Capacity Building Grant: Cairns Base Hospital

Cairns Base Hospital Emergency Department is committed to attracting the best emergency physicians and trainees. Our research commitment over the years, particularly the ability to provide 4.10.70 direction and opportunities, has been recognised by our peers as significant, particularly in an environment of heavy clinical \workloads and limited funding opportunities. In the past two years the CBH executive has worked to balance this by increasing staff numbers and allowing more academic opportunities for Emergency Physician and trainees alike.

This Capacity building grant allows the Hospital to appoint, for three years, Associate Professor Jamie Seymour from the James Cook University, School of Medicine and Tropical Biology, as a Research Fellow. A/Prof Seymour has a history of involvement in research with the Hospital's ED -- primarily, but not restricted to, toxinology and advice in study design and analysis. This grant enabled the Hospital to considerably expand and formalise the collaboration.

In his role as Senior Research Fellow, A/Prof Seymour will provide the experience and expertise need to help the Department apply for successful grant applications and help attract and immerse Emergency Medicine trainees in a fertile research environment that actively encourages them with their 4:10:70 as well as research in thelr ongoing career. The department believes that this approach will also increase its attractiveness to emergency physicians in relation to job placement and has unanimous support from the consultants in the department.

The department envisages that the Research Fellow would conduct research training on a weekly basis as part of the present teaching protocol where research ideas and published studies are discussed and examined, where experimental design and statistical analysis of proposed research projects can be developed.

Capacity Building Grant: The Townsville Hospital

The Townsville Hospital Emergency Department (ED) aimed to increase research capacity in the ED . The vision was to create a sustainable research culture within the ED, with a positive research profile and a clear point of contact making Townsville attractive for collaborative research and to establish a track record of research success and outputs ensuring the long-term future of ED research.

Capacity Building Grant: Gold Coast University Hospital

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

This was 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 assessed 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 hypothesised that effective intervention for reducing EDLOS would translate into improved patient outcomes, particularly in subgroups identified as associated with the most harm from overcrowding.

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.

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.

Is Helicopter Transport Safe for Divers with Decompression Illness?

Diving is a common recreational activity for both Queenslanders and tourists alike. It forms the basis for whole tourism industries based on the Great Barrier Reef. Unfortunately diving does have risks which includes decompression illness (DCI). DCI involves formation of gas bubbles and can be fatal. Treatment usually involves re-pressurisation in special chambers designed to ‘squash’ the bubbles and reduce symptoms. Affected divers can only receive this treatment in certain hospitals. They may need to be transported urgently by helicopters from the reef to hospital. However, some people believe that the vibration of the helicopter may increase the number of bubbles and make symptoms worse before divers can access treatment. This study will determine if this is true – will bubbles actually be increased by the vibration associated with helicopter flight? If vibration does increase bubble formation, then in the future alternative strategies for transporting DCI patients can be implemented to reduce the risk to these patients. To ensure safety the vibration record of helicopter flight will be recorded and reproduced using a vibrating basket model. Healthy volunteers accompanying divers in the recompression chamber will be assessed with a special ultrasound to detect bubbles following the ‘dive’ and then placed in the vibrating basket. The number of bubbles present after this will be measured again. This study will help ensure safe transport of injured divers not just in Queensland but internationally. This global importance is represented in the research team, which includes members from both Canada and other Australian states, which are collaborating in a Queensland based study.

Prospective evaluation of an innovative system for online clinical assessment of practical skills (eCAPS) for Emergency Medicine residents and registrars.

The current project will involve the implementation and evaluation of a pioneering protocol for the online clinical assessment of practical skills (eCAPS) for medical residents and registrars training in Emergency Medicine. It will use a variety of web-based video technologies to facilitate the learning and innovative assessment of physical examinations of the musculoskeletal system initially targeting the knee and shoulder joints. Specifically, eCAPS includes three interdependent elements with a progressive (asynchronous to synchronous) organization of online instructor and learner-generated video resources to allow formative and summative assessments of practical competencies of Emergency Medicine residents and registrars performing selected physical examinations of the musculoskeletal system. This includes:

1. an integrated series of web-based video lectures and tailored clinical demonstrations of practical skill sets (musculoskeletal examinations) by experts in the field;

2. resident/registrar (“learner”) generated video demonstrations of selected, clinically relevant practical skills recorded with portable USB cameras (asynchronous) uploaded to a secure response and feedback online repository for personal and peer-community access; and

3. real time (synchronous) video assessment of residents/registrars completing practical skill sets for physical examination of the musculoskeletal system within a simulated OSCE (Objective Structured Clinical Examination) scenario using readily accessible web-based technologies (e.g. Skype).

The evaluation of the proposed implementation of the eCAPS protocol will provide important baseline information on aspects such as the flexibility, viability and generalizability of emerging online learning options for developing and assessing practical/procedural skills within an Emergency Medicine training program.
Furthermore, the current project will provide insights into the learning outcomes of the eCAPS protocol and the potential applications of this online approach for facilitating the standardization, validation and recording of clinical competence across a range of training levels and settings including rural and remote Emergency Medicine contexts.

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.

Comparing intern’s assessments using mini-Clinical Evaluation Exercise (mini-CEX) with existing workplace based assessments in emergency medicine term.

With increasing numbers of Australian medical graduates, there has been a significant increase in the intern teaching and supervision workload in emergency departments (EDs). As a result, there is the potential for dilution of supervision, making assessment of intern performance more challenging. The current process for evaluating interns has no formal requirement for direct observation of an intern’s history taking or clinical examination skills. Rather the assessment of their abilities is largely derived from the quality of presentation of their clinical findings to the senior doctors supervising them. In most EDs end of term assessments are based on facilitated discussion involving these senior medical staff at the end of term. This method has a number of potential problems. It may miss critical gaps in performance through lack of direct observation. Moreover, it is likely to disproportionately favour those with excellent communication skills.

It has been suggested that deficiencies with the current work based assessment practices in pre-vocational medical education may be addressed through use of a tool called the mini-CEX. The mini-CEX was introduced in the mid 1990s. It requires direct observation of intern’s clinical skills on a real patient, providing information in an authentic context for summative assessment purposes. It also facilitates timely and case relevant feedback to the interns, and thus is useful for formative feedback.