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.

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.

Single centre validation of the Canadian Syncope Risk Score

Syncope is a transient loss of consciousness with full recovery, and is a common presenting problem to the emergency department (ED). Most patients presenting with syncope have a benign cause, but others may be at risk for serious adverse outcomes. The problem is that there is currently no validated tool for knowing which patients are at risk and which can be safely discharged. Several clinical prediction rules have been developed over the years, however the sensitivity and specificity of these rules vary. This has led to an over-admission of patients who could otherwise be safely discharged, based on clinician discretion. These patients are subjected to multiple tests, including cardiac telemetry for monitoring which not only has low yield, but also results in significant costs to the healthcare system.

The Canadian Syncope Risk Score (CSRS) is the latest decision tool developed in an attempt to predict serious outcomes in patients presenting with syncope to the ED, but it has not yet been validated. This study aims to validate the CSRS at a single site, providing the first step in guiding clinicians to make better risk assessments and disposition decisions for patients with syncope. Furthermore, an innovative economic model will assess the impact of this decision tool on the healthcare system. This project is the first, critical phase toward better informed decision-making by clinicians for patients with syncope. Ultimately, this tool will enable a change to clinical practice that will result in improved patient outcomes and enhanced, targeted healthcare delivery.

Pictured to the right: Members of the Syncope research team from left to right: Ms Helena Cooney, Dr Alan Yan, Dr Jason Chan, Dr Emma Ballard (QIMR), Dr Jonathan Hunter and Dr David Brain (AusHSI)