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).

Criteria Led Discharge from Emergency Department Short Stay Unit

The Emergency Department Short stay unit (EDSSU) is used to facilitate flow through the Emergency department (ED) for patients requiring further investigations, treatment or period of observations, with the likely disposition of home. Current access block issues and increasing patient presentations means the SSU is consistently full, with multiple patients waiting to be transferred to this unit. Furthermore, limited medical staffing with only one junior doctor to follow up on these patients creates an exit block during periods of increased activity. Criteria Led discharge (CLD) is a proposed strategy that allows for safe and timely discharge of patients by nursing staff from the EDSSU once diagnosis-specific criteria have been met without the need for final medical review. Post initial assessment and investigations, medical staff can identify specific patient cohorts for the CLD pathway. Nursing staff can then discharge patients once criteria is met. CLD is not a new concept; being used among wards and paediatric centres statewide, however it has not been utilised within the adult emergency space in Queensland to the best of our knowledge. This process will decrease length of stay (LOS) within the ED and EDSSU, increasing patient satisfaction with the healthcare service, redirecting medical resources allowing medical staff to prioritise acute patient presentations or perform critical emergency procedures, and alleviate pressures created by medical sick leave when no residents can be allocated to SSU as nursing staff can manage and discharge this cohort of patients using the CLD pathway.

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.

Paediatric peripheral intravenous cannulation package to improve practice: the experience of a mixed metropolitan Emergency Department.

Insertion of intravenous (IV) cannulas (often called a drip) in children is difficult and potentially distressing for the child and their family. The goal of this project is to use the best evidence available to improve and standardise the procedure of placing the drip, so we improve our success on the first attempt and reduce complications. The evidence-based bundle includes a decision-making guide, visual pictures, and resources to support staff performing the procedure. Best practice techniques include appropriate pain relief, holding and distracting the child well, and dressing the drip securely so it is less likely to fall out. The project will describe how well the resources are used, and will hopefully show improved practice, meaning it is more likely the drip is inserted successfully on the first attempt, less likely to fall out, and there are less complications such as infection, excessive pain, or reinsertion.

Single centre validation of the Canadian Syncope Risk Score

Syncope is a transient loss of consciousness with full recovery, and is a common presenting problem to the emergency department (ED). Most patients presenting with syncope have a benign cause, but others may be at risk for serious adverse outcomes. The problem is that there is currently no validated tool for knowing which patients are at risk and which can be safely discharged. Several clinical prediction rules have been developed over the years, however the sensitivity and specificity of these rules vary. This has led to an over-admission of patients who could otherwise be safely discharged, based on clinician discretion. These patients are subjected to multiple tests, including cardiac telemetry for monitoring which not only has low yield, but also results in significant costs to the healthcare system.

The Canadian Syncope Risk Score (CSRS) is the latest decision tool developed in an attempt to predict serious outcomes in patients presenting with syncope to the ED, but it has not yet been validated. This study aims to validate the CSRS at a single site, providing the first step in guiding clinicians to make better risk assessments and disposition decisions for patients with syncope. Furthermore, an innovative economic model will assess the impact of this decision tool on the healthcare system. This project is the first, critical phase toward better informed decision-making by clinicians for patients with syncope. Ultimately, this tool will enable a change to clinical practice that will result in improved patient outcomes and enhanced, targeted healthcare delivery.

Pictured to the right: Members of the Syncope research team from left to right: Ms Helena Cooney, Dr Alan Yan, Dr Jason Chan, Dr Emma Ballard (QIMR), Dr Jonathan Hunter and Dr David Brain (AusHSI)

Research capacity building: Redcliffe Hospital

Redcliffe Hospital Emergency Department (ED) has a growing research track record and an increasing number of clinical staff engaging in research-related activities. To capitalise on this burgeoning interest, we will funding a dedicated Clinical Research Coordinator to provide active support, coordination and promotion of both current and future research activities. The aim of our endeavour is to establish research as a core element of ED activity, together with education & training, provision of clinical care and maintenance of standards in healthcare. We intend to conduct our future research under the auspices of leaders and champions representing four thematic headings: 1. Clinical Care, 2. National Standards, 3. Systems and Process Design, 4. Education and Training.

