Application of the HEART score to the “intermediate risk” patient group may help identify those who are at lowest risk of cardiac events, therefore, not benefit from further testing

Chest pain is a very common presentation to emergency departments and has wide variety of causes including life threatening conditions such as a heart attack and benign causes such as a muscular strain. Often the biggest challenge is to appropriately identify an individual's risk of suffering a heart attack, while ensuring that the harms associated with potential over-investigation are minimised. This requires an efficient and systematic risk stratification process, and has been the focus of a lot of research. Currently, in Queensland the approach to this challenge is to use a blood test called troponin, along with ECG, to determine an individuals level of risk. This allows a large number of patients to be discharged quickly, but also results in many people falling into an intermediate risk group. The Sunshine Coast Health Service has recently started using the internationally validated HEART Score to further risk stratify this intermediate risk group, to identify those who do not require further testing and those that are at a level of risk that do require further investigation. These patients are then seen in a rapid access chest pain clinic. This study assesses the safety of this pathway which is unique in the way it combines the two approaches, and in that it assessing patients who are intermediate risk by HEART Score in an outpatient setting when normally they would be admitted to hospital.

Deadly Steps in the Emergency Department with Aboriginal and Torres Strait Islander Consumers: an evaluation of a co-design cultural safety improvement and awareness tool

Aboriginal and Torres Strait Islander (A&TSI) people presenting emergency departments are more likely to experience difficulty in communicating with healthcare providers, feel isolated, and experience shame and distress. These feelings lead to them leaving before they have been seen, or leaving before their treatment is completed, and they experience poorer health outcomes. Cultural safety is the ability of an organisation to meet the cultural needs of a group of people, and improved emergency department cultural safety has been shown to reduce rate of Aboriginal and Torres Strait Islander people leaving without being treated or before their treatment is completed. The 15 Steps Challenge Toolkit was developed in the NHS and is effective in assisting healthcare providers to see a clinical space “through the eyes of consumers”. This project aims to adapt the NHS 15 Steps Challenge toolkit to make it relevant to the experience of Aboriginal and Torres Strait Islander peoples using co-design methodology based on the “Yerin Dilly” model, which outlines values and processes to make research culturally safe. The project will be conducted in three phases to develop, trial and evaluate the Deadly Steps process. It will use both qualitative and quantitative methodologies to evaluate the process. The impacts of this project will be an improved process for evaluating and identifying opportunities to improve cultural safety, new cultural safety educational materials for healthcare providers, and improved experiences for Aboriginal and Torres Strait Islander people attending emergency departments in the Redcliffe, Caboolture, Sunshine Coast University, and Nambour hospitals.

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.