Safety and efficacy prehospital procedural sedation for fracture and dislocation reduction

Queensland Ambulance Service (QAS) Critical Care Paramedics are authorised to perform reduction of displaced fractures and dislocations in the presence of neurovascular compromise. This is frequently facilitated by procedural sedation with ketamine. Performance of this procedure in the prehospital setting is not well reported in the medical literature

Using the QAS database of electronic Ambulance Report Forms we will identify all cases where fracture or dislocation reduction was performed and report on the efficacy of this procedure using resolution of neurovascular compromise as the primary endpoint. We will use the requirement for further sedation and reduction in the emergency department as a secondary measure of the success of the procedure. The incidence of adverse events related to the sedation or to the procedure will also be reported.

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.

Ultrasound-guided supraclavicular block versus Bier block for closed reduction of upper extremity injuries in the emergency department: an open-label, non-inferiority, randomised control trial

Upper limb injuries including bony fractures/dislocations, are sometimes deformed and require realignment in the emergency department (ED). Numerous techniques are available to allow this procedure to be painless. Bier block (BB) involves placing a band on the upper part of the affected arm to constrict blood flow, with injection of numbing agent into a hand vein on the same side to make the entire arm numb. An alternative technique is ultrasound guided supraclavicular blocks (UGSCB), which involves introducing a needle under ultrasound guidance to nerves situated just above the collar bone and injecting numbing agent around these nerves to make the arm go numb. However, the effectiveness of UGSCB when performed by ED doctors is unknown and patients might recover more quickly. We aim to conduct a randomised trial to compare UGSCB versus BB for re-aligning fractures/dislocations of the upper limb in the ED.

Assessment of emergency presentations, outcomes and departmental impact of patients presenting after COVID-19 immunisation to a tertiary Paediatric Emergency Department.

Since the introduction of COVID-19 immunisations for young people aged 0-16yrs, patients and families have presented to the Emergency Department (ED) with concerns about possible side-effects. There have been rare but potentially serious complications of these immunisations reported worldwide including inflammation of the heart muscle and lining. These patients therefore need careful assessment and investigation in the Emergency Department.

This study will measure the number of patients presenting with these concerns, how they have been cared for and the outcomes of these assessments. It will assess the impact on Emergency Department (ED) resources and whether guidelines for assessment and reporting side effects have been followed. This information will be used to improve care pathways for this group of patients in the future.

External Ventricular Devices in Aeromedical Retrieval- Are they Safe?

Nationally, 1-2 % of the population will sustain a significant bleed due to the rupture of an abnormal ballooning of the blood vessels within the brain. A complication of this, called hydrocephalus, requires a drain to be inserted into the brain to reduce excessive fluid build-up, until the definitive management is achieved. Advances in interventional radiology techniques such as endovascular coiling have become common practice in the management of these patients. In Queensland, endovascular coiling is mostly performed in Brisbane, and therefore patients outside of the Brisbane area are required to travel for this treatment. For critically unwell patients in North Queensland, the only option is aeromedical retrieval. This area of aeromedical retrieval has not been previously explored therefore this project will look at the safety of aeromedical transports of patients with an invasive drain in a patient’s brain to work towards statewide guidelines.

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.

Predicting in-flight hypotension in aeromedical trauma patients

In-flight hypotension (low blood pressure) leading to patient deterioration is a common and challenging clinical problem in aeromedical trauma patients. Predicting this risk is currently primarily based on clinical gestalt, without specific validated risk prediction tools. The Triage Revised Trauma Score (TRTS) is a clinical risk prediction tool calculated using only vital signs, making it well suited to the resource-limited pre-hospital environment.

A Life Flight Retrieval Medicine internal audit in 2021 suggested an association between the TRTS and in-flight hypotension for trauma patients. Based on these preliminary findings, this study will address the research question, “what is the relationship between pre-flight TRTS and in-flight hypotension in trauma patients undergoing aeromedical retrieval?”.

Knowledge gained from this study may allow aeromedical doctors to make more informed decisions about their patients before aeromedical transport.

Maximising the effects of feedback in regional emergency medicine

Feedback improves performance. Yet establishing effective feedback practices in emergency medicine (EM) is challenging. Supervisors need to balance delivering patient care with delivering feedback in fast-paced environments. These challenges are particularly burdensome in regional settings where the workforce is less experienced, and teams are less established.

To resolve this challenge, efforts are often directed towards developing supervisors’ feedback skills. Yet with the challenges experienced by regional EM supervisors, the model of ‘supervisor driving feedback’ is inefficient. What has been overlooked is developing trainees as active participants in feedback practices. Evidence suggests that this approach may improve feedback practices in EM and offers a way to alleviate the feedback burden experienced by EM supervisors in regional settings.

Does the Clinical Frailty Scale predict re-presentations to the ED in elderly community-dwelling people following an initial presentation from a fall?

Falls in the elderly community-dwelling population are a common presentation to Australian Emergency Departments (ED). The Australian Institute of Health and Welfare reported an estimated 125,000 people aged 65+ were hospitalised due to falls in 2016/17. Fallers presenting to the ED that are elderly and frail, may then be discharged directly home.

The Clinical Frailty Scale (CFS) has been widely used and is associated with mortality, comorbidity, increased length of stay and falls (Church 2020). Despite its expansive utilisation, no studies have assessed the correlation of CFS scores with re-presentation to the ED following a fall.

Improving the ability to identify patients who are at risk of re-presenting with falls could aid in focusing physiotherapy and allied health resources towards these patients during their initial ED presentation.

Endovascular Clot Retrieval Pathway for Acute Ischaemic Stroke: Outcomes After-Hours in an Australian Metropolitan ED

Stroke is a leading cause of death and one of the most common causes of disability in Australia. For ischaemic strokes occurring secondary to a large vessel occlusion (LVO), mechanical thrombectomy is an effective intervention, with the outcome largely dependent on time to thrombectomy.

This study will analyse the assessment, management, and clinical outcomes of patients presenting to the ED with acute stroke, with a particular focus of those undergoing mechanical thrombectomy. Researchers aim to determine variability of workflow and decision-making processes that may occur after-hours. Based on current literature, variability may have a corresponding deleterious effect on patient outcomes.

By reviewing workflow processes and identifying relevant time barriers in a Queensland Comprehensive Stroke Centre, researchers aim to inform the future design and implementation of “Code Stroke” clinical pathways in Queensland.