The overarching aim of this study is to estimate the magnitude of the need for care at the end of life care in the emergency department, and to describe care delivery practices, processes and outcomes for older people who present to the emergency department requiring end of life care.
Australians aged 65 years and over account for 22% of emergency department presentations. Currently, this group makes up 15% of the population, but this predicted to rise to 20% by 2037.
There are two trajectories of end of life in the emergency department: ‘unexpected’ and ‘expected’ deaths. Unexpected deaths stem from acute illness or sudden, traumatic events. Expected deaths stem from deterioration of chronic illnesses.
When expected deaths occur in the emergency department, staff dissatisfaction and distress as well as frustration for patients and their families can result. In Singapore, around 50% of deaths in people aged ≥ 65 who died in one emergency department were considered ‘expected’. This highlights the need to understand if the situation is the same here in Australia and to what extent quality end of life care is provided for both trajectories of dying (i.e. expected and unexpected). Our study will identify the ‘unexpected’ and the ‘expected’ deaths among people aged ≥ 65 who die within 48 hours of emergency department presentation.
From a health perspective, a disaster overwhelms the normal operating capacity of a health service, where an outside health response is required to restore and maintain the normal day-to-day health services and standards of care for the disaster-affected community. The Australian healthcare system is tested annually with disasters of a conventional nature (e.g., floods, cyclones, bushfires), however, the Australian healthcare system has not been recently tested by non-conventional disasters such as Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) disasters. As a result, the ability to determine the healthcare system response is difficult. Further, there is no research specific to the Australian emergency department’s capacity for disaster response in CBRNe events.
This study addresses this gap. We will use a mixed methods approach to undertake two discrete, yet related studies. Study 1 involves undertaking surveys with key emergency disaster personnel from seven Queensland hospitals to describe the capacity of hospital emergency care services ability to respond following a CBRNe disaster. Study 2 includes undertaking focus groups with key clinicians and leaders from the participating sites to identify and explore enablers and barriers within emergency care services to provide CBRNe disaster response. Findings from these studies will provide an evidence base regarding the capacity for several Queensland emergency departments, located in metropolitan, regional and rural settings, to respond to disasters.READ MORE
Peripheral intravenous cannulation (PIVC) is a vital part of modern medicine, however the use of cannulas has become prolific, with many never used. The patient risks that are associated with PIVC are well documented, including pain and even infections, which can be severe and lead to death.
PIVCs which are inserted but never used (idle PIVC), have the risks and downsides, but no potential benefits. Reducing the rate of idle PIVC may reduce the overall rate of risks, side-effects and infections associated with PIVC, but it may also .lead to patients who require PIVC not receiving one.
In this study, we are looking into the reasons why clinicians decide to insert a PIVC. We aim to describe: I) the proportion of PIVCs placed that do not get used within 24 hours (idle PIVCs), II) differences between the pre-hospital setting and the emergency department and III) describe which factors are associated with clinicians’ decision making regarding PIVC insertion.READ MORE
This research project is looking at cellulitis in the Torres Straits. Cellulitis is a bacterial infection of the skin that requires antibiotics. People with cellulitis usually have an area of red and hot skin and sometimes can have fevers and become really unwell. Germs called Staphylococus aureus and Streptococcus pyogenes typically cause cellulitis. It potentially can cause serious infections and are a common presentation to emergency departments and admission to hospital.
In a tropical environment such as the Torres Strait cellulitis is extremely common and contributes to a significant burden on the healthcare system. Often patients present to health care facilities in the Torres Strait with cellulitis and are transported into Thursday Island Hospital for intravenous antibiotics. This is associated with significant retrieval, emergency and hospital costs. However the treatment of cellulitis in the community has been found to be practical, safe, and cost effective. We want to find out if cellulitis can be treated at home instead of in the hospital here in the Torres Straits.
The aim of this study is to validate outpatient intravenous antibiotic management of cellulitis in the Torres Straits. We anticipate that results from this study will improve preventable emergency and hospital admissions thus having significant health economic savings here in the Torres Straits.READ MORE
In a severe trauma, major bleeding or haemorrhaging is associated significant morbidity and mortality. Haemorrhage can be compounded by Trauma Induced Coagulopathy. It is postulated that early replacement of low fibrinogen levels may reduce haemorrhage and improve outcomes. Fibrinogen concentrate is an alternative way to replace fibrinogen.
