SAFE STEPS – SAFE and Seamless Transition through Enhanced Proactive Support

The physical health equivalent of a relapse in a mental health patient would be a repeat stroke or heart attack. Episodes may be fatal and the chances of full recovery decreases with each episode. Every effort must be made to detect and prevent emerging crisis in the community. Currently, patients present to Emergency Department (ED) despite being open to community case management, using precious ED resources. There is limited evidence regarding reducing unplanned ED presentations, with some needing psychiatric inpatient care. Princess Alexandra Hospital employed a Transition Coordinator to support the care of people who are deteriorating in the community. The Transition Coordinator has been collating a unique dataset, names of patients who have been flagged as deteriorating and have received support successfully, as well as those who have had unplanned presentations to ED or have needed admission. Our proposed study will analyse this dataset and identify key defining characteristics of planned and unplanned admissions. We will also survey patients, families and staff regarding what helps in a crisis and why they presented to the ED rather than to the community clinic. A clinical audit of the notes will also provide information on what happened in the lead up to an unplanned admission. In-depth interviews with patients and supporting family and staff will provide further insights. The findings will inform service changes. They will be pulled into a replicable package to free up ED resources and inpatients beds through provision of early detection and treatment in the community.

Lamotrigine Poisoning: an Australian TOxicology Monitoring (ATOM) Study

Lamotrigine is an antiepileptic medication used in the management of seizure disorders and bipolar affective disorder but is being increasingly prescribed for many off-label indications including emotionally unstable personality disorder.

In overdose lamotrigine usually causes mild to moderate toxicity, however following large poisonings life-threatening cardiac and neurological effects can occur. There is limited research to guide clinicians both in the assessment and management of lamotrigine poisoning.

This is a study observing people who have taken lamotrigine overdoses and will compare the concentration of lamotrigine in their blood with the clinical effects that occur. We want to be able to know what the lowest dose is that can cause severe toxicity and also if there are treatments that we can give which can help clear lamotrigine from a person’s system more quickly.

Knowing these answers can help us better recognise which patients will have severe toxicity and better manage those patients in an effort to reduce harm and death. It is expected the results of this study will be incorporated into Poison Information Centre and national guidelines of the management of lamotrigine poisoning.

Emergency department waiting time predictions in real-time

Emergency department (ED) waiting times are a significant predictor of the patient experience.

Simple prediction methods, such as rolling average, are used by hospitals in Australia to predict waiting time for patients. Although this approach is inexpensive to implement, the forecasts have limited accuracy and consequently most Australian hospital EDs do not report expected waiting times to the public.

A solution that is capable of sourcing data from ED information systems and feed it into prediction models to generate waiting time forecasts would bring practical benefits for staff and patients. There is also potential to assist clinicians and nurses to estimate demand for care and calibrate workflow.

For patients, the knowledge may reduce anxiety associated with uncertainty about the waiting time and reduce the number of patients who leave before treatment.

This project aims to use advanced statistical models and machine-learning algorithms to capture dynamic fluctuations in waiting time, to implement and validate the prediction performance of these models. The project will also build ED research capacity by educating staff on forecast modelling and data management techniques.

Reaction of Emergency Services uPON Disasters in Queensland

From 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.

Dermatology in the Emergency Department

Patients presenting to the Princess Alexandra Hospital Emergency Department with dermatological conditions present a significant demand on resources. It is estimated that in many Emergency Departments (ED) at least one in 25 patients present with a skin condition. Many dermatological presentations may be better managed in an alternative environment either because they are non-urgent or require more specialised and expert care. This project aims to better understand the presentation of skin conditions to a large adult Queensland ED. The research will describe the current diagnosis and management of this cohort to the ED, assess the resource implications and understand the rationale for the patients attending ED instead of a General Practice clinic. The data will provide the information for determining the need for increased GP support such a expansion of tele-dermatology services or for the creation of a local or district acute dermatology clinic.

Randomised controlled trial of two antidote regimens for paracetamol overdose

Paracetamol is the commonest medications taken in overdose and is the leading cause of acute liver failure in the developed world. The antidote, acetylcysteine, which replenishes liver glutathione was developed in the 1970’s. However the regimen (20 hours duration) was never subjected to either a randomised controlled trial or any dose ranging studies. The regimen gives a large loading dose and the remainder of the infusion (20 hours) is given to mirror the time taken for paracetamol to be cleared by the liver. This time is only an average and depends on the degree of liver damage. For normal livers it is much shorter (12 hours).

