Does a Vascular Access Specialist Model in the Emergency Department (VAS-ED) improve peripheral intravenous catheter outcomes? A Randomised Controlled Trial

More than 6 million peripheral intravenous catheters (PIVCs) are inserted in patients' veins in Australian emergency departments (EDs) annually. These devices can be challenging to insert, and over half will fail before the treatment is finished. Although ED clinicians regularly insert PIVCs, most inserters are junior medical or nursing staff who often default to short PIVCs because that is what they were trained to insert. These “generalist” inserters often don’t have the skills or knowledge to select alternate vascular access devices appropriate to the patient's needs. In contrast, Vascular Access Specialists (VAS) are experts with advanced assessment and expertise in inserting and managing vascular access devices, a model that has proven successful in inpatient wards, but hasn’t yet been tested in the ED setting.

In this study, we will compare the effectiveness and cost of using VAS specialists versus generalist inserters for peripheral IV device selection and insertion. In total, 320 ED patients will be recruited and randomly allocated to receive either a VAS or generalist inserter (standard care). We will compare outcomes including first-time insertion success, device failure rates, complications, patient satisfaction, and cost between the two groups. Additionally, we will interview clinicians to better understand the barriers and facilitators to implementing and using a VAS model.

We expect that patients who have a peripheral IV device inserted by a VAS will have higher first-time insertion success, and be more satisfied with their care than patients allocated to the generalist group.

Efficacy of pressure pad vs pressure bandage immobilisation for snake bite first aid

Snake bite affects thousands of Australians every year, but few die as a result due to high quality first aid and timely medical care. Good first aid should be simple, standardised, use minimal or readily available equipment, and be able to be utilised effectively with no or minimal training by the rescuer. Over time the first aid methods used to manage snake bite in Australia have been questioned due to issues with efficacy, and some emerging evidence of harm from their use. There is little experimental data in the literature to support current first aid practices, and what exists suggests further research is required. Our study aims to examine and compare the effectiveness of two first aid methods by tracking the movement of a mock venom through the body when each first aid method is used. This will provide important information about the suitability of current techniques used in Australia and whether a proposed simpler alternative technique is as effective. If this is demonstrated to be correct it provides a basis for modifying current snake bite first aid recommendations.

Comparison of pressure points versus tourniquet application for first aid control of arterial bleeding in beachgoers: a randomised controlled cross over trial

Arterial injuries to the lower limb, such as from a shark bite or deep laceration, can lead to catastrophic bleeding and death. Current first aid measures involve trained personnel applying an arterial tourniquet. However, even a short delay in haemorrhage management can lead to significant blood loss, brain injury or death. There is growing evidence that the simple technique of applying pressure to the groin can effectively occlude blood flow through the femoral artery, buying time for medically trained personnel to attend. One potential application of this technique is the treatment of shark attack victims with lower limb injuries, where beachgoers without medical training who have only seen a sign on a beach could apply life saving first aid. There is plethora of other potential applications outside marine encounters where this technique could be critical in reducing blood loss such as limb trauma from motor vehicle accidents, workplace injuries or military settings. The benefits are the simplicity of the technique which may be both easily and effectively performed by bystanders with no medical training. Using a non-clinical environment, we intend on performing a randomised trial to evaluate the efficacy of non-medically trained beachgoers performing pressure points compared with the application of a commercial arterial tourniquet after reading an infographic. We will measure the reduction in arterial blood flow using doppler ultrasound. The project aims to generate translatable research with the goal of influencing local, national, and international first aid guidelines.

Biomarkers for rapid diagnosis of paediatric sepsis

Sepsis is a time critical medical emergency that arises when the body starts to attack its own tissues and organs in response to an infection. Sepsis can result in organ dysfunction, multi-organ failure and death if not treated promptly, and is a leading cause of death in children worldwide. Sepsis often presents with non-specific signs common to many mild infections, making it difficult to detect early and accurately, leading to delaying appropriate treatments and resulting in severe sepsis. Therefore, it is vital to identify new approaches to rapidly identify the type of infection and predict the severity of the condition in patients presenting with suspected sepsis to enable early initiation of appropriate treatments.

