Results for Royal Brisbane & Women's Hospital


Prescribing patterns and communication for oxycodone on ED discharge

There are growing public health concerns that opioid medications are being increasingly and excessively prescribed. These medications may have a serious side effect profile including sedation, tolerance, and development of addiction, and may subsequently be diverted in the community for non-medical use.

The objective of this study is to evaluate the effectiveness of an intervention for discharge oxycodone prescribing relevant to Australian Emergency Departments. The principal aims are to decrease the amount of oxycodone prescribed, improve practitioner awareness of local opioid prescribing behaviour, and improve documentation around oxycodone use on discharge.

This quality assurance evaluation study will measure the success of a multifaceted oxycodone prescribing intervention and its impact on oxycodone prescribing for patients discharged home from the Emergency Department (ED). The project is hypothesized to reduce oxycodone prescribing, improve discharge documentation, and ensure appropriate follow up plans are in place.

Pain is a common symptom in ED patients, and is often the primary reason patients seek emergency medical attention. A recent baseline audit of local prescribing records revealed oxycodone, an opioid pain medication, is prescribed in approximately 5% of patients discharged home from this ED (with an annual census of 77,500 presentations). Clinical documentation and discharge communication was either absent, incomplete, or inconsistent when discharge plans for dosing, duration of therapy, follow-up reviews and de-escalation of therapy were analysed.

To our knowledge, no published Australian data is available on oxycodone prescribing behaviours from EDs. If this project is successful, the amount of oxycodone prescribed will reduce, patients will be better informed, and the quality of medical handover to General Practitioners will improve.

With 7.4 million patient presentations to Australian EDs in 2014-15, the successful translation of an oxycodone prescribing intervention through clinical awareness and action would contribute to reducing the overall burden of opioids in the broader community

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Too much of a good thing; Does fluid resuscitation worsen septic shock?

Patients with infections are a leading cause of presentations to the Emergency Department (ED), with severe sepsis and infection causing an estimated 20,000 deaths each day across the world. Treatment is aimed at eradicating the infection and supporting the patient while recovery can take place. Frequently patients develop low blood pressure as a result of immune response that can ultimately result in further organ injury (termed septic shock). Intravenous fluids are recommended by international guidelines as the first line therapy in the ED to treat low blood pressure of sepsis with the hope of preventing organ injury and death.

Despite 50 years of use in sepsis, the rationale for fluids remains based in theory rather than clear evidence it is effective in saving lives. Disconcertingly, there is now increasing evidence that fluids in sepsis are ineffective and may actually worsen patient survival. Despite this fluids continue to be recommended and used liberally in the ED resulting in conflict between our historical practice and the best evidence. We have developed an animal model of septic shock and resuscitation in order to test the effectiveness of fluid resuscitation. This will allow us to both understand the true effect but also investigate the underlying physiological mechanisms of any harms.

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Paced Electrocardiogram Requiring Fast Emergent Coronary Therapy (PERFECT) Study.

The aim of this study is to assess the performance characteristics of the modified Sgarbossa criteria for diagnosis of ACO in VPR. This is a multi-centre international trial. The number of patients presenting to our Emergency Departments with pacemakers continues to increase. Investigating whether such patients are having a heart attack is challenging. For patients without pacemakers, ECG criteria can be used to identify a subset of patients who are having a heart attack. However, for patients with pacemakers, there are no accurate electrocardiograph (ECG) criteria to diagnose heart attacks.

This research has the potential to identify AMI in patients with VPR and improve Emergency Medical care in a time critical management decision. As such, it will develop emergency medicine research in Queensland and internationally by improving patients care and outcomes. It also will develop education and knowledge that will be recognised worldwide.

Smith et al have derived criteria (modified Sgarbossa’s criteria) for diagnosing heart attack using ECG characteristics in patients with a known abnormal ECG trace. This study will assess the accuracy of the Sgarbossa’s criteria in patients with pacemakers

We will collect data on demographics and ECG criteria for patients with pacemakers who present to the Emergency Department at the Royal Brisbane and Women’s Hospital with potential heart attack. We will then examine the results from the patient’s angiogram. An angiogram is when a contrast is inserted into an artery and images of the hearts blood vessels taken, to see if there is coronary blood vessel occlusion. We will identify whether the ECG criteria of patients with paced rhythms are accurate in identifying patients who did or did not have a coronary blood vessel occlusion on angiogram.

The data will combined with data from multiple sites around the world to help validate ECG criteria for diagnosing heart attack in patients with pacemakers.

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The sepsis registry: A prospective database to characterise and facilitate improved outcome for admitted patients with community-acquired infection.

This study aims to improve our understanding of sepsis in Australian Emergency Departments. We will do this by analysing in great detail the spectrum of infection syndromes presenting to the Emergency Department of a typical large Australian hospital over a period of several years. This will allow us to:

1) Identify the number of patients presenting to hospitals each year with severe infections and the outcome of these presentations.
2) Analyse the factors and information available to doctors in the Emergency Department that are associated with overall prognosis in patients with infection.
3) Build a comprehensive picture of the spectrum of infective agents that cause patients to be admitted to Australian hospitals.
4) Identify the most appropriate combination of antibiotics which should be used in the early treatment of the most severely ill patients with infection.

The cornerstone of this project is a large database which will capture detailed information on all patients presenting to the Emergency Department of a typical large Australian hospital who are subsequently admitted with infection.

