Innovative Corrective Services and Ambulance Response Evaluation (ICARE): A Queensland Ambulance and Queensland Corrective Services initiative to improve the management of prisoners with minor orthopaedic injuries.

The Queensland Ambulance Service (QAS) provides out-of-hospital medical services to approximately 900,000 patients annually, and as the publicly funded provider of prehospital emergency care is called to respond to persons incarcerated within correctional facilities. The primary complaint of patients attended by QAS in this setting are minor orthopaedic injuries to the upper arm and hand. In current practice, paramedics provide short-lasting analgesia and temporary limb splinting or bleeding control, before conveying the patient to an emergency department for further management. Transport of patients from correctional facilities to public hospitals is complex, presenting potential risks to staff and the public, and is time consuming and resource intensive. As these injuries are predominately uncomplicated fractures or simple lacerations, it has been postulated these patients may be more appropriately managed by enhancing the care that can be provided onsite by the QAS, with the patient subsequently managed through an outpatient clinic and thereby avoiding an unnecessary presentation to hospital. This project proposes developing a new collaborative treatment pathway involving the QAS, QLD Health and QCS for patients with minor orthopaedic injury. The aim is to reduce unnecessary, time and resource intensive transports to hospital emergency departments for this cohort of patients. Grant funding is sought to undertake an evaluation of this initiative. This model of care provision, if proven effective, could potentially be considered for implementation in other correctional facilities or austere healthcare settings where primary health care resources are stretched, and consequently additional demands are placed on emergency care settings.

Can interactive online learning using enhanced technology adequately teach trauma-based procedural skills to emergency nursing clinicians?

Injury and trauma are common presentations to Queensland Emergency Departments. Clinicians caring for trauma victims must maintain competency with trauma procedures and interventions to apply them in a time-critical context, accurately, and therefore achieve the best outcome for individual patients. Engagement with traditional educational approaches, such as face-to-face training, is challenged by workload, shift patterns, clinician location and lack of opportunity to attend dedicated training events. A previous learning needs analysis of trauma education programs has highlighted that the greatest challenges are often faced by clinicians in rural and remote locations. One solution is to include the use of online learning platforms, to connect and assess clinician knowledge, with positive feedback regarding the engagement and experience for the learner. This study aims to use high-fidelity interactive online education, using a range of technologies including 360 videos with user interaction capabilities to design and develop a scalable model for future-proofing trauma education across Queensland. The research will test the effectiveness of (1) the approach to design and development in terms of scalability and (2) the online resources and assessment procedures in terms of the impact on knowledge and skill development.

Suspected Pulmonary Embolism Exclusion with D-dimers in Emergency Departments (SPEED-ED)

Pulmonary embolism (PE) refers to blood clots in the lung. They can cause sudden death, collapse, chest pain, shortness of breath yet sometimes they cause no symptoms at all and are discovered incidentally. As they can be severe, they have become regarded as a not-to-miss diagnosis. As they can present with a variety of symptoms, emergency clinicians consider the possibility of PE on a frequent basis.

When considering whether a patient has a PE, the clinician may confirm or exclude the diagnosis directly with definitive chest scans. However, these scans are time consuming, costly and have other side effects including exposure to radiation and to chemical contrast agents. When patients are assessed to be less likely of having a PE, it is often possible to safely exclude PE by applying a set of clinical decision rules or doing a blood test called a D-dimer. If the level of D-dimer is below a certain threshold, then PE can be excluded.

We aim to safely exclude PE without scans where possible. Evidence has been building that employing a higher D-dimer threshold is reasonable, yet uptake of this newer approach is limited. We hope to demonstrate that a higher threshold can work in Australia without compromising safety. This will be a large study that answers this question and if shown to be the case, then patient care can be improved while using less resources in busy emergency departments.

A randomised controlled trial of plasmalyte versus normal saline as resuscitation and maintenance fluid therapy for patients presenting with diabetic ketoacidosis (BEST-DKA) BalancEd fluids vs Saline Trial in Diabetic KetoAcidosis

We propose to conduct a multi-centre blinded cluster cross over randomised clinical trial (RCT) of plasmalyte (PL), a balanced salt solution versus normal saline (NS) in patients admitted to an Intensive Care Unit (ICU) with diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. DKA results in elevated acid levels in the blood leading to severe dehydration and electrolyte imbalance.

ICU admission rates for patients with DKA in Australia has risen annually. In 2019 and 2020, there were 2751 and 2812 admissions to ICUs respectively. Almost all patients present through the Emergency Departments and in regional hospitals, they are often admitted to the ICU.

NS is often used as the first line fluid for dehydration, but NS use frequently results in persistent acidosis. We have shown in a pilot trial, conducted in 7 Queensland regional Emergency departments and ICUs, that the use of a balanced salt solution such as PL resulted in a more rapid resolution of acidosis with trends to shorter length of ICU and hospital stay as compared to NS. The efficacy of PL in DKA needs evaluation in a large clinical trial.

We plan to study 480 patients from Australia of whom a third will be expected to be enrolled in Queensland. Patients will be randomised to receive either NS or PL and the primary end point is hospital length of stay. This proposed trial will answer a fundamental clinical question and will inform policy and practice in Australia and New Zealand and around the world.

