEISTY – Fibrinogen Early In Severe Trauma study

This clinical trial aims to improve the quality of the resuscitation of patients with traumatic haemorrhage. We are enrolling 100 patients from four major trauma centres in Queensland. Patients admitted with severe traumatic bleeding will be given either Fibrinogen concentrate or cryoprecipitate. Time to administration of these products and effects on blood fibrinogen levels will be measured. We are using innovative technology to identify hypofibrinogenaemia; we will provide data to define the optimal method of replacement and monitoring of the end points of resuscitation; and provide data on the role of fibrinogen concentrate and its use in traumatic haemorrhage. We are also exposing a broad range of ED physicians to potential practice changing research that may be translated to use in other patient groups with critical bleeding.

More than 7000 Australians are treated for severe trauma every year. Major bleeding in the setting of trauma is associated with poor outcomes and increased rates of death. Severe trauma causes a decrease in the factors within the blood that helps clots to form and stop bleeding. This loss of clotting factors is associated with worse outcomes and it is proposed that early replacement of these factors may reduce bleeding and improve outcomes. Fibrinogen is one of the key clotting factors that needs to be replaced in severe traumatic bleeding. Currently fibrinogen is replaced using cryoprecipitate; a blood product obtained from healthy volunteer donors. This is a precious resource that is stored frozen in the blood bank; it can take a long time to administer and place significant strain on blood banks. Fibrinogen concentrate (FC) is an alternative product used to assist in blood clotting. It is stored in powder form, can be reconstituted at the bedside and given quickly. The study will investigate whether it is quicker to administer FC than cryoprecipitate, which will reduce haemorrhage and improve outcomes. With positive impact for both large urban metropolitan areas and remote isolated communities.

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Comparison of the Implementation of Interventions for Controlling Laboratory Blood Tests Ordering in Four Queensland Teaching Hospital Emergency Departments.

Doctors frequently need to order blood tests in the Emergency Department when patients come to hospital with a medical or surgical emergency. In all but the most trivial cases, laboratory blood tests are requested as part of the diagnostic workup. Doctors and even the patient are often concerned about missing a diagnosis if enough blood tests are not done. However, medical research worldwide has revealed that test ordering is excessive and often unnecessary.

The growth in test ordering places an enormous financial strain on our health care system, and includes unnecessary investigations or treatment. Thus, reducing the number of unnecessary tests is important for patients to avoid undue discomfort and worry, and for the hospital to improve work efficiency and reduce costs.

Health care professionals have, therefore, worked out various ways to ensure tests are ordered only when needed. These have included education of junior medical staff, protocols for ordering tests, audits of tests ordered, and feedback of audits to staff. These methods have been successful in reducing test ordering in the short-term, but sustaining a long-term reduction is more difficult.

Queensland Hospital Emergency Departments have implemented methods to reduce excessive test ordering, but it is not known which method is most effective. The aim of this study is to determine maximum efficacy, by comparing the number of tests ordered in four of the busiest Emergency Departments in the state. Specifically we will compare the average number of blood tests ordered per patient treated in the Emergency Department taking into account their age, severity of their illness, and whether or not they were admitted to hospital.

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End of Life Issues – Withdrawal of treatment/Decision to not treat in the Emergency Department: A prospective multi-centre study.

Not infrequently, doctors working in the Emergency Department (ED) have to decide on how they are to provide treatment to dying patients. Specifically, they have to decide whether to actively treat or whether they should limit or withdraw treatment on patients who are not anticipated to live. Such decisions should be governed by legislature as well as standards set by the Australian Council on Health Care Standards (ACHCS). However, research conducted in our hospital has indicated that doctors consider a wide variety of factors including patient’s and family’s wishes when making such end-of-life decisions. We therefore raise the following questions. First, what factors do doctors take into account when they withdraw or withhold treatment in the ED? Second, are such decisions made in accordance with legislative requirements? To date, no research has examined this issue.

This study addresses this gap by focussing on the decisions leading to withdrawal of treatment in the ED. It is a multi-centre review of patients who die in 2009 in a number of Australian and New Zealand hospitals. The primary aim is to describe the factors that doctors consider when making the decisions to withdraw or withhold life-sustaining treatment. The secondary aims are to determine 1) whether Australian doctors are conducting such processes in line with ACHCS guidelines and 2) whether Queensland doctors are making such decisions in accordance with Queensland legislation.

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Australia, Asia and New Zealand Dyspnoea in Emergency Departments Study

Shortness of breath (dyspnoea) is a terrifying symptom experienced by patients and is a common reason for presentation to Emergency Departments. There are a wide range of causes including flair up due to chronic conditions such as asthma, heart failure, chronic lung disease or liver or kidney failure. Acute conditions such as a collapsed lung, chest infection (including pneumonia), trauma (including fractured ribs), airway blockage or an allergic reaction can also be the cause.

There is significant knowledge about patients who are admitted to hospital with common causes, however there is little conclusive information about Dyspnoea as a symptom, the distribution of causes, the proportion of patients requiring admission and whether treatment complies with evidence-based guidelines.

A recent pilot study in Europe found that 53 per cent of patients had a respiratory cause for symptoms, 22 per cent had a cardiac cause, and 15 per cent had both cardiac and respiratory components. Almost two-thirds were admitted to hospital with over one-third discharged from ED. However, in many ways, the study raised more questions than it answered. The study was also too small to comment on adherence to evidence-based guidelines.

