Drug Overdose with Reduced Consciousness: Patient and Staff Perspectives. A Mixed Methods Study

Drug overdoses are a common reasons for Emergency Department (ED) presentation. Overdoses may be intentional (self-harm), recreational, or accidental and often lead to reduced consciousness. Patients often need extra attention to their airway and breathing. They can be managed conservatively with oxygen, observation and regular nursing assessments. However, some require intubation: insertion of a breathing tube under sedation.

There is practice variation between doctors as to which overdose patients require intubation. Thus, the patient’s perspective becomes paramount, as their experiences influence management. We also need to understand clinician thought processes to ensure that care is standardised where possible.

This qualitative research is innovative in being the first to assess the patient experience around airway and breathing management for drug overdose with reduced consciousness, and assessing clinician attitudes. This will be done through patient and clinician questionnaires and semi-structured interviews.

AIM 1: To investigate the patient experience for an ED presentation with drug overdose and reduced conscious level. To understand the impact that interventions such as intubation can have on patients.

AIM 2: Explore clinician attitudes to the management of airway and breathing for these patients. Barriers to a conservative approach, triggers for intubation, departmental pressures and existing frameworks of care.

The research will provide insight into how this vulnerable patient population experience their care, and how clinicians reach critical decisions. It will inform development of a pathway of care to be used in the ED assessment of airway and breathing management for patients with drug overdose and reduced consciousness.

Improved Respiratory Support in Remote Settings for Children: A Paediatric Acute Respiratory Intervention Study (PARIS), PARIS on Country

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.

Comparison of pressure points versus tourniquet application for first aid control of arterial bleeding in beachgoers: a randomised controlled cross over trial

Arterial injuries to the lower limb, such as from a shark bite or deep laceration, can lead to catastrophic bleeding and death. Current first aid measures involve trained personnel applying an arterial tourniquet. However, even a short delay in haemorrhage management can lead to significant blood loss, brain injury or death. There is growing evidence that the simple technique of applying pressure to the groin can effectively occlude blood flow through the femoral artery, buying time for medically trained personnel to attend. One potential application of this technique is the treatment of shark attack victims with lower limb injuries, where beachgoers without medical training who have only seen a sign on a beach could apply life saving first aid. There is plethora of other potential applications outside marine encounters where this technique could be critical in reducing blood loss such as limb trauma from motor vehicle accidents, workplace injuries or military settings. The benefits are the simplicity of the technique which may be both easily and effectively performed by bystanders with no medical training. Using a non-clinical environment, we intend on performing a randomised trial to evaluate the efficacy of non-medically trained beachgoers performing pressure points compared with the application of a commercial arterial tourniquet after reading an infographic. We will measure the reduction in arterial blood flow using doppler ultrasound. The project aims to generate translatable research with the goal of influencing local, national, and international first aid guidelines.

Biomarkers for rapid diagnosis of paediatric sepsis

Sepsis is a time critical medical emergency that arises when the body starts to attack its own tissues and organs in response to an infection. Sepsis can result in organ dysfunction, multi-organ failure and death if not treated promptly, and is a leading cause of death in children worldwide. Sepsis often presents with non-specific signs common to many mild infections, making it difficult to detect early and accurately, leading to delaying appropriate treatments and resulting in severe sepsis. Therefore, it is vital to identify new approaches to rapidly identify the type of infection and predict the severity of the condition in patients presenting with suspected sepsis to enable early initiation of appropriate treatments.

Recent advances in genomic technologies have shown that gene expression based infection testing has the potential to provide much faster and more precise results. This results in more accurate diagnosis of infections and appropriate timely treatments. Our study will utilise an advanced gene expression analysis approach named single-cell RNA sequencing to identify new approaches for sepsis diagnosis. This could lead to development of a rapid testing method which can predict the type of infection (bacterial or viral) and the severity of the condition with a quick turnaround time for results, improving patient outcomes, reducing unnecessary antibiotic use, and shortening hospital length of stay.

