Implementation of Nasal High Flow: A Remote Context

In this study, the clinician-researchers are exploring whether nasal high flow (NHF) therapy can be safely and effectively used to improve health outcomes for infants with bronchiolitis in isolated remote communities, in particular for remote Indigenous Australians who have a higher incidence rate of bronchiolitis than non-Indigenous Australians. There is a desire by clinicians to implement NHF in remote areas, but this should undergo similar scientific scrutiny as previous published data.

NHF is a respiratory support system that provides support for people with respiratory conditions and is applied by high flow oxygen through nasal prongs. The therapy can avoid an escalation of care during hospitalisation. The safety of NHF has been widely studied in tertiary areas and regional hospitals, however, there is a lack of evidence to support safe use in remote settings.

In this study, the researchers are employing a two-phased approach: Firstly, an expert working party establishing agreed safe clinical boundaries for the NHF implementation and utilising expert viewpoints for implementation when managing infants with bronchiolitis. Secondly, a comparison of the outcomes before and after implementation to observe a reduction in escalation of care leading to reduced transfers. A community engagement process, with the focus to keep community members in their country/home environment, will be established to measure psychological, social-emotional and economic benefits of NHF.

Improving blood culture collections in the emergency department

The primary aim of this study is to assess the effectiveness of an intervention designed to improve the quality of blood cultures collected in a busy emergency department.

Blood cultures are tests that are frequently ordered by emergency doctors to detect and identify bacteria present in the blood of patients who are unwell. The test requires a sample of blood to be collected from the patient. Like many tests, the quality of the results is related to the quality of the sample collection process.

Several factors may influence the quality of sample collection and increase the chance of sample contamination. These include not collecting enough blood and poor sterility of the collection process. Contamination of blood cultures may result in the patient staying longer in hospital, being prescribed unnecessary antibiotics and increasing the costs of care.

This study will implement a rigorous intervention to reduce contamination rates in blood culture samples collected at the Emergency and Trauma Centre at the Royal Brisbane and Women’s Hospital. The intervention comprises: education to staff that collect blood cultures; the introduction of blood culture collection kits; and regular feedback of quality indicators to the clinicians that collect blood cultures.

If successful, a reduction in blood culture contamination rates and single sets of cultures should be seen, and the average volume of blood cultured should increase. These outcomes may help to reduce patient length of stay, cost of care, with positive effects in anti-microbial stewardship and patient flow.

Paediatric Reduction in Emergency Cannula Accidental REmoval Trial – PRECARE trial

The aim of this study is to evaluate securement devices for peripheral intravenous catheters (PIVC) in the paediatric ED to determine which method is most effective for reducing PIVC failure, associated costs, acceptability and patient distress.

Infants and children depend on PIVCs for the provision of medical therapy within the emergency department and during hospitalisation. However, PIVC insertion and management is challenging and more than 25% of devices fail. PIVC failure is costly for both the patient and healthcare organisation. Failure may require the child to undergo traumatic reinsertion procedures, delay important medical treatment and prolong length of hospital stay. One way to reduce PIVC failure is with effective PIVC dressing and securement, by ensuring correct catheter position in the vein.

Our trial aims to test if new advances in catheter securement, medical grade superglue (Histoacryl) and an integrated dressing securement product (SorbaView SHIELD), are effective at preventing cannula failure and complications in paediatric patients. Using a three arm, randomised controlled trial, this study will recruit 460 paediatric patients at two regional emergency departments (Logan Hospital, Ipswich Hospital). Children will be randomised to receive PIVC securement by i) standard care, ii) advanced dressing or iii) medical grade superglue and advanced dressing. The main outcome of this trial is PIVC failure, with other important questions surrounding cost effectiveness and patient comfort also to be explored.

It is important for effective, improved cannula security to be explored as this is frequently a first line device choice for treatment, being highly effective in rapid treatment situations. A result in improved treatment delivery will benefit with cost savings in not only product but clinician time spent re-inserting, and a reduction in unnecessary, painful procedures for children.

Valuing patients’ experience in the emergency department

Improving patient experiences is part of Queensland’s 2016-2020 Strategic Plan to enable safe, quality healthcare services. Yet, current emergency department(ED) patient experience measures, including the burdensome 82-item Queensland Health (QH) ED patient experience survey, fail to reflect patient preferences for care experiences, inhibiting the design and evaluation of healthcare services that reflect patient preferences, and the delivery of value-based healthcare.

The aim of this project is to develop an ED patient experience classification system and accompanying scoring algorithm that can be used to both measure and value patient experiences in Queensland EDs. It will provide a proof of concept for an Australia-wide development, valuation and knowledge transfer study.