For that reason, a larger EuroDEM (digital elevation model) study is planned for 2014. The study will be complemented by the Australia, Asia and New Zealand Dyspnoea Departments of Emergency Medicine (AANZDEM) which will collect data from a different region with different systems of care. It will focus on the range of causes, variation over seasons and geographical areas, and compliance with recommended treatments.

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Ladder related injuries.

Injuries and even death as a consequence of falls from ladders are increasing, especially in the home environment where elderly men are the most frequently presenting age group. There is considerable interest among health and safety professionals to develop injury prevention campaigns focusing on both ladders and their correct use. However there are large gaps in our knowledge, particularly in relation to the product choice, contribution of alcohol or medications, and compliance of safety practices at the time of the accident. This study is a collaboration bringing together expertise in emergency medicine, health economics, accident prevention and product safety. It aims to inform prevention and safety product campaigns by using ED data from two hospitals. Both retrospective data and prospective interviews with patients will be collected to describe the patterns, circumstances and outcomes of patients presenting to the emergency department as a result of injuries from ladder-related falls.

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Queensland pre-hospital study identifying which trauma patients are at risk of bleeding to death.

Injury is the leading cause of death and the second highest contributor to the burden of disease of Australians aged between 12 and 24 years. One of the contributing factors to trauma death is the inability for the injured patient to clot properly. Studies have shown that in approximately 10-50% of trauma patients the blood does not clot properly, with patients exhibiting abnormal clotting up to 4 times more likely to die from their injuries.
This study aims to estimate the proportion of injured patients with clotting problems at the time paramedics treat them. The Queensland Ambulance Service (QAS) High Acuity Response Unit (HARU) currently services the Greater Brisbane area and will commence operations on the Gold Coast Area in the latter half of 2015. The HARU provides advanced trauma interventions including blood transfusions and ultrasound scans to detect internal bleeding. In 2014 the HARU treated approximately 370 moderate to severely injured patients in the Greater Brisbane area.
In this study, HARU team members will take blood from patients during their treatment in the field. The blood will then be analysed to see if there are any clotting abnormalities. They will also perform a quick screening blood test in the field to see if this screening test corresponds to the laboratory analysis.
Identifying which patients are not clotting properly prior to hospital arrival may pave the way for life saving treatment to be started on the way to hospital, and for rapid intervention on arrival at hospital.

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The HALT-IT trial: Tranexamic Acid for the Treatment of Gastrointestinal Bleeding, an International Trial

Gastrointestinal (GI) bleeding is a common emergency with a substantial mortality rate. Bleeding from the upper gastrointestinal system is caused by ulcers, stomach inflammation and oesophageal varices and carries a fatality rate of up to 10%. Lower GI bleeding has a variety of causes and a case fatality of about 15%. Between 10% and 25% of patients will have a repeat bleed after their first episode, and these people are four times more likely to die than people without repeated bleeding.

The clotting of blood helps to stem bleeding and blood clot break down may play an important role in GI bleeding and re-bleeding. Tranexamic acid (TXA) is a drug used to reduce clot breakdown. It has been shown to reduce the probability of requiring a blood transfusion by about a third in surgical patients, without causing serious side effects from promoting clotting. This high quality randomised controlled trial will investigate the effectiveness and safety of TXA in GI bleeding.

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Measuring quality of care for musculoskeletal injuries in the Emergency Department.

The increasing demand on emergency health care in Australia has seen recent emphasis on clinical redesign initiatives that are focused on time-based performance measures and activity-based funding. While congestion in emergency departments continues, and emphasis is placed on reaching these time targets, the quality of care that patients receive when presenting with non-life threatening injuries is potentially compromised.

To date, there is a lack of high-level evidence surrounding the type of quality indicators (QIs) that should be used in EDs to measure quality of care. This project will develop QIs for care of patients who present to EDs with musculoskeletal injuries under appropriate expert review. The final QI set will allow application across EDs and will contribute to comparison and optimisation of emergency care for patients in ED with musculoskeletal injuries.

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Multicentre randomised controlled trial incorporating bedside lung ultrasound into the diagnosis of congestive cardiac failure in breathless older patients.

Many older persons present to the Emergency Department complaining of shortness of breath (Dyspnoea). This can be an important forewarning of heart failure, but is also present in many other conditions. In most cases, several bedside tests are carried out to identify those patients with heart failure. Despite these investigations, which include blood tests, electrocardiograph and chest x-ray, heart failure is initially misdiagnosed in up to one quarter of patients in the emergency department. This project focuses on secondary prevention of the complications of the disease caused by missed diagnosis.

Some European hospitals use bedside lung ultrasound as an adjunct to the above tests, claiming it improves recognition of heart failure, and should decrease the time to appropriate treatment. The European model of ultrasound practice is significantly different from the Australian model, and there is limited evidence supporting either model provided in the literature.

This is a multi-centre study following on from a successful pilot project. A safe, simple protocol has been tested in an Australian Emergency Department, in parallel to normal diagnostic strategies. To prove the protocol actually improves patient care, it now has to be tested as part of the diagnostic workup for breathlessness compared with the conventional diagnostic procedure.

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