Prothrombinex-VF® for coagulopathy of liver disease in acutely bleeding patients; Too much of a good thing?

Chronic liver disease (CLD) is prevalent in Australian society and is the 11th leading cause of premature death (1). Thirty eight percent of patients experience gastrointestinal bleeding (GI) as a complication(2). The underlying balance between bleeding and clotting tendency is altered in chronic liver disease, making management of acute bleeding challenging in the emergency setting(3). There is a lack of high-quality evidence to guide the best combination of blood products and other medications to stop bleeding(4).

Prothrombinex®-VF is a blood product which can help to improve the level of clotting factors in the body thereby reducing bleeding tendency. It is indicated for anticoagulant reversal in acute bleeding(5). In practice many emergency physicians have used the product for patients with chronic liver disease who present with acute bleeding, although it is not licensed for this indication(6).

A retrospective Queensland study performed by this author showed that half of Prothrombinex®-VF usage for liver disease was in the emergency department by emergency physicians. It suggested that the product makes little impact on reversal of laboratory blood clotting tests and it raised important safety concerns regarding the develop of a syndrome of accelerated bleeding and clotting concurrently(6).

This expanded statewide audit of Prothrombinex®-VF in chronic liver disease in Queensland seeks to define efficacy and safety of the product. There is no statewide guideline for Prothrombinex®-VF and this data will contribute valuable information to developing future guidance for clinicians.

Composition, Quality and Delivery of Major Haemorrhage Protocols (MHP) and critical bleeding clinical practice guidelines in hospitals across Queensland Health

Major bleeding is a leading cause of death in trauma patients. Blood product replacement is a key component of damage control resuscitation aimed at limiting coagulopathy until definitive control of bleeding is achieved. Although Major Haemorrhage Protocols (MHP) are now widely used in the initial resuscitation of traumatically injured patients (1), protocols can vary based upon individual institutions' capabilities and processes.

Within Australia, the National Blood Authority 2011 Patient Blood Management Guideline Module 1: Critical Care/ Massive Transfusion (2) recommended institutions develop standardized MHP to guide clinicians regarding the dose, timing and ratio of blood component therapy for bleeding trauma patients. However, it is currently unknown if these guidelines are implemented and if so, what institutional variations occur. While the guidelines provide a robust review of the evidence base for MHP, there is little information about the logistics of MHP implementation.

Our project aims are firstly to compare the available trauma bleeding protocols across Queensland for content and quality. Secondly, we wish to understand the institution's capabilities of delivering an MHP in terms of the structure and processes available to them. Thirdly we want to explore the experiences of clinicians involved in delivering an MHP for trauma patients in both tertiary, rural and remote hospitals within Queensland.

Expected benefits are to identify potential disparity of care for trauma patients in terms of MHP content, availability of resources and access to blood products. This information can help guide improvements in education, blood products availability and cost-effective care across Queensland.

Fluid resuscitation in emergency patients with sepsis and hypotension (ARISE Fluids)

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.

STOPAsthmaQLD

Grass pollen is the major outdoor allergen globally and grass pollen exposure has an important measurable and manageable impact on the medical burden of asthma. We propose investigating the role of allergy status on triggers for asthma in patients visiting hospital emergency departments in two regions of south east Queensland over a two year period, coinciding with NHMRC and ARC funded environmental health research led by collaborator CI Davies.

Data on weather and pollen exposure will be integrated with direct assessment of specific IgE profiles and respiratory viral triggers of asthma. Patients, including children over 12 years, presenting with primary diagnosis of asthma to a major urban hospital in a subtropical region and rural hospitals in the temperate regions of the Darling Downs will be recruited with informed consent.

Outcomes of this study are expected to inform need for utilising local current pollen exposure information to manage emergency department demand surges and underpin better management of pollen allergies outside of hospital by allergy physician and general practice.

Developing a regional strategy for reducing non-urgent emergency department presentations

Many people who attend hospital emergency departments (EDs) are triaged as having non-urgent concerns, which could be managed by other health services such as the GP. The way regional health services are designed can contribute to the rate of non-urgent presentations in EDs. The impact of non-urgent patients in EDs can result in crowding, ambulance diversion and access block, which are linked to poorer patient outcomes, increased morbidity and staff burnout. While some recognition of this problem exists nationally, many policies or strategies implemented to reduce the incidence of these presentations have not been evidence-based, effective or economically evaluated. We aim to develop a draft regional strategy for reducing non-urgent presentations in emergency.

