Results for Princess Alexandra Hospital


Randomised controlled trial of two antidote regimens for paracetamol overdose

Paracetamol is the commonest medications taken in overdose and is the leading cause of acute liver failure in the developed world. The antidote, acetylcysteine, which replenishes liver glutathione was developed in the 1970’s. However the regimen (20 hours duration) was never subjected to either a randomised controlled trial or any dose ranging studies. The regimen gives a large loading dose and the remainder of the infusion (20 hours) is given to mirror the time taken for paracetamol to be cleared by the liver. This time is only an average and depends on the degree of liver damage. For normal livers it is much shorter (12 hours).

The aim of the study is to compare acetylcysteine given over 20 hours compared to 12 hours for patients presenting early with paracetamol overdose to see if it provides the same protection against liver damage. The research design will be a multicentre non inferiority per protocol unblinded randomised controlled trial of a 20 hour versus a 12 hour regimen of acetylcysteine in paracetamol overdose. The study will be undertaken at the Princes Alexandra, Calvary Mater Newcastle and Prince of Wales hospitals. Eligible patients will be paracetamol overdoses less than 30g presenting within 8 hours of ingestion.

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Research Scholarship: Dr Colin Page

Doctorate of Philosophy (PHD) to study the antidotes and treatments that are commonly used by medical staff when looking after patients who are affected by drug toxicity.

Dr Colin Page was awarded the Noel Stevenson Fellowship, in honour of eminent Queensland emergency medicine physician, Dr Noel Stevenson. Dr Page has developed a clinical toxicology service at Princess Alexandra Hospital and Queensland through a locally run clinical toxicology unit and is the honorary medical director of the Queensland Poisons Information Centre.

Clinical toxicology is the speciality that manages patients who are affected by drug toxicity either accidentally or in overdose. The project will primarily research antidotes and other treatments that are used in the management of toxicology patients. This will allow the introduction of safer treatments, new treatments and progressing the scientific basis behind treatments used in clinical toxicology e.g. activated charcoal.

The PhD will be based at Princess Alexandra Hospital within the clinical toxicology unit with extension to other toxicology units/hospitals within Australia. It will be undertaken through the University of Newcastle (NSW) under the supervision of A/Prof Geoff Isbister and Prof Nicholas Buckley, who are both leaders in clinical toxicology research publications.

Post-PhD, Dr Page intends to continue to research in the area of clinical toxicology by building up the capacity for toxicology research in Queensland and continued collaboration with interstate colleagues.

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Capacity Building Grant: Princess Alexandra Hospital

The Princess Alexandra Hospital (PAH) Emergency Department is a designated Level 6 Trauma Centre. In 2012, in excess of 50,000 patients presented to the PAH ED, of which more than 35 per cent were admitted.
Clinical expertise within the PAH ED is wide, with specific disease emphasis in toxicology, chronic disease, multi-system disease associated with the elderly population, cardiovascular disease, sepsis and septic shock, infectious diseases and critical care.
The PAH ED is a tertiary referral hospital for trainees of the Australasian College for Emergency Medicine and excels in service delivery and education; areas in which it has a national reputation for excellence.
The outcome from Phase 1 of the QEMRF funded three-year plan to increase research capacity within the PAH ED was successful with all key performance indicators being exceeded.
Phase 2 will build on the platform created in Phase 1 focusing on research promoting prevention or control of diseases.
The vision for research within the PAH ED is that the ED will be regarded as a leader in emergency medicine research attracting clinical and research staff and producing outcomes which will change clinical practice and improve the health and well-being of patients.

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Evaluation of therapeutic subclavian atrial compression

Two-thirds of people who sustain trauma to the upper limb proximal artery die from traumatic blood loss before reaching hospital. Timely stabilization of the injury, control of bleeding, and rapid transportation to an emergency department could dramatically improve the rate of survival. We know from research that these measures dramatically approval the rate of survival for traumatic injuries of other parts of the body. In this study, we will test the safety and efficacy of a particular procedure that we predict will improve the management of these injuries in the pre-hospital setting. We predict that the use of this procedure by paramedics on patients while in transit can improve patient outcomes. The study will test the safety and efficacy of a technique we refer to as therapeutic subclavian artery compression (TSAC). We argue that this relatively simple procedure may successfully control arterial bleeding in the proximal part of the upper limb, and prevent death from traumatic blood loss.

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Blind Prescribing and the prescribing preparedness of doctors in Emergency Departments.

“Blind Prescribing” describes the situation where a medical practitioner prescribes a medication they know little about.
Theoretically, ‘blind prescribing’ could lead to higher rates of medication error and unsafe medical practice. The project aims to determine if Blind Prescribing occurs in emergency medicine, to identify the prevalence of the practice, and propose situational and contextual factors pertinent to Emergency medicine that are thought to enable this practice.

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Placement of antiseptic solution and hand lotion as a factor influencing hand hygiene compliance in the emergency department.

Effective hand washing and hand hygiene are universally recognized as the simplest ways to prevent the spread of infection. As well as limiting the spread of disease, hand washing is one of the few effective ways to reduce the development of antibiotic resistant infections. Despite this, many studies have shown that hand hygiene and compliance best-practice standards is universally poor amongst doctors and nurses working in hospitals. Previous studies have identified many factors reported to affect hand washing compliance. The time to undertake hand hygiene, the individual’s knowledge of hand hygiene techniques, their attitudes towards its importance, workloads, and the context in which they work are all known to influence hand hygiene practices.