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Capacity Building Grant: Royal Brisbane Hospital

The Royal Brisbane and Women’s Hospital (RBWH) Department of Emergency Medicine (DEM) is constantly looking for better ways to improve the care of the sick and injured. Patients are cared for by a team of professionals including doctors, nurses and other allied health professionals. Improvements in care come largely from high quality research.
Our medical specialists in Emergency work on a wide range of challenging, innovative emergency medicine research topics. Their results are reported in some of the top professional journals, including the Lancet. Research led by other team members including nurses, however, is scarce despite the fact that these clinicians play an integral part in emergency care. We believe one of the main reasons for this is the lack of senior research mentors accessible to all clinicians in our department.
We propose creation of a dedicated research position to enhance capacity, develop grants and opportunity for research among our multidisciplinary team. She/he will identify key research questions, design scientific studies, write and submit proposals for funding, supervise the collection and analysis of study data, and support the preparation of reports for presenting and publishing in medical, nursing, and other professional meetings and journals. He/she will also provide training, guidance and encouragement to all ED staff to participate in research; liaise with other investigators (external to DEM) to facilitate optimum conduct of all departmental interdisciplinary projects. Furthermore, she/he will establish collaboration and professional partnerships with academic institutions and other research bodies to attract funds, grants and research to the department.
This position will help to improve the quality of emergency medicine research outputs from the RWBH and boost multidisciplinary team focused research in the department. It will also help build the knowledge base and provide the evidence to guide interventions by all health care workers in the emergency department.

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Validation and Impact of the Four-Hour Rule in the Emergency Department

This is a national collaborative research project approved by the National Health and Medical Research Council Partnership Projects scheme. This project aims to identify how the four-hour rule is effective in reducing access block and the adverse effects of emergency department overcrowding on patients. In particular, it will assess the impact of the four-hour rule as a policy intervention in reducing emergency department length of stay (EDLOS) over time in WA and compare the outcomes against comparable hospitals in NSW, Qld and ACT.
This project hypothesises that effective intervention for reducing EDLOS will translate into improved patient outcomes, particularly in subgroups identified as associated with the most harm from overcrowding.
This research has the potential to develop and promote long-term partnerships amongst hospitals, health services, ambulance services and researchers to conduct collaborative research related to adverse patient outcomes, overcrowding and access block in emergency departments.

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Research Scholarship Grant: Prof Louise Cullen

This study is important because it will more rapidly move patients out of acute beds. It will do this by diagnosing patients with heart attacks up to four hours earlier and allowing earlier testing of patients without a heart attack but with potential heart disease, thus preventing overnight admissions. Approximately 80 per cent of patients who present to our ED each year with chest pain do not have a heart problem. Therefore, early discharge or admission of these patients would free up significant hospital resources, improve hospital flows and reduce the economic burden on the health care system.
It may also reduce mortality associated with overcrowding. Given that overcrowding is associated with an excess of approximately 1,500 deaths per year one, the potential decrease in mortality may be significant.
Testing very low-risk patients frequently wastes time and resources and subjects patients to unnecessary provocative testing (e.g. treadmill testing). Provocative testing carries a risk of life-threatening heart rhythms or heart attack and if the test gives a false positive result further tests may be unnecessarily performed each with their own risk and complications. Identifying a very low risk cohort, who do not require extensive investigation, is the key.

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A randomised, un-blinded trial of continuous infusion versus bolus dosing of flucloxacilin in the management of uncomplicated cellulitis in an Emergency Department Short Stay Ward.

Skin infections are common in the Emergency Department. Currently, such infections are treated by admitting the patient to hospital for 24 hours and giving them four injections of an antibiotic called flucloxacillin. However, an alternative way to administer antibiotics is to attach a device to the patient’s arm which infuses the flucloxacillin over a 24 hour period. We anticipate that this device will reduce the time that nurses spend giving injections and also reduce the cost to the hospital associated with giving patients multiple injections.

The overall aim of this study is to trial the antibiotic device to determine whether it saves nursing time and health care costs without reducing the quality of care provided to patients. To achieve this aim, we will conduct a randomized controlled trial where half of the patients who present to our department with skin infections will be given a continuous infusion of antibiotics while the other half will be given the traditional treatment. We will then compare the time taken to administer the antibiotic in the two groups and consider the costs associated with each type of treatment. It is anticipated that the study will change the way that skin infections are treated in the Emergency Department and will result in considerable cost savings for the hospital.

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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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Examining Sepsis in the Emergency Department

Infections, particularly serious infections leading to sepsis, cost the Australian healthcare system millions of dollars every year and impose a significant burden of illness on the Australian community. Serious infections also have the capacity to cause tragedy at a much more personal level, with lethal outcomes possible even in young healthy individuals. Despite the significant consequences of these illnesses, we have very limited information about the best way to identify and treat infection in Emergency Departments. Therefore, research that provides more information is vital.

We are conducting a ground breaking body of research to improve our understanding of infection in Australian Emergency Departments. We will conduct a group of studies focusing on early identification and treatment of infection. Specifically, four studies will be conducted across two hospitals. The first will identify the types of historical and clinical information available to doctors during the early stages of assessment that predicts whether an individual is likely to become very ill with infection. Identifying these patients at risk of progression to severe illness can be difficult, and is important because certain potentially life-saving treatments are most effective when given early. The second study will identify the types of bacteria that cause infection in our community. The third study will examine the potential beneficial effect of a commonly prescribed class of cholesterol-lowering drugs (“statins”) on patients admitted with infection. Finally, in the fourth study we will develop an antibiotic order set that covers the major bacteria causing severe infections. This will enable earlier effective treatment of seriously ill patients. These studies are the first of their kind conducted in Australia and will ultimately enable doctors to identify and treat severe infection earlier.

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