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).READ MORE
Pulmonary embolism (PE) refers to blood clots in the lung. They can cause sudden death, collapse, chest pain, shortness of breath yet sometimes they cause no symptoms at all and are discovered incidentally. As they can be severe, they have become regarded as a not-to-miss diagnosis. As they can present with a variety of symptoms, emergency clinicians consider the possibility of PE on a frequent basis.
When considering whether a patient has a PE, the clinician may confirm or exclude the diagnosis directly with definitive chest scans. However, these scans are time consuming, costly and have other side effects including exposure to radiation and to chemical contrast agents. When patients are assessed to be less likely of having a PE, it is often possible to safely exclude PE by applying a set of clinical decision rules or doing a blood test called a D-dimer. If the level of D-dimer is below a certain threshold, then PE can be excluded.
We aim to safely exclude PE without scans where possible. Evidence has been building that employing a higher D-dimer threshold is reasonable, yet uptake of this newer approach is limited. We hope to demonstrate that a higher threshold can work in Australia without compromising safety. This will be a large study that answers this question and if shown to be the case, then patient care can be improved while using less resources in busy emergency departments.READ MORE
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.READ MORE
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.READ MORE
The emergency department (ED) is a stressful workplace. The stressful work environment has resulted in high levels of psychological distress with some using mal-adaptive coping strategies. High staff turnover is evident in some EDs. To guide the development of strategies for clinicians, health services, policy makers, and emergency colleges, this research will provide a national picture regarding the impact of stressors on health and performance.
The well-being of staff is a priority for Emergency Medicine and Nursing colleges in Australia. Research reports have emerged highlighting concerns with post-traumatic stress, sleeping problems, cardiovascular disease and increasing rates of suicide among healthcare staff. This research is critical to address such concerning trends.
This multi-disciplinary research collaborative is new, consisting of expert clinical and academic leaders from emergency nursing and medicine coming together to provide a robust approach to understand, from a national perspective, where opportunities exist to enhance clinician wellbeing and the effectiveness of local, state, or national practice or policy measures, through the longitudinal design.
This research will provide a comprehensive Queensland, as well as a national understanding of the impact of stressors on the health and performance of ED staff. When applied longitudinally, the questionnaire can be used to evaluate the outcomes of interventions and policies that seek to promote positive coping strategies for ED clinicians.READ MORE
Major bleeding is a leading cause of death in trauma patients. Blood product replacement is a key component of damage control resuscitation aimed at limiting coagulopathy until definitive control of bleeding is achieved. Although Major Haemorrhage Protocols (MHP) are now widely used in the initial resuscitation of traumatically injured patients (1), protocols can vary based upon individual institutions' capabilities and processes.
Within Australia, the National Blood Authority 2011 Patient Blood Management Guideline Module 1: Critical Care/ Massive Transfusion (2) recommended institutions develop standardized MHP to guide clinicians regarding the dose, timing and ratio of blood component therapy for bleeding trauma patients. However, it is currently unknown if these guidelines are implemented and if so, what institutional variations occur. While the guidelines provide a robust review of the evidence base for MHP, there is little information about the logistics of MHP implementation.
Our project aims are firstly to compare the available trauma bleeding protocols across Queensland for content and quality. Secondly, we wish to understand the institution's capabilities of delivering an MHP in terms of the structure and processes available to them. Thirdly we want to explore the experiences of clinicians involved in delivering an MHP for trauma patients in both tertiary, rural and remote hospitals within Queensland.