Validation of a Modified Fibrinogen on Admission with Trauma (FibAT) Score in the Australian Setting

Soon after injury, some individuals develop a condition where their body doesn't clot properly, leading to increased blood transfusions and increased mortality. An important aspect of clotting is a protein called fibrinogen which forms the scaffolding on which clots are formed. Fibrinogen is the first aspect of clotting that is impaired, but it is easily replaced if it is recognised with a specific blood test. Unfortunately this blood test may not be available rapidly in rural hospitals, which may lead to a delay in recognition. A scoring system called the Fibrinogen on Admission for Trauma (FibAT) has been developed in France, but includes criteria/interventions which we don't routinely do in Australia. In this study we will evaluate the FibAT's accuracy in detecting low levels of fibrinogen using data from 3 Queensland trauma centres. We will only use criteria that is available in rural settings.
This study is expected to show that even a modified FibAT is quite good at ruling in low fibrinogen so that it can be replaced early when a patient arrives in a rural hospital.

Research Capacity Building Grant – The Prince Charles Hospital

The proposed Research Capacity Building grant aims to increase participation in research, strengthen the research culture and ensure that research becomes core business within The Prince Charles Hospital Emergency Department (TPCH-ED). The strategic vision includes strengthening of systems and structures that enable researchers, both novice and experienced, across all disciplines to participate in high-leverage, practice-changing research activities, with a view to embedding a research culture into day-to-day practice. A core element is the strengthening of collaborations between departments, across disciplines and with other health facilities. The proposed strategy is the training of a group of research nurses to equip them with the foundation skills, knowledge, and preliminary experience to actively promote and support research in the department. The model is one of appointment of experienced clinical nurses, new to research roles, in part-time sequential appointments. Recruitment from existing ED workforce would be ideal, allowing retention of a substantive position which the researcher would return to after the research immersion. This would assist in embedding a research culture amongst clinical nurses and provide opportunity for continuation of research engagement on return to clinical duties. The expected benefit of this approach is that there will be a highly visible research focus within the ED, with multiple opportunities for engagement, underpinned by the premise that depth and breadth in a research group, rather than reliance on a few key individuals, is paramount. This proposal would ensure that research enthusiasm and knowledge is shared across a multidisciplinary group of dedicated individuals and retained within the organization.

Research Capacity Building Grant – Townsville University Hospital

The aim of the proposed EMF grant is to enable Townsville University Hospitals' emergency department (TUH DEM) to create a stable platform for prolific, innovative and translational research. Further more, it will contribute to the strategic vision of TUH DEM being a centre of excellence in EM research and innovation that delivers high-quality emergency care. The research capacity building grant will support an Emergency Medicine Clinical Research Coordinator to assist research active emergency clinicians in sustaining ongoing projects, designing and conducting new high-quality, outcome-oriented projects, nurturing the next generation of EM researchers and embedding research into daily business of TUH-DEM.

SPASMS: Study of Paediatric Appendicitis Scores and Management Strategies

Abdominal pain is one of the commonest reasons for children to attend the emergency department (ED), and acute appendicitis is the most common cause of abdominal pain requiring surgery. There are various clinical prediction scores that have been developed to help doctors diagnose appendicitis; however, most scores were developed overseas and are not routinely used in Australian EDs. The aim of this project is to review different published scores and compare them with overall clinician impression in diagnosing acute appendicitis in children presenting to ED.

The project will include all patients presenting to the ED with abdominal pain that are having investigations for possible appendicitis. The treating doctor will be asked to complete a case report form detailing patient history, examination findings, investigation results, as well as their overall clinical impression of the patient’s likelihood of having the diagnosis of appendicitis. Data collected will be analysed by project researchers to determine which scores are the most helpful for clinicians in diagnosing acute appendicitis in children presenting to Australian EDs, with the expectation that this will improve future care provided to children with abdominal pain.

Treatment for nausea and vomiting: A multi-arm double blind, placebo-controlled trial comparing the efficacy of droperidol, metoclopramide, and ondansetron for patients in the prehospital setting.

Nausea and vomiting are common reasons for people to call an ambulance. In Queensland, paramedics can provide a medication called Ondansetron to reduce the severity of nausea and vomiting. Alternative medicines, such as metoclopramide and droperidol, are also used in the emergency department or by ambulance services in other states. Despite the widespread use of medications for nausea and vomiting, little is known about their effectiveness in the prehospital setting. The limited evidence that exists comes from small studies in the emergency department setting, and indicates that medications may be no more effective than placebo for reducing nausea and vomiting. In this study, we aim to determine the effectiveness of medicines for nausea and vomiting in the prehospital environment. We will randomly assign patients who have nausea and/or vomiting to receive either ondansetron, metoclopramide, droperidol or a placebo as a prehospital treatment. Patients will rate the severity of their symptoms before and after receiving the medication, and we will compare these symptoms between groups to identify the most effective medicines. The study will help to optimise the treatment provided to the large number of patients who call an ambulance for nausea or vomiting.

Research Capacity Building Grant – Retrieval Services Queensland

We propose to establish a 0.4FTE Research Coordinator role at RSQ to lead development of research capacity and culture within the agency, and provide support across our partner organisations – Lifeflight Retrieval Medicine (LRM) and the Royal Flying Doctor Service (RFDS) – QLD Section.

The Research Coordinator will provide a dedicated research focused role that will form part of the Research Leadership Team within RSQ, reporting to the RSQ Clinical Director for Research and Evaluation. They will be a key liaison with research partners and collaborators across the broader health sector, working closely with the Clinical Director.

It is anticipated that through the provision of dedicated research expertise and resourcing this position will greatly assist with the development of research capacity and culture within RSQ, and in turn RFDS and LRM. The proposed contribution of this role to the development of an RSQ Research Strategy will support identification of areas of research priority for the agency and provide a platform to foster collaborations with clinicians and researchers with shared interests, thereby building RSQ’s research network. Importantly, establishment of a Research Governance Framework will increase accessibility to RSQ data, staff and patients for the purpose of research, whilst providing a clear and risk managed process for overseeing all research activities, which is a vital function in supporting the agency’s growing research capacity.