Does a Vascular Access Specialist Model in the Emergency Department (VAS-ED) improve peripheral intravenous catheter outcomes? A Randomised Controlled Trial

More than 6 million peripheral intravenous catheters (PIVCs) are inserted in patients' veins in Australian emergency departments (EDs) annually. These devices can be challenging to insert, and over half will fail before the treatment is finished. Although ED clinicians regularly insert PIVCs, most inserters are junior medical or nursing staff who often default to short PIVCs because that is what they were trained to insert. These “generalist” inserters often don’t have the skills or knowledge to select alternate vascular access devices appropriate to the patient's needs. In contrast, Vascular Access Specialists (VAS) are experts with advanced assessment and expertise in inserting and managing vascular access devices, a model that has proven successful in inpatient wards, but hasn’t yet been tested in the ED setting.

In this study, we will compare the effectiveness and cost of using VAS specialists versus generalist inserters for peripheral IV device selection and insertion. In total, 320 ED patients will be recruited and randomly allocated to receive either a VAS or generalist inserter (standard care). We will compare outcomes including first-time insertion success, device failure rates, complications, patient satisfaction, and cost between the two groups. Additionally, we will interview clinicians to better understand the barriers and facilitators to implementing and using a VAS model.

We expect that patients who have a peripheral IV device inserted by a VAS will have higher first-time insertion success, and be more satisfied with their care than patients allocated to the generalist group.

Can interactive online learning using enhanced technology adequately teach trauma-based procedural skills to emergency nursing clinicians?

Injury and trauma are common presentations to Queensland Emergency Departments. Clinicians caring for trauma victims must maintain competency with trauma procedures and interventions to apply them in a time-critical context, accurately, and therefore achieve the best outcome for individual patients. Engagement with traditional educational approaches, such as face-to-face training, is challenged by workload, shift patterns, clinician location and lack of opportunity to attend dedicated training events. A previous learning needs analysis of trauma education programs has highlighted that the greatest challenges are often faced by clinicians in rural and remote locations. One solution is to include the use of online learning platforms, to connect and assess clinician knowledge, with positive feedback regarding the engagement and experience for the learner. This study aims to use high-fidelity interactive online education, using a range of technologies including 360 videos with user interaction capabilities to design and develop a scalable model for future-proofing trauma education across Queensland. The research will test the effectiveness of (1) the approach to design and development in terms of scalability and (2) the online resources and assessment procedures in terms of the impact on knowledge and skill development.

Validation of a Modified Fibrinogen on Admission with Trauma (FibAT) Score in the Australian Setting

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.

Treatment for nausea and vomiting: A multi-arm double blind, placebo-controlled trial comparing the efficacy of droperidol, metoclopramide, and ondansetron for patients in the prehospital setting.

Nausea and vomiting are common reasons for people to call an ambulance. In Queensland, paramedics can provide a medication called Ondansetron to reduce the severity of nausea and vomiting. Alternative medicines, such as metoclopramide and droperidol, are also used in the emergency department or by ambulance services in other states. Despite the widespread use of medications for nausea and vomiting, little is known about their effectiveness in the prehospital setting. The limited evidence that exists comes from small studies in the emergency department setting, and indicates that medications may be no more effective than placebo for reducing nausea and vomiting. In this study, we aim to determine the effectiveness of medicines for nausea and vomiting in the prehospital environment. We will randomly assign patients who have nausea and/or vomiting to receive either ondansetron, metoclopramide, droperidol or a placebo as a prehospital treatment. Patients will rate the severity of their symptoms before and after receiving the medication, and we will compare these symptoms between groups to identify the most effective medicines. The study will help to optimise the treatment provided to the large number of patients who call an ambulance for nausea or vomiting.

Relief of chest pain in the Emergency Department (RELIEF)

Many patients who present to the Emergency Department with painful conditions have extensive delays to receive pain relief. This may result in unnecessary discomfort for patients and can also mean that patients have an extended length of stay. This study focusses on improving the pain relief given to patients who present to the Emergency Department with chest pain. The study has multiple aims. The first is to identify how long patients presenting to emergency department with chest pain wait to receive adequate pain relief. The second is to document how delays to pain relief impact on the patient and on the healthcare system (in terms of greater hospital admissions, longer length of stay and the types of cardiac testing that can be performed). The third aim is to see whether a novel education campaign highlighting the importance of providing pain relief as soon as possible after the patient presents to the Emergency Department can reduce the length of time before a patient is provided pain relief. This campaign will particularly focus on the nursing staff and will empower them to advocate for rapid pain relief. It is anticipated that this campaign will reduce the time taken to provide pain relief to patients. It is also hoped to reduce hospital length of stay and hospital admissions. This study is important for improving patient comfort and improving patient and health service outcomes.