The aim of the study is to compare acetylcysteine given over 20 hours compared to 12 hours for patients presenting early with paracetamol overdose to see if it provides the same protection against liver damage. The research design will be a multicentre non inferiority per protocol unblinded randomised controlled trial of a 20 hour versus a 12 hour regimen of acetylcysteine in paracetamol overdose. The study will be undertaken at the Princes Alexandra, Calvary Mater Newcastle and Prince of Wales hospitals. Eligible patients will be paracetamol overdoses less than 30g presenting within 8 hours of ingestion.

Noel Stevenson Research Scholarship: Dr Colin Page

Dr Colin Page was awarded the Noel Stevenson Fellowship (in honour of eminent Queensland emergency medicine physician, Dr Noel Stevenson) to undertake a Doctorate of Philosophy (PHD). Dr Page is studying the antidotes and treatments that are commonly used by medical staff when looking after patients who are affected by drug toxicity. The PhD will be based at Princess Alexandra Hospital within the clinical toxicology unit with extension to other toxicology units/hospitals within Australia. It will be undertaken through the University of Newcastle (NSW) under the supervision of A/Prof Geoff Isbister and Prof Nicholas Buckley, who are both leaders in clinical toxicology research publications.

Dr Page has developed a clinical toxicology service at Princess Alexandra Hospital and Queensland through a locally run clinical toxicology unit and is the honorary medical director of the Queensland Poisons Information Centre. Clinical toxicology is the speciality that manages patients who are affected by drug toxicity either accidentally or in overdose. The project will primarily research antidotes and other treatments that are used in the management of toxicology patients. This will allow the introduction of safer treatments, new treatments and progressing the scientific basis behind treatments used in clinical toxicology.

Capacity Building Grant: Princess Alexandra Hospital

The Princess Alexandra Hospital (PAH) Emergency Department is a designated Level 6 Trauma Centre. In 2012, in excess of 50,000 patients presented to the PAH ED, of which more than 35 per cent were admitted.
Clinical expertise within the PAH ED is wide, with specific disease emphasis in toxicology, chronic disease, multi-system disease associated with the elderly population, cardiovascular disease, sepsis and septic shock, infectious diseases and critical care.
The PAH ED is a tertiary referral hospital for trainees of the Australasian College for Emergency Medicine and excels in service delivery and education; areas in which it has a national reputation for excellence.
The outcome from Phase 1 of the QEMRF funded three-year plan to increase research capacity within the PAH ED was successful with all key performance indicators being exceeded.
Phase 2 will build on the platform created in Phase 1 focusing on research promoting prevention or control of diseases.
The vision for research within the PAH ED is that the ED will be regarded as a leader in emergency medicine research attracting clinical and research staff and producing outcomes which will change clinical practice and improve the health and well-being of patients.

Evaluation of therapeutic subclavian atrial compression

Two-thirds of people who sustain trauma to the upper limb proximal artery die from traumatic blood loss before reaching hospital. Timely stabilization of the injury, control of bleeding, and rapid transportation to an emergency department could dramatically improve the rate of survival. We know from research that these measures dramatically approval the rate of survival for traumatic injuries of other parts of the body. In this study, we will test the safety and efficacy of a particular procedure that we predict will improve the management of these injuries in the pre-hospital setting. We predict that the use of this procedure by paramedics on patients while in transit can improve patient outcomes. The study will test the safety and efficacy of a technique we refer to as therapeutic subclavian artery compression (TSAC). We argue that this relatively simple procedure may successfully control arterial bleeding in the proximal part of the upper limb, and prevent death from traumatic blood loss.

Blind Prescribing and the prescribing preparedness of doctors in Emergency Departments.

“Blind Prescribing” describes the situation where a medical practitioner prescribes a medication they know little about.
Theoretically, ‘blind prescribing’ could lead to higher rates of medication error and unsafe medical practice. The project aims to determine if Blind Prescribing occurs in emergency medicine, to identify the prevalence of the practice, and propose situational and contextual factors pertinent to Emergency medicine that are thought to enable this practice.