Optimising patient flow: reducing delay to discharge from acute wards to residential aged care facilities (RACF) to improve access block in the emergency department

Emergency departments (EDs) are overcrowded and unable to meet the ever-increasing demands for healthcare. Access block is the most significant contributor to ED overcrowding. Access block refers to delays in admitted patients leaving the ED due to an unavailability of inpatient beds. The consequences of access block can be catastrophic, including adverse events, higher mortality rates, reduced quality of care, and increased costs.

Large numbers of patients who occupy acute beds are non-acute and considered safe and ready for discharge. These patients are predominantly waiting for residential aged care facility (RACF) placement. In addition to financial and patient flow strain, hospital stays longer than required creates significant risk of functional decline.

As the largest public health service in Queensland, Metro North Health has made significant investments in various successful hospital avoidance, substitution and navigation programs. However, timely access and flow of patients to RAC, which increases availability of inpatient beds for patient admission from ED, remains a significant issue. Therefore, this research investigates: How can we reduce discharge delay from acute wards to RACFs to improve access block?

This research will characterise the cohort of patients who are ready for discharge and waiting for RACF placement, and understand the barriers and solutions to discharge delay. These findings can then be used in future phases of this research program to predict patients who will have a delayed discharge, target strategies and pathways at admission, model the impact of released acute bed capacity on access block, and develop metrics for inpatient stays.

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.

Automated Clinical Data Extraction to Enhance Toxicology Services and Improve Emergency Medicine Outcomes: Project STREAM (System for Toxicology Research and Emergency Medicine)

Problem: Emergency Medicine research faces significant challenges due to outdated data collection methods, particularly when it comes to the use of clinical data. These issues lead to incomplete datasets and inaccuracies, negatively affecting research quality and patient care. Clinical Toxicology, a sub-specialty of Emergency Medicine, is an excellent example, where currently crucial clinical datasets are compromised by inconsistent practices and manual entry.

Research Question: How can we improve access to emergency care, improve the burden that toxicology patients place upon the emergency care system, and enhance data collection and efficiency in toxicology services by developing automated data extraction methods and standardized practices?

Proposed Solution: We propose the development of the STREAM, an automated clinical data extraction system designed to enhance data collection and analysis in emergency medicine.

Significance: This project addresses the enormous burden that toxicology patients place on emergency care. Toxicology is an area of emergency practice which relies on clinical information contained in databases to support the delivery of quality patient care. By improving data quality and standardizing practices, we aim to enhance research accuracy and optimize resources.

Innovation: The project introduces an innovative, cutting-edge automated tool to overcome current inefficiencies in data collection. This approach will enhance data management and research capabilities, providing a model for other clinical research areas.

Expected Impact: The project will improve the management of poisoning and toxic exposure, benefiting other emergency clinical research areas that rely on detailed data analysis. We anticipate higher-quality data, reduced manual workload, and better patient outcomes.

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 Kids Pain Collaborative: A collaborative implementation study of acute paediatric pain care in an outer metropolitan, mixed emergency department

Although pain is the most common reason for children to come to the emergency department (ED), it is frequently under-treated and under-recognised. We know children are particularly vulnerable to inadequate pain care, relying on adults to interpret their pain and act as advocates. A recent audit of children presenting in pain at Redcliffe ED found that many children with broken arms waited for prolonged periods (48 – 174 minutes) for pain medicine. The Redcliffe ED team identified significant barriers to pain care: staff’s inability to identify pain in children, lack of parental/clinician advocacy and lack of knowledge around paediatric medicines. To address this deficit in pain care, the Kids Pain Collaborative (KPC), an interdisciplinary collaboration of experienced ED clinicians, academic nurse researchers and ED consumers, has been established to transform paediatric pain care in Redcliffe ED.

The KPC is committed to optimising ED pain care at the systems level so that no child has to wait in pain. Our aim is to co-design, implement and evaluate an innovative evidence-based model of paediatric pain care which will begin with the child and family at triage. Engaging families in pain care assessment, optimising pain care processes and facilitating a workplace culture of prioritising pain is key to the success of this project. This project aims to reduce suffering for children and their families and inform paediatric pain care practice and policy at a State level. Research design draws on recent successful implementation research undertaken at the Queensland Children’s Hospital ED (1).

Can interactive online learning using enhanced technology adequately teach trauma-based procedural skills to emergency nursing clinicians?

