Results for Project Grant


Better ways of pain management in adults with hip fractures

Hip fractures are extremely painful yet medications which are usually used to manage the pain can have significant complications, particularly in frail individuals. Numbing medications injected into the groin on the side of the hip fracture have been shown to decrease pain, confusion and chest infections in patients with hip fracture awaiting an operation.

It is usual for most patients presenting to emergency departments with a hip fracture to get a single injection of numbing medication. What isn’t known is whether multiple regular doses of numbing medications injected regularly via a plastic tube in the groin are more effective than a single injection in managing the pain of hip fractures.
The purpose of this study is to show multiple regular doses of numbing medications are better than a single injection. This will be achieved by examining the difference in the amount of pain, the quantity of pain medications, and the degree of confusion between the patients getting multiple doses and those getting a single injection.

This study will be the first of its kind to be done in an emergency department and is also unique in that it will involve patients with dementia who make up more than a third of patients with hip fracture and are usually excluded from studies. The study is expected to help manage the pain of the 1.6 million hip fracture patients worldwide and give emergency doctors an additional option of managing hip fracture pain.

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Using bedside ultrasound to diagnose forearm fractures in children

This is a multicentre, open-labelled diagnostic randomised controlled trial to comparing the use of portable ultrasound and x-ray imaging to diagnose a buckle fracture in children. The trial will determine if there are differences in functional outcomes, patient and care-giver preferences, and health system benefits.

Children frequently present to the emergency department with forearm injuries and often have an x-ray to assess if there is a fracture. Due to the soft and plastic nature of the bones in young children, injuries can cause their bones to bend, known as a buckle fracture. Bedside ultrasound is a test that emergency practitioners can use to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Ultrasound in this setting is well tolerated, only requiring light touch and gentle manipulation of the forearm and has similar accuracy when compared with x-rays for diagnosing children’s forearm fractures.

This is the first trial of its kind to assess whether an x-ray is unnecessary when there is either a buckle fracture or no fracture seen on a portable ultrasound machine. This is important as they can be treated at the time of review without any further delay, which will avoid these children being exposed to ionising radiation. Children will be randomised to receive either an ultrasound or x-ray for their forearm injury. Both groups will be followed up to see whether there are any differences in their recovery and to determine any complications. We will also determine the time and cost implications of this new approach, which could enable families to go home earlier and could be more cost-effective, with less x-rays being ordered.

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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.

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Fibrinogen Early In Severe Trauma studY II (FEISTY II)

In a severe trauma, major bleeding or haemorrhaging is associated significant morbidity and mortality. Haemorrhage can be compounded by Trauma Induced Coagulopathy. It is postulated that early replacement of low fibrinogen levels may reduce haemorrhage and improve outcomes. Fibrinogen concentrate is an alternative way to replace fibrinogen.

In the FEISTY pilot trial, we demonstrated that a guided fibrinogen replacement strategy utilising either fibrinogen concentrate or cryoprecipitate is feasible. We found that fibrinogen concentrate was significantly faster to administer. The follow-on FEISTY II Trial will evaluate relevant patient-centred endpoints of a guided dose of FC Vs cryoprecipitate in traumatic haemorrhage. This larger study builds on the success of FEISTY to include multiple trauma centres in Australia and overseas.

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Fluid resuscitation in emergency patients with sepsis and hypotension (ARISE Fluids)

The question of fluid volume in resuscitation has been identified as the top priority in sepsis research by emergency physicians in the United Kingdom, Australia and New Zealand. Guidelines and sepsis pathways recommend an initial intravenous (IV) fluid bolus of 30ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this strategy. Both observational data as well as randomised studies suggest there may be harm associated with injudicious use of fluids in sepsis. Since there is equipoise regarding a more liberal or restricted fluid volume resuscitation as first line treatment for sepsis-related hypotension, we conducted the pilot multicentre REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH) trial comparing a restricted fluid protocol with early initiation of vasopressor support against standard guideline care.

The data from REFRESH will inform feasibility of a large, multicentre phase III study. However, further ground work is essential for the optimal design of a Phase III trial that will provide valuable information on feasibility (road test recruitment rate and screening processes) as well as refinement of the protocol (sample size estimation, processes of care, prevalence of the population of interest, real world clinical practice regarding fluid use).

In this ARISE Fluids study, we aim to provide more insight into current practice by conducting a bi-national multi-site prospective observational study of fluid administration in (suspected) sepsis and hypotension in the Emergency Departments of Australia and New Zealand hospitals. Sites have been selected on the basis of having expressed interest in participating in a phase III trial.

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STOPAsthmaQLD

Grass pollen is the major outdoor allergen globally and grass pollen exposure has an important measurable and manageable impact on the medical burden of asthma. We propose investigating the role of allergy status on triggers for asthma in patients visiting hospital emergency departments in two regions of south east Queensland over a two year period, coinciding with NHMRC and ARC funded environmental health research led by collaborator CI Davies.