Emergency Examination Authorities and their impacts on North Queensland Hospitals

Emergency Departments (EDs) receive persons suffering major disturbances in their mental capacities, detained and transported by police or ambulance. The Public Health Act 2005 (Qld) (‘PHA’) – amended and in force 5 March 2017 – requires police and ambulance officers to make out an Emergency Examination Authority (EEA) at handover.1 Previously, Emergency Examination Orders (EEOs) were made out under Queensland’s Mental Health Act 2000 (‘MHA’). At handover, police and ambulance officers must make out an EEA. From handover at the ED, the PHA prescribes specific responsibilities, e.g. a doctor or health practitioner must explain to the person that they may be detained for 6-12 hours, the ED Director can order their forced return if they abscond and must take reasonable steps to return patients to a place requested.

Using qualitative and quantitative information the study focuses on the time and personnel resources required to investigate how EDs in north Queensland have responded.

No study has assessed the impacts on Queensland EDs of increasing numbers of mental health related presentations in light of legislative changes governing emergency assessment

Improving the care of skin infections in the Torres Straits

This research project is looking at cellulitis in the Torres Straits. Cellulitis is a bacterial infection of the skin that requires antibiotics. People with cellulitis usually have an area of red and hot skin and sometimes can have fevers and become really unwell. Germs called Staphylococus aureus and Streptococcus pyogenes typically cause cellulitis. It potentially can cause serious infections and are a common presentation to emergency departments and admission to hospital.

In a tropical environment such as the Torres Strait cellulitis is extremely common and contributes to a significant burden on the healthcare system. Often patients present to health care facilities in the Torres Strait with cellulitis and are transported into Thursday Island Hospital for intravenous antibiotics. This is associated with significant retrieval, emergency and hospital costs. However the treatment of cellulitis in the community has been found to be practical, safe, and cost effective. We want to find out if cellulitis can be treated at home instead of in the hospital here in the Torres Straits.

The aim of this study is to validate outpatient intravenous antibiotic management of cellulitis in the Torres Straits. We anticipate that results from this study will improve preventable emergency and hospital admissions thus having significant health economic savings here in the Torres Straits.

Can children be sedated effectively with only one needle?

Procedural sedation in emergency departments is performed on a daily basis. The current management plan arguably inflicts unnecessary pain and distress on children. This open label, multicenter, randomised control trial is investigating whether paediatric procedural sedation can be achieved with just one needle. The research team’s focus is the on determining the best outcome for the child in procedural sedation, prioritising psychological as well as medical consequences.

Understanding why aged care residents are transferred to the ED

In Australia, the existing model of emergency department care is struggling to cater for the needs of the older population. A large proportion of older patients arriving at emergency departments are from residential aged care facilities (RACFs). Nursing staff in RACFs often participate in decision making pertaining to transfer of residents to the emergency department, but very little research has been done on the decision making involved in this process.

The mixed methods study will engage with RACF nursing staff to understand their decision to transfer a resident, their perception of communication with the emergency department, and the services that influence the decision.

Junior doctors at triage improve patient flow in the ED

Introducing a novel model of care to the emergency department may provide significant reductions in key performance indicators, such as patient length of stay, or the National Emergency Access Target (NEAT).

In previous studies, researchers have found that rostering a physician to work at triage can lead to significant improvements on a range of metrics, including time to treatment, patient length of stay and rate of patients who left before receiving treatment. However, in a regional hospital where staffing numbers and budgets are under pressure this model may not be possible.

The objective of this study is to implement a novel model of care at triage in the Hervey Bay Hospital Emergency Department. For a trial period of three months, junior doctors (PHO/registrar level) will be rostered to work at triage on alternate day shifts. A range of outcome measures will be compared with day shifts when junior doctors are not rostered at triage. This model may be relevant for other regional emergency departments.

Early resuscitation in paediatric sepsis

Sepsis is a leading cause of death and disability in children, globally accounting for more than one million childhood deaths per year. Recommended sepsis treatment currently consists of intravenous antibiotics and aggressive fluid boluses followed by inotropes and consideration for intravenous steroids. However, the evidence for interventions other than antibiotics is limited and aggressive fluid administration may be associated with harm. Therefore, fluid-sparing algorithms using early inotropes to treat shock have been proposed. Another strategy to hasten shock resolution consists in intravenous steroids, alone or in combination with thiamine and vitamin C, postulated to support metabolic dysfunction in recent studies.

In this project, the research team is conducting a randomised controlled pilot trial in children presenting with septic shock. They are assessing the feasibility of a fluid-sparing algorithm using early inotropes and early intravenous administration of Vitamin C, Thiamine and Hydrocortisone and the impact on survival free of organ dysfunction.