The next phase of studies, titled "Paris on Country," represents a continuation of efforts in Australia and New Zealand to enhance care for infants and children presenting with acute respiratory issues in emergency departments. Through these studies, we have successfully implemented changes in treatment protocols, aimed at alleviating respiratory distress and reducing anxiety for both patients and their parents.
In rural and remote areas of Queensland, approximately 38 percent of the state's total population resides. However, access to healthcare and emergency services in these areas can significantly differ from urban regions. The primary goal of this project is to elevate the standard of care for children experiencing acute respiratory distress in remote and regional settings to match the level of care available in larger cities.
Soon after injury, some individuals develop a condition where their body doesn't clot properly, leading to increased blood transfusions and increased mortality. An important aspect of clotting is a protein called fibrinogen which forms the scaffolding on which clots are formed. Fibrinogen is the first aspect of clotting that is impaired, but it is easily replaced if it is recognised with a specific blood test. Unfortunately this blood test may not be available rapidly in rural hospitals, which may lead to a delay in recognition. A scoring system called the Fibrinogen on Admission for Trauma (FibAT) has been developed in France, but includes criteria/interventions which we don't routinely do in Australia. In this study we will evaluate the FibAT's accuracy in detecting low levels of fibrinogen using data from 3 Queensland trauma centres. We will only use criteria that is available in rural settings.
This study is expected to show that even a modified FibAT is quite good at ruling in low fibrinogen so that it can be replaced early when a patient arrives in a rural hospital.
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 MOREMajor 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 MOREGlobally, road traffic accidents are a leading cause of death in younger adults, particularly as a result of traumatic brain injury (TBI). Patients in rural and remote locations who have suspected TBI may need transfer for definitive investigation and management. Despite established guidelines on the need for CT imaging in minor TBI, we believe low-value transfers of this population group occur, placing an unnecessary burden on the patient, their family, and the healthcare system. This project aims to explore the interhospital transfer of people with mTBI, in an attempt to identify if and how such low-value care can be avoided, with resultant financial and personal cost savings to the individual and the healthcare system.
READ MOREFrom a health perspective, a disaster overwhelms the normal operating capacity of a health service, where an outside health response is required to restore and maintain the normal day-to-day health services and standards of care for the disaster-affected community. The Australian healthcare system is tested annually with disasters of a conventional nature (e.g., floods, cyclones, bushfires), however, the Australian healthcare system has not been recently tested by non-conventional disasters such as Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) disasters. As a result, the ability to determine the healthcare system response is difficult. Further, there is no research specific to the Australian emergency department’s capacity for disaster response in CBRNe events.
This study addresses this gap. We will use a mixed methods approach to undertake two discrete, yet related studies. Study 1 involves undertaking surveys with key emergency disaster personnel from seven Queensland hospitals to describe the capacity of hospital emergency care services ability to respond following a CBRNe disaster. Study 2 includes undertaking focus groups with key clinicians and leaders from the participating sites to identify and explore enablers and barriers within emergency care services to provide CBRNe disaster response. Findings from these studies will provide an evidence base regarding the capacity for several Queensland emergency departments, located in metropolitan, regional and rural settings, to respond to disasters.
READ MOREThe 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.
READ MORELife threatening bacterial infections such as sepsis are a leading cause of childhood mortality. International authorities recognise the urgent need for better recognition, diagnosis, and management of children with sepsis. Children in regional and remote settings are at particular risk for late or inaccurate diagnosis resulting in worse outcomes.
In this study, the researchers are testing the feasibility, performance, time-to-diagnosis, and cost impact of applying the most advanced genomics-based sepsis diagnostic tools. This could lead to better treatment of infections, reduce unnecessary antibiotic use, shorten hospital length of stay, improve patient outcomes, and allow patients and families to be managed closer to home, with the aim to provide the same care for all children around the state. We are recruiting acutely ill children presenting with suspected sepsis to Emergency Departments, including regional and remote centres in Queensland.
READ MORETraumatic injuries in children are a leading cause of death and disability in Australia. In high income countries, 40% of child deaths are because of traumatic injuries. Fibrinogen is one of the key clotting factors that need to be replaced in severe traumatic bleeding.
Currently, fibrinogen is replaced using cryoprecipitate; a blood product obtained from healthy volunteer donors. This is a precious resource that is stored frozen in the blood bank; it can take a long time to administer and place significant strain on blood banks. Fibrinogen concentrate (FC) is an alternative product used to assist in blood clotting. It is a product that is derived from blood plasma but stored in powder form and can be reconstituted at the bedside and given quickly. The study will investigate whether it is quicker to administer FC than cryoprecipitate, which may reduce haemorrhage and improve outcomes.
This study will enrol 30 children from three major paediatric trauma centres in Queensland admitted with severe traumatic bleeding. Time to administration of fibrinogen replacement and the effect of fibrinogen levels will be measured.
READ MOREDomestic and family violence (DFV) against women is the number one cause of hospitalisations in Australian girls and women aged 15-54 years. It is also the number one cause of death and disability in women aged 15 to 44. Although most victims of fatal DFV access health services in the 24 months prior to their deaths, many victims living with DFV go unnoticed in the community. Health care providers are well placed to identify DFV victims and refer them to appropriate services. The ED has been described as a good place to undertake identification of DFV victims in several published research papers. Yet, how to do this remains controversial, and there are no standard protocols in place in our EDs. In this project, we aim to describe the current DFV health practice culture in five Queensland EDs. Knowledge, beliefs, and attitudes, as well as what’s actually happening to detect cases of DFV, will be assessed among our front-line ED social workers, nurses, and doctors. We aim to determine how many presentations to ED are identified and referred to social worker services for DFV. Ultimately, this research will both raise awareness about the potential of the ED to detect DFV, and will help pave the way forward to a well-informed and structured ED DFV screening program for Queensland, with applicability internationally.
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