Propofol on trial for headaches in the Emergency Department setting

Headache is a common and frequently disabling clinical disorder that accounts for nearly 2% of all emergency department presentations. Often patients are experiencing a headache that is not responding to commonly available medications. However, there is no good evidence to support which available hospital medications consistently offer effective pain relief to individuals with these types of refractory headache. Understandably this is a challenging scenario in the emergency department setting for both the patient and physician that often leads to inadequate or unsatisfactory symptom relief.

In a few small trials, there has been promising evidence that the medication propofol is potentially an effective, safe and quick treatment alternative for stubborn headaches. It is important to note that propofol is not a new medication and is routinely used on a daily basis throughout hospitals for both general anaesthesia and procedural sedation.

It is the intention of this research project to demonstrate that infusing a low dose of this medication over a relatively short period of time is an effective new use for a familiar and already commonly utilised medication. This treatment is aimed at a specific cohort of patients who present with acute or subacute migraine-like headache in whom the standard available treatment options have failed.

This study has the potential to introduce a new safe and effective treatment option for stubborn headaches that can significantly reduce treatment times by rapidly restoring patients to baseline levels of function and comfort. Furthermore it reduces overall lengths of stay in the emergency department and contributes to overall improved emergency department patient flow.

Procedural sedation in the Emergency Department; A comprehensive analysis of a prospective registry of consecutive procedural sedations and telephone follow-up

Patients frequently present to the Emergency Department (ED) requiring brief but painful procedures as part of their medical treatment. Completion of these procedures in a safe and timely manner should be a core competency of an Emergency Physician. Insufficient data currently exists to guide the Emergency Physicians in the conduct of these procedures. A specific and highly comprehensive registry of patient related parameters, patient and physician satisfaction with the sedative episode is required.

EASI – Efforts to Attenuate the Spread of Infection: A prospective, multi-centre microbiological survey of Ultrasound Equipment in Australian Emergency Departments and Intensive Care units.

One of the causes of patients getting sick in hospital is the transfer of bacteria from one patient to the other (nosocomial infection). This transfer of bacteria can lead to serious illness, even death. There are numerous precautions taken in hospital to prevent this, such as hand washing, wearing gloves, sterile gowns and gloves during procedures etc. There has been a tremendous growth in the use of point of care ultrasound to assist clinicians in the Emergency Department, Intensive Care Unit and Anaesthetic Department. We suspect that probes, which are in contact with patients’ skin are not cleaned as often or as thoroughly as they should be. This might lead to bacterial colonization.

Often the ultrasound probes are used to assist with invasive procedures such as the placement of central and peripheral venous catheters. There is a potential for the probes to be contaminated by patients’ blood during these procedures, as well as their skin bacteria. This situation would clearly pose a risk to the well being of our patients and staff, and these procedures are most commonly performed on our sickest, most at risk patients.

We aim to investigate the bacterial colonization and blood contamination on ultrasound probes in the Emergency Departments and Intensive Care Units across numerous hospitals in South East Queensland. The amount of bacteria, the type of bacteria and the amount of blood contamination will be investigated and reported. This study has the potential to demonstrate possible contamination of our sickest patients by blood and pathogenic bacteria from ultrasound probes used by the clinicians who are caring for them. The results should lead to recommendations regarding standardised work practices for the use of this equipment in the Intensive Care Unit and the Emergency Department.

Reducing Emergency Department demand through expanded primary healthcare practice.

Patient demand on Emergency Departments (EDs) is rising by over 3% per annum contributing to congestion. ED congestion is known to be associated with poor health outcomes and reduced efficiency; the latter is characterised by increased waiting time, length of stay and ambulance diversion. Even though the National Emergency Access Target (the four-hour rule) has reduced the level of access block, initiatives to reduce ED demands have not had significant effect to date.
Previous research undertaken by the emergency health research group at QUT has described in detail the increases in demand and has identified some contributing factors. Our research highlighted reduced access to primary healthcare is one important factor associated with increased ED demand.

The aim of this project is built on our earlier work investigating factors that influence the choice made by patients between ED and primary healthcare for acute illness, and to thus identify viable primary healthcare alternatives for diverting ED patients so as to reduce ED demand. This project will provide the necessary evidence base to subsequently develop a NHMRC grant application to trial a national model of expanded primary healthcare practice to reduce ED demand. Importantly, this project will facilitate better integration and knowledge exchange between existing primary and secondary health sectors in Queensland through the stakeholder involvement.