Injury and trauma are common presentations to Queensland Emergency Departments. Clinicians caring for trauma victims must maintain competency with trauma procedures and interventions to apply them in a time-critical context, accurately, and therefore achieve the best outcome for individual patients. Engagement with traditional educational approaches, such as face-to-face training, is challenged by workload, shift patterns, clinician location and lack of opportunity to attend dedicated training events. A previous learning needs analysis of trauma education programs has highlighted that the greatest challenges are often faced by clinicians in rural and remote locations. One solution is to include the use of online learning platforms, to connect and assess clinician knowledge, with positive feedback regarding the engagement and experience for the learner. This study aims to use high-fidelity interactive online education, using a range of technologies including 360 videos with user interaction capabilities to design and develop a scalable model for future-proofing trauma education across Queensland. The research will test the effectiveness of (1) the approach to design and development in terms of scalability and (2) the online resources and assessment procedures in terms of the impact on knowledge and skill development.

Point of care lactate testing for the earlier recognition, antimicrobial administration, and definitive management of Paediatric Sepsis in the Emergency Department

This research project will examine the impact of implementing a point of care lactate machine on the earlier administration of antibiotics in paediatric patients diagnosed with sepsis in the Emergency Department. Elevated lactate levels have been shown to be an accurate prognostic factor in predicting morbidities among patients with sepsis. Current practice requires serum lactate samples collected via intravenous cannulation, a task that is both time consuming and challenging for paediatric patients and clinicians. The point of care lactate machine is a portable, single operator handheld device, requiring finger-prick blood sample to obtain an accurate lactate result. This negates the need for intravenous cannulation to obtain objective data to aid clinical decision making. This may result in the earlier recognition of sepsis, administration of antibiotics and transfer to definitive care.

Applications of a novel neurosurgical service accessibility index to improve emergency care of people sustaining a road trauma-related traumatic brain injury in Queensland

Queensland’s dispersed population poses significant challenges to emergency trauma system design, requiring both road and aeromedical retrieval services, trauma outreach services and specialist transfer protocols for time critical injuries to maximise survival.

Road trauma is one of the main mechanisms causing traumatic brain injury (TBI). Pinpointing geographic regions with significant disadvantage for timely access to neurosurgical services is needed for targeting education, treatment and outreach services to Queensland regions most in need.

The Injury Treatment and Rehabilitation Accessibility Queensland Index (iTRAQI) is a tool being developed by this team, and piloted for TBI. iTRAQI maps aeromedical/road transport access routes and uses travel time to acute neurosurgical and rehabilitation services to rank accessibility among Queensland localities under realistic scenarios.

This project will map actual pathways to definitive neurosurgical care for moderate-to-severe road trauma-related TBI and compare them to modelled iTRAQI pathways using linked prehospital, emergency, hospitalisation and compensation data.

From Big Data to the Bedside: answering big questions in emergency department pain care using artificial intelligence and patient-reported outcomes

One of the main reasons that acute pain is not well treated in the emergency department (ED) setting is that pain is difficult to measure. While patient-reported outcome measures (PROMS) are commonly used to help guide treatment of pain in settings such as chronic pain care, cancer care and migraine care, there are no similar tools available for patients with acute pain in the ED. Further hampering efforts to provide better ED pain care is poor overall understanding of the numbers and types of patients that experience pain.

Since it is a symptom rather than a diagnosis, information about pain is not systematically collected and is often obscured within free-text clinical notes. The lack of readily-available data makes it difficult to determine who exactly has experienced pain, and to design research studies to evaluate new and existing treatments.

Researchers aim to validate a PROM for pain care in the ED by administering to 400 patients who present with pain to one of two large hospital EDs. The aim is to find out the incidence and characteristics of patients who present with pain to the Royal Brisbane and Women’s Hospital ED, by using novel machine- and deep-learning techniques to process free-text information from clinical notes. This study will provide new knowledge and techniques that are essential for clinician-researchers to design and conduct studies that will ultimately improve pain care in the ED.

PaNURAMA Inter-facility Transfer Tool: a validation study of the Paediatric Non-Urgent, Risk Assessment, Management and nurse escort Assessment Tool for safe children’s inter-facility Transfer

Most paediatric inter-facility transfers within Australia are for children that do not qualify for specialist paediatric retrieval services but still require access to specialised paediatric care not offered at the local healthcare facility.

Evidence-based transfer guidance for children requiring retrieval are well established. However, for children who do not meet retrieval criteria, there is little guidance for referring and accepting clinicians on how to coordinate safe transfer. Nurse escorts are often deployed but may not be trained sufficiently to deal with arising complications during transfer. Additionally, with the availability and scope of paramedics, the deployment of nurse escorts may not be required, and unecessarily deplete valuable resources at referring facilities.

A risk stratification tool has been developed to determine which non-urgent transfers require higher level consultation and management prior to and during transfer, and nursing escort. The validation of this tool may assist to accurately identify higher-risk children, enabling application of appropriate safeguards, an appropriate level of consultation and escort, and supporting clinician decision-making surrounding transport Australia-wide.