Data on weather and pollen exposure will be integrated with direct assessment of specific IgE profiles and respiratory viral triggers of asthma. Patients, including children over 12 years, presenting with primary diagnosis of asthma to a major urban hospital in a subtropical region and rural hospitals in the temperate regions of the Darling Downs will be recruited with informed consent.

Outcomes of this study are expected to inform need for utilising local current pollen exposure information to manage emergency department demand surges and underpin better management of pollen allergies outside of hospital by allergy physician and general practice.

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International mass gathering impact on Gold Coast Hospitals’ emergency departments

The objective of this study is to describe the impact of the 2018 Commonwealth Games held in Queensland, Australia on the emergency departments in the Gold Coast region. This research has two key aims, which align with two discrete but related studies:

Study 1 Aim: To describe and determine whether changes in patient, health service, and economic outcomes occur before, during and after the Commonwealth Games.
Study 2 Aim: To explore healthcare staff experience of planning, preparedness and lessons learnt from the Commonwealth Games.

Findings from this study will provide an evidence base regarding the impact of a large sporting mass gathering on public and private emergency departments, forming an invaluable resource for future Commonwealth Games planners, as well as response planning for other mass gatherings, sporting or otherwise.

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Evaluation of the Geriatric Emergency Department Intervention (GEDI) implementation

Advances in health have led to populations living longer with more chronic disease and frailty. Frail older people presenting to emergency departments (EDs) have special needs that are often overlooked. In response, the innovative Geriatric Emergency Department Intervention (GEDI) was developed by clinicians at Nambour Hospital, Queensland.

GEDI is a unique nurse-led, physician-championed model of service delivery which facilitates advanced assessment tailored to the individual, nurse-initiated specialist referral, fast-tracking of care through the ED and appropriate safe discharge planning for persons aged 70 and over, including those from residential aged care facilities. A successful trial in one ED was awarded the 2016 Queensland Premier’s Award for Excellence. The evaluative research we conducted found that when older adults presented to ED during the times the GEDI team was working they were more likely to be discharged, if admitted they spent, on average, 24 hours less in hospital and the costs of their care were reduced by up to 30%.

The staffing for a trial of GEDI in two further Queensland EDs will be funded by the Queensland Health Improvement Unit. This EMF-funded evaluation project employs the principles of implementation science to evaluate the introduction of GEDI into these EDs to determine whether the knowledge learned from the trial can be translated to other sites and to determine the best strategies for future implementations of GEDI across Queensland and interstate. If implementation is found to be successful future roll out of GEDI will improve patient outcomes and reduce costs in Queensland and across the country.

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Assessing Children’s Head Injury: Variation in CT scan use (APHIRST-Gap)

This study will collect information from the records of 3000 children from 30 hospitals presenting after a head injury in 2016 and will interview staff to look at different factors influencing the care provided. APHIRST-Gap is expected to provided crucial information on scan rates and inform strategies, including national guideline development to standardise and improve the care of children with head injury across Australia and New Zealand.

Head injury is a common reason children present to Emergency Departments in Australia and New Zealand. While most are minor the important issue for emergency clinicians is to determine whether a particular child is at risk of a serious head injury such as a bleed on the brain. A computerised tomography(CT) scan is the investigation of choice to look for these injuries. Its use is not without risks though, including those of sedation, and radiation induced cancer.

Several “rules” have been designed to guide doctors in the decision between risk of injury and risk of scan. The recently published Australasian APHIRST study examined three of these rules in our context. It found that all three rules performed well, clinicians made good judgements on who to scan, and the overall rate of CT scan use was low(10%). APHIRST was limited to 10 large metropolitan, and predominately children specific hospitals. Most children in Australia are not seen in these hospitals. Further research is required to determine whether there is a large variation in scan use between different hospitals and how best to apply these findings to a broader range of hospitals.

This trial is being run by the PREDICT network and the Principal Investigator is A/Prof Franz Babl.

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Preventing chronic pain after whiplash injury

After whiplash injury, half of patients never fully recover. The human and economic cost is enormous, and current mainstay treatments are ineffective. Most recovery, if it occurs, takes place in the first two to three months. This early time period offers a ‘window of opportunity’ to pro-actively intervene and prevent the chronic pain. The Emergency Department (ED) is ideally placed to provide very early intervention. We have shown that upregulation of pain in the central nervous system occurs soon after whiplash injury and predicts poor recovery. We aim to target these central nervous system processes with pregabalin in conjunction with evidence based physiotherapy advice/exercise in the ED. The results have potential to fundamentally change the treatment of acute whiplash injury.

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Improving jellyfish sting treatment

EMF funding is improving emergency care for the elderly

Trauma: better treatment for severe bleeding

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