A randomised controlled trial of plasmalyte versus normal saline as resuscitation and maintenance fluid therapy for patients presenting with diabetic ketoacidosis (BEST-DKA) BalancEd fluids vs Saline Trial in Diabetic KetoAcidosis

We propose to conduct a multi-centre blinded cluster cross over randomised clinical trial (RCT) of plasmalyte (PL), a balanced salt solution versus normal saline (NS) in patients admitted to an Intensive Care Unit (ICU) with diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. DKA results in elevated acid levels in the blood leading to severe dehydration and electrolyte imbalance.

ICU admission rates for patients with DKA in Australia has risen annually. In 2019 and 2020, there were 2751 and 2812 admissions to ICUs respectively. Almost all patients present through the Emergency Departments and in regional hospitals, they are often admitted to the ICU.

NS is often used as the first line fluid for dehydration, but NS use frequently results in persistent acidosis. We have shown in a pilot trial, conducted in 7 Queensland regional Emergency departments and ICUs, that the use of a balanced salt solution such as PL resulted in a more rapid resolution of acidosis with trends to shorter length of ICU and hospital stay as compared to NS. The efficacy of PL in DKA needs evaluation in a large clinical trial.

We plan to study 480 patients from Australia of whom a third will be expected to be enrolled in Queensland. Patients will be randomised to receive either NS or PL and the primary end point is hospital length of stay. This proposed trial will answer a fundamental clinical question and will inform policy and practice in Australia and New Zealand and around the world.

National Emergency Department Stress, Coping and Intention to Leave Survey: DESTRESS

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.

Composition, Quality and Delivery of Major Haemorrhage Protocols (MHP) and critical bleeding clinical practice guidelines in hospitals across Queensland Health

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.

An Occupational Therapy Pathway for Mild Traumatic Brain Injury ED presentations across the lifespan

Mild Traumatic Brain Injury (mTBI) is a significant burden to Queensland emergency departments (EDs) in adults and children. Between 2019-2020, there were 958 presentations of isolated mTBI to Gold Coast Hospital Health Service EDs, of these 73% presented outside of usual business hours and 26% re-presented within 3 weeks of their initial presentation, complaining of persistent symptoms.

The Occupational Therapy (OT) Outpatient Service identified an innovative medical substitution practice model involving specialist follow up for patients to facilitate recovery, link into appropriate specialty referrals where indicated, and prevent ED representations. It is anticipated that the implementation of the OT pathway will lead to enhanced clinical outcomes (including quality of life and return to work/school), decreased ED length of stay for monitoring of symptoms and decreased ED readmission.

The primary aim of this research is to evaluate the impact of this Occupational Therapy (OT) intervention pathway for patients presenting to ED with a mTBI outside of business hours compared to pre-implementation care. The study also aims to evaluate the feasibility of implementing the pathway in relation to adherence, patient and staff acceptability and satisfaction.

Buddy-up: research reach, adoption, and implementation

The “Buddy Study” funded in the EMF grant round 25 showed a common type of hand fracture can be treated without a plaster – a finding that if applied broadly could result in patients returning to work faster and significant healthcare savings. However, since the study was published in 2019 it is unclear to what degree there has been a change in how clinicians actually treat this fracture.

This follow up study will explore factors related to research reach, adoption, and implementation at two hospitals in Queensland to 1) inform a strategy to implement knowledge related to hand fractures and to 2) explore how participation in research affects implementation.

Cellulitis in the emergency department

Cellulitis is an infection of the skin and underlying soft tissues and leads to redness, pain and sometimes fever. Once diagnosed, the emergency doctor needs to decide an appropriate type and dose of antibiotic and decide to give it orally (tables/capsules) or intravenously (via a drip).

Despite this being a common diagnosis in the ED, guidelines are not based on high-quality evidence making it difficult for doctors to make evidence-based choices and there is wide variation in how cellulitis is treated. This prospective cohort management study aims to describe the ED management and clinical outcomes of adult patients with cellulitis.