Recent advances in genomic technologies have shown that gene expression based infection testing has the potential to provide much faster and more precise results. This results in more accurate diagnosis of infections and appropriate timely treatments. Our study will utilise an advanced gene expression analysis approach named single-cell RNA sequencing to identify new approaches for sepsis diagnosis. This could lead to development of a rapid testing method which can predict the type of infection (bacterial or viral) and the severity of the condition with a quick turnaround time for results, improving patient outcomes, reducing unnecessary antibiotic use, and shortening hospital length of stay.

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).

A structures, process and outcome evaluation of the Residential Aged care District Assessment and Referral Rapid Response (RADAR RR) model

Older persons from residential aged care homes (RACF) have unique needs that are often overlooked in our traditional emergency departments (EDs). This can lead to under triage, prolonged length of ED stays, unnecessary investigations and iatrogenic hospital acquired complications (1). The Residential Aged Care District Assessment and Referral Rapid Response (RADAR RR) model is a pre-hospital Queensland Ambulance Service (QAS) co-responder model providing ED equivalent care in the resident’s home for acute illness and injury. RADAR RR model operates between 0800 and 2000, 7 days a week. We hope to evaluate the clinical and cost outcomes of the RADAR RR model and determine if it is equivalent to the care provided by traditional ED models of care in an urban setting. We will also review the structures and processes required for effective service delivery which will in turn guide the development of a toolkit to assist other hospitals in adopting the RADAR RR model if appropriate for their area. Finally, given increasing pressure for high value models of care we will undertake an economic evaluation to determine if the RADAR RR model is more economically efficient than the traditional ED model of care.

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.

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.

Pharmacological Emergency management of Agitation in Children and Young People – randomised controlled trials of Oral and intraMuscular medication: PEAChY-O and PEAChY-M

Acute severe behavioural disturbance (ASBD) is an emergency situation where a patient experiences severe agitation or aggression. These individuals commonly present to the emergency department (ED) for treatment. Medications are often provided to assist the person to feel calmer. In most instances, oral medications are used. When the patient is extremely agitated, an intramuscular (IM) injection will be given.

In individuals less than 18 years, there is minimal available evidence to guide doctors about which medications work best. It is also not known how well these medications are tolerated by these young people. Therefore, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network is running two trials across a number of Australian EDs to create evidence to be used to guide the treatment for these young people.

The first study (PEAChY-O) compares two oral medications - olanzapine and diazepam - to determine which medication works better. The second study (PEAChY-M) compares two IM medications – olanzapine and droperidol. These medications were chosen because they are used as standard of care in Australian EDs and are recommended on current Clinical Practice Guidelines (CPGs). These are important studies because they will be the first trials to compare any medications head-to-head in a randomised trial across either the oral or IM routes.
Once the results are available, they will be used to guide future clinical practice including influencing the recommendations made in Australian guidelines, ensuring that these young people receive evidence-based treatments.

Prothrombinex-VF® for coagulopathy of liver disease in acutely bleeding patients; Too much of a good thing?

Chronic liver disease (CLD) is prevalent in Australian society and is the 11th leading cause of premature death (1). Thirty eight percent of patients experience gastrointestinal bleeding (GI) as a complication(2). The underlying balance between bleeding and clotting tendency is altered in chronic liver disease, making management of acute bleeding challenging in the emergency setting(3). There is a lack of high-quality evidence to guide the best combination of blood products and other medications to stop bleeding(4).

Prothrombinex®-VF is a blood product which can help to improve the level of clotting factors in the body thereby reducing bleeding tendency. It is indicated for anticoagulant reversal in acute bleeding(5). In practice many emergency physicians have used the product for patients with chronic liver disease who present with acute bleeding, although it is not licensed for this indication(6).

A retrospective Queensland study performed by this author showed that half of Prothrombinex®-VF usage for liver disease was in the emergency department by emergency physicians. It suggested that the product makes little impact on reversal of laboratory blood clotting tests and it raised important safety concerns regarding the develop of a syndrome of accelerated bleeding and clotting concurrently(6).

This expanded statewide audit of Prothrombinex®-VF in chronic liver disease in Queensland seeks to define efficacy and safety of the product. There is no statewide guideline for Prothrombinex®-VF and this data will contribute valuable information to developing future guidance for clinicians.