One important factor known to influence hand hygiene factors is the availability and accessibility of equipment to carry out effective hand hygiene, such as antiseptic solutions. It is well-documented that compliance with hand hygiene is directly proportional to the accessibility and availability of products to decontaminate hands. In the context of the emergency department, where there are significant time and resource pressures, the time it takes to undertake hand hygiene and the accessibility of products to do so are important. Despite this, little evidence exists that examines the relationship between the positioning of hand hygiene solutions relative to the sink and its effect on hand hygiene compliance.

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Regulatory systems for occupational exposures in emergency care: Contemporary challenges for the emergency physician in prevention, control and management.

Healthcare workers in emergency departments are at high risk of exposure to blood-borne infections from occupational exposure. The financial and human costs of these injuries are significant. The risks such health care workers face are made more difficult in recent times because of three interconnected reasons. First, emergency care workers are at high risk of occupational exposures because of the nature of their work and the environment they operate in. They work in highly volatile and high-stakes situations. Second, emergency departments face unprecedented demands for emergency medical care. With increased numbers of patients, waiting times for medical treatment inevitably increase, leading to patient dissatisfaction, aggression and violence, larger and heavier workloads, decreased patient and staff satisfaction, and higher staff turnover and burnout. Third, emergency physicians are routinely called upon to manage healthcare workers who have sustained these occupational exposure injuries. The more patients there are, the more at risk emergency physicians and others are at risk of occupational exposures.

These injuries are largely preventable. Emergency physicians have key roles to play with their prevention, but lack a rigorous reporting system and sensitive data management system with a universal regulatory framework to do so. While national guidelines exist to govern the clinical management of such injuries, there is no consistency of regulatory and legislative workplace health and safety frameworks in which emergency physicians are required to operate across the country, making their prevention, control and management by emergency physicians highly problematic. This study will provide a definitive systematic review of the legislative and regulatory workplace health and safety frameworks governing the management, control and prevention of occupational exposures across Australia. Moreover, the study will provide baseline data and pilot research for a larger study that suggests the development of a culture of patient safety within the emergency department and the wider hospital environment first requires a culture of staff safety. For the true financial and human costs of occupational exposures to be known, it is critical to gauge the extent the problem. When we consider the estimated under-reporting in the United States or Australia, where it is estimated that up to 85% of occupational exposures are not reported due to the systematic under-reporting of sharps injuries, the financial and human costs associated with occupational exposures are significant.

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Pilot project to assess measures of psychological impact of providing CPR on a related victim of cardiac arrest.

Cardiopulmonary resuscitation (CPR) provision by bystanders has a well recognized link to improved outcome in cardiac arrest sufferers. However, a victim of cardiac arrest is more likely to receive CPR from a non-related bystander than from a related witness. It is thought that there are psychological barriers to the provision of CPR by related persons.

The overall aim of the proposed pilot study is to examine the effects of CPR provision on persons who are related bystanders of a victim of cardiac arrest. The three key purposes for the proposed pilot study, therefore, are: (1) to assess the proposed recruitment strategy; (2) to evaluate the usefulness of the selected test instruments in the context of the larger study and its aims; and, (3) to establish whether or not participants will perceive subjective psychological distress (or possibly even psychological benefit) through the administration of the selected assessment tools.

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Developing a quality framework for the care of older patients in the Emergency Department.

Over the next 20 years there is expected to be a burgeoning in the number of people aged ≥ 70 years in Australia. This rapid aging of our population is expected to result in a marked increase in elderly patient presentations to Emergency Departments. Elderly patients have complex care needs that are highly time- and resource-intensive. In addition, the elderly more commonly have poor outcomes after discharge from emergency, with higher rates of missed diagnoses and medication errors. However, survival and health outcomes of elderly have been shown to improve with high quality care. Quality indicators (QIs) are tools that allow levels of performance to be measured and, as part of a quality management system, provide opportunity for improving care delivery.

This project aims to develop a set of QIs that are both relevant and feasible in the Australian emergency department setting, by means of the following 3 phases:
1. Defining best practice in terms of emergency department care of the older patient via a detailed, systematic search of the scientific literature. An expert panel including emergency medicine specialists, geriatricians, nursing, allied health staff and academics will then develop a set of potential indicators of quality care for this patient group.
2. The candidate indicators will be field tested in eight Australian sites and assessed for their measurability, cost and ability to correctly identify quality of care delivered (in terms of environment, processes of care and outcomes achieved).
3. Finally, the expert panel will review findings of the field-testing and decide on the final set of indicators through a consensus process.

The result of this project will be a set of QIs that will be able to be utilised to allow comparison across centres and optimization of emergency care delivered to the ever-increasing elderly population.

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C.R.A.S.H. study: A randomised study of tissue oxygenation in an ovine model of haemorrhagic shock comparing the effect of colloid, fresh red cells, aged red cells and saline.

Blood loss is a major cause of early deaths after trauma, accounting for 51% of the deaths occurring during the initial 48 hours after hospital admission. Decisions made in the early treatment of severe blood loss have important consequences for patient survival and length of time in the Intensive Care Unit. Red blood cell (RBC) transfusion is a key component of the management in acute haemorrhagic shock, based on the assumption that transfused RBCs improve delivery of oxygen to the tissues. However existing evidence suggests this may not be the case. Recent studies suggest however that transfusion of older blood may worsen both morbidity and mortality in certain patient subgroups. The aetiology behind this association shown in this retrospective study is unclear, but seems related to an alteration in risk/benefit profile of old vs new blood. Hence, this project will investigate the ability of typical fluids used in haemorrhagic shock in ED departments to improve oxygen delivery to vital organs following severe haemorrhage.

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