Prior research on this project was funded by La Trobe University ($20,000), the Clifford Craig Medical Research Trust ($5000) and a University of Tasmania Scholarship ($5000).

Assessing Children’s Head Injury: Variation in CT scan use (APHIRST-Gap)

This study will collect information from the records of 3000 children from 30 hospitals presenting after a head injury in 2016 and will interview staff to look at different factors influencing the care provided. APHIRST-Gap is expected to provide crucial information on scan rates and inform strategies, including national guideline development to standardise and improve the care of children with head injury across Australia and New Zealand.

Head injury is a common reason children present to Emergency Departments in Australia and New Zealand. While most are minor the important issue for emergency clinicians is to determine whether a particular child is at risk of a serious head injury such as a bleed on the brain. A computerised tomography(CT) scan is the investigation of choice to look for these injuries. Its presents risks though, including the risk of sedation, and radiation induced cancer.

Several “rules” have been designed to guide doctors in the decision, by weighing up the risk of injury with the risks associated with the scan. The published Australasian APHIRST study examined three of these rules. It found that all three rules performed well, clinicians made sound judgements, and the overall rate of CT scan use was low (10%). APHIRST was limited to 10 large metropolitan, and predominately paediatric hospitals. Most children in Australia are not seen in these hospitals. Further research is required to determine whether there is a large variation in scan use between different hospitals and how best to apply these findings to a broader range of hospitals.

This trial is being run by the PREDICT network and the Principal Investigator is Prof Franz Babl.

Domestic and family violence screening in the emergency department

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.

Impact of the Emergency Department Patient Admissions Predictive Tool (EDPAPT)

Hospital occupancy rates regularly approach 100%, with resultant access block, ambulance bypass, and the last-minute cancellation of elective surgery patients. More efficient management of inpatient beds to reduce these predicaments is imperative. This project will evaluate the impact of a patient admission forecasting system - the Emergency Department Patient Admissions Predictive Tool (EDPAPT) - that has been developed from analysis of historical admissions data at the Gold Coast Hospital.

The aim of the project will determine whether a model that forecasts patient admissions can assist with the allocation of inpatient beds to alleviate one of the major problems of most Emergency Department (ED)s: overcrowding and access block. Specifically it will determine whether the number of elective surgery cancellations and ambulance bypass occurrences are impacted by using a prediction tool, and what impact there is on ED and bed management work practices. The study will also determine if bed managers will make use of prediction tools or whether there are barriers to their use of it, such as perceived inaccuracies, preferences to rely on own judgements or default to current, familiar modus operandi.

The project was a collaboration with CSIRO’s Australian eHealth Research Centre and Queensland Health, with support from Griffith University and the Queensland University of Technology.

A randomised controlled trial of interventional versus conservative treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) is defined as a collapsed lung with air in the pleural cavity that occurs in the absence of clinically apparent underlying lung disease. PSP is a significant global health problem affecting adolescents and young adults. Throughout the 20th century the treatment of PSP was predominantly bed rest, with invasive treatment reserved for severely symptomatic episodes. A study in 1966 suggested that managing large and small PSP in the community was safe. Despite this, rates of intervention have steadily increased over the decades. The reasons for this are unclear and this approach has recently been questioned in the scientific literature. Preliminary data suggests that a conservative approach to management may allow faster healing and reduce the risk of recurrence from around 25 per cent to 5 per cent in the first year. Conservative management is also likely to reduce the risks of prolonged admission due to persistent leak from approximately 30 per cent to less than 10 per cent and of other complications related to interventional management. Clinicians are, however, unlikely to change a practice entrenched for decades and re-enforced by current international guidelines without robust evidence.

This study will significantly increase our understanding of Primary spontaneous pneumothorax and its optimal management. If allowing the lung to remain collapsed initially results in improved healing of the pleural defect and lower recurrence rates then this study will contribute to improve outcomes and a reduction in the morbidity associated with current treatment.

SWAMPED: Linking best practice workforce models to Emergency Department funding

The aims of this research are to link best practice ED workforce models to available ED funding under an activity-based funding (ABF), while contributing to the development of an improved national activity and outcome-based ED funding model. This research will identify the current status of funding of EDs, identify and critically appraise models for funding of EDs and identify the workforce implications of those funding models and propose a State-wide ED clinical workforce framework.