In the FEISTY pilot trial, we demonstrated that a guided fibrinogen replacement strategy utilising either fibrinogen concentrate or cryoprecipitate is feasible. We found that fibrinogen concentrate was significantly faster to administer. The follow-on FEISTY II Trial will evaluate relevant patient-centred endpoints of a guided dose of FC Vs cryoprecipitate in traumatic haemorrhage. This larger study builds on the success of FEISTY to include multiple trauma centres in Australia and overseas.READ MORE
The question of fluid volume in resuscitation has been identified as the top priority in sepsis research by emergency physicians in the United Kingdom, Australia and New Zealand. Guidelines and sepsis pathways recommend an initial intravenous (IV) fluid bolus of 30ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this strategy. Both observational data as well as randomised studies suggest there may be harm associated with injudicious use of fluids in sepsis. Since there is equipoise regarding a more liberal or restricted fluid volume resuscitation as first line treatment for sepsis-related hypotension, we conducted the pilot multicentre REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH) trial comparing a restricted fluid protocol with early initiation of vasopressor support against standard guideline care.
The data from REFRESH will inform feasibility of a large, multicentre phase III study. However, further ground work is essential for the optimal design of a Phase III trial that will provide valuable information on feasibility (road test recruitment rate and screening processes) as well as refinement of the protocol (sample size estimation, processes of care, prevalence of the population of interest, real world clinical practice regarding fluid use).
In this ARISE Fluids study, we aim to provide more insight into current practice by conducting a bi-national multi-site prospective observational study of fluid administration in (suspected) sepsis and hypotension in the Emergency Departments of Australia and New Zealand hospitals. Sites have been selected on the basis of having expressed interest in participating in a phase III trial.READ MORE
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.READ MORE
Domestic and family violence (DFV) against women is the number one cause of hospitalisations in Australian girls and women aged 15-54 years. It is also the number one cause of death and disability in women aged 15 to 44. Although most victims of fatal DFV access health services in the 24 months prior to their deaths, many victims living with DFV go unnoticed in the community. Health care providers are well placed to identify DFV victims and refer them to appropriate services. The ED has been described as a good place to undertake identification of DFV victims in several published research papers. Yet, how to do this remains controversial, and there are no standard protocols in place in our EDs. In this project, we aim to describe the current DFV health practice culture in five Queensland EDs. Knowledge, beliefs, and attitudes, as well as what’s actually happening to detect cases of DFV, will be assessed among our front-line ED social workers, nurses, and doctors. We aim to determine how many presentations to ED are identified and referred to social worker services for DFV. Ultimately, this research will both raise awareness about the potential of the ED to detect DFV, and will help pave the way forward to a well-informed and structured ED DFV screening program for Queensland, with applicability internationally.READ MORE
Mild traumatic brain injury (mTBI) is a common injury with potentially profound consequences. Although many patients recover within a few days to a few weeks, an estimated 15-40% develop post-concussion syndrome (PCS), which consists of an array of cognitive, emotional, and physical symptoms.(TBI symptoms that persist beyond three months often develop into a chronic, potentially life-long, health problem.) PCS is associated with problems returning to work, social difficulties, higher healthcare utilisation, and poorer quality of life. The mitigation of PCS represents a significant clinical problem. An effective evidence-based early intervention to prevent PCS is sorely needed.
There is a growing consensus that differences in patient outcomes from mTBI are due to a range of biopsychosocial factors. For example, stress, anxiety, cognitive biases, sleep disturbance, and structural brain damage are among a number of factors that influence PCS symptom report. A focus on modifiable psychosocial factors (e.g., thoughts and behaviours) offers a promising solution: Cognitive Behavioural therapy (CBT) is well suited to altering the maladaptive beliefs, misattributions, cognitive biases and coping behaviours that promote chronicity in PCS.
The purpose of this study wass to examine the feasibility and effectiveness of a Cognitive-behavioural psychotherapy (CBT)-based early intervention for patients at high-risk of developing PCS after mTBI.READ MORE
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.READ MORE