Trials in Emergency for Advancing Management of Sepsis: TEAM SEPSIS

Severe infection (sepsis) takes the lives of over 2000 Queenslanders every year. Despite this toll and intense global research, few advances and innovations have improved sepsis management for decades. The TEAM SEPSIS project comprises three studies to improve the diagnosis and treatment of patients with sepsis in the Emergency Department (ED).

ICARUS-MD is a randomised controlled trial assigning patients to receive or not receive albumin in addition to standard sepsis care. Albumin will be commenced in the early phase of emergency treatment and continued each day for ten days. Albumin has the potential to improve outcomes if started early in the ED - ICARUS-MD may provide much needed evidence.

ARTEMIS is an observational study in a subset of ICARUS-MD patients with blood samples taken across several time points to determine the effect of albumin on the function of the critical lining of small blood vessels – the endothelial glycocalyx.

BETTER aims to improve the investigation of septic patients in ED by validating a novel test for bacteraemia in patients at highest risk for this condition. The study will use patients from the ICARUS-MD cohort as well as other emergency patients with low white cell count and suspected infection. Earlier diagnosis of bacteraemia enables directed therapy, improves patient outcomes, and conserves our most powerful antibiotics for patients who need them.

This programme of collaborative research involving ED and infectious diseases clinicians promises to advance knowledge of the best approach to diagnosis and treatment for emergency patients at highest risk from sepsis.

Endovascular Clot Retrieval Pathway for Acute Ischaemic Stroke: Outcomes After-Hours in an Australian Metropolitan ED

Stroke is a leading cause of death and one of the most common causes of disability in Australia. For ischaemic strokes occurring secondary to a large vessel occlusion (LVO), mechanical thrombectomy is an effective intervention, with the outcome largely dependent on time to thrombectomy.

This study will analyse the assessment, management, and clinical outcomes of patients presenting to the ED with acute stroke, with a particular focus of those undergoing mechanical thrombectomy. Researchers aim to determine variability of workflow and decision-making processes that may occur after-hours. Based on current literature, variability may have a corresponding deleterious effect on patient outcomes.

By reviewing workflow processes and identifying relevant time barriers in a Queensland Comprehensive Stroke Centre, researchers aim to inform the future design and implementation of “Code Stroke” clinical pathways in Queensland.

Subculture: Investigating the frequency and outcomes of subsequent blood cultures

Blood cultures are tests performed to identify whether patients have pathogens in their blood, such as bacteria and fungi. Emergency clinicians frequently order blood cultures to prescribe appropriate antibiotics for patients. Blood cultures are particularly important to rapidly identify and treat severe infection.

For test accuracy, the best time to collect blood cultures is before a patient has received an antibiotic. However, patients with severe infections may have multiple sets of blood cultures taken over several days. It is unknown whether taking multiple blood cultures improves patient care.

This study will investigate how many patients have repeat blood cultures and whether subsequent blood cultures yield the same result. If found to be redundant, it may be possible to avoid unnecessary blood tests, improve patient comfort, decrease costs to the health service, and reduce practitioner workloads.

From Big Data to the Bedside: answering big questions in emergency department pain care using artificial intelligence and patient-reported outcomes

One of the main reasons that acute pain is not well treated in the emergency department (ED) setting is that pain is difficult to measure. While patient-reported outcome measures (PROMS) are commonly used to help guide treatment of pain in settings such as chronic pain care, cancer care and migraine care, there are no similar tools available for patients with acute pain in the ED. Further hampering efforts to provide better ED pain care is poor overall understanding of the numbers and types of patients that experience pain.

Since it is a symptom rather than a diagnosis, information about pain is not systematically collected and is often obscured within free-text clinical notes. The lack of readily-available data makes it difficult to determine who exactly has experienced pain, and to design research studies to evaluate new and existing treatments.

Researchers aim to validate a PROM for pain care in the ED by administering to 400 patients who present with pain to one of two large hospital EDs. The aim is to find out the incidence and characteristics of patients who present with pain to the Royal Brisbane and Women’s Hospital ED, by using novel machine- and deep-learning techniques to process free-text information from clinical notes. This study will provide new knowledge and techniques that are essential for clinician-researchers to design and conduct studies that will ultimately improve pain care in the ED.

How long can a clinician wearing personal protective equipment (PPE) safely work in a high-risk isolation area during one continuous shift?

Patients with COVID-19 symptoms are isolated and treated in a high-risk zone (HRZ) within the emergency department. Entry is restricted to essential staff wearing personal protective equipment (PPE).

HRZ doctors and nurses typically work 5-10 hour shifts, during which meal and toilet breaks must be taken outside the HRZ. Doffing (taking off PPE) and repeated donning (putting on PPE) are discouraged to conserve PPE. Doctors and nurses often work continuously with minimum breaks because they must doff before exiting and don before entering the HRZ. PPE traps body heat generated by physical activity, adding to mental and physical fatigue, and potential breaches in infection control precautions.

This study will investigate the length-of-time doctors or nurses can safely work in HRZ in one continuous shift.