Expected benefits are to identify potential disparity of care for trauma patients in terms of MHP content, availability of resources and access to blood products. This information can help guide improvements in education, blood products availability and cost-effective care across Queensland.READ MORE
Injuries confer a substantial burden on ambulance services. Ensuring optimal pain management for injured patients in the out-of-hospital setting is imperative, and even more so for those living in rural/remote areas, where transportation times to hospital may be longer. There is evidence for the potential for improvement in pain relief in the out-of-hospital setting. Inadequate pain relief has lasting negative physiological and psychological implications and decreases overall quality of life. While there is little research focusing specifically on management of pain incurred through trauma in regional/rural/remote environments, there are several reasons that pain management may be suboptimal in rural/remote trauma patients, compared with patients in major cities. This research aims to describe pre-hospital pain management for trauma patients in regional/rural/remote Queensland and to compare this with pain management provided in major cities. Secondarily, we aim to identify and describe perceived barriers/facilitators of optimal pain management among paramedics in rural/remote areas, compared with those in major cities. This study will incorporate three components:
1) Data from the Queensland Ambulance Service(QAS) will be used to describe current pain management practices for those sustaining injury;
2) Queensland paramedics will be surveyed to gather information on pain management and whether/how this differs across major cities/rural/remote settings;
3) Interviews with rural and remote paramedics will be conducted about their experiences and perceptions in managing pain in trauma patients
Ultimately our goal is to identify explicit opportunities to mitigate barriers and enhance enablers to optimise pain management for those experiencing trauma in rural/ remote settings.READ MORE
The current assessment for emergency department (ED) patients with chest pain focuses on the short-term risk of heart attack, to differentiate low risk patients from those at high risk and requiring further treatment. This has been shown to be safe and effective for non-Indigenous patients, however, deaths from heart attack in Indigenous Australians occur, on average, at younger ages than non-Indigenous Australians.
Due to the high lifetime prevalence of heart attack in Indigenous Australians, ED investigations that focus on both short- and long-term risks may improve outcomes. Understanding rates of, and the types of patients who have coronary artery disease in this cohort would provide additional information about who requires further testing.
The aim of this study is to measure the rate of coronary artery disease in Aboriginal and Torres Strait Islander people who present to the ED with chest pain. By identifying how many Indigenous patients with chest pain in the ED have coronary artery disease, researchers aim to establish foundational knowledge to develop a heart attack risk assessment that is specific to Indigenous patients.READ MORE
Head injury results in a high degree of ongoing disability. Risk of Traumatic Brain Injury (TBI) is higher in the 15-19 and 75+ age groups with older Australians having a three times greater incidence compared to the general population (Pozzato, Tate, Rosenkoetter, & Cameron, 2019).
There are two distinct aspects to a severe head injury - the primary injury and the secondary injury that occurs as a result of deranged brain functioning. Treatments are targeted at minimising the damage occurring during the secondary stage and to protect damaged brain tissue by optimising blood flow, oxygen delivery and reducing the metabolic needs of the brain.
There is currently no way to closely monitor the 'real-time' physiologic changes beyond clinical symptoms such as changes in pupil size, heart rate, blood pressure etc. and, in the case of rising pressure in the brain, treatment is initiated on clinical suspicion alone. Electroencephalograms (brain wave monitors) have shown promise in their ability to detect brain oxygen starvation, seizure presence and increased pressure in the brain.
This pilot of Quantitative EEG (qEEG) will measure these changes during prehospital care of TBI, the results of this research would be used to guide larger studies into the use of this technology.READ MORE
Patient flow in emergency departments (ED) is impeded when the number of patients exceed physical and/or staffing capacity. This is often referred to as crowding, and is common problem for EDs across the country, adversely impacting patients, staff and the healthcare system.
While many strategies have been reported and trialled to mitigate the consequences of crowding and address its causes, there is no one solution that fits all EDs.
Researchers propose to develop and test a computer model to mimic the ED, simulating patient flow to provide forecasts that can inform policy makers. This is especially important in periods of anticipated high demand for emergency services such as in the current COVID-19 pandemic.
Emergency doctors will team-up with academic researchers to model patient flow in the emergency department to consider operational changes and provide knowledge to guide decision-making for improvement strategies that will lead to faster, more effective patient care, better outcomes and more effective, economical choices.
This innovative collaboration between doctors and university researchers aims to solve real-life system-level problems affecting patient care. The research will generate practical outcomes that improve clinical practice at a system level so that we can better care for our patients.READ MORE