Frank Garlick Research Scholarship: Dr Joseph Ting

The Frank Garlick Research Scholarship enabled Dr Joseph Ting to complete the Master of Science (Clinical Trials) at the University of London.

The sepsis registry: A prospective database to characterise and facilitate improved outcome for admitted patients with community-acquired infection.

This study aims to improve our understanding of sepsis in Australian Emergency Departments. We will do this by analysing in great detail the spectrum of infection syndromes presenting to the Emergency Department of a typical large Australian hospital over a period of several years. This will allow us to:

1) Identify the number of patients presenting to hospitals each year with severe infections and the outcome of these presentations.
2) Analyse the factors and information available to doctors in the Emergency Department that are associated with overall prognosis in patients with infection.
3) Build a comprehensive picture of the spectrum of infective agents that cause patients to be admitted to Australian hospitals.
4) Identify the most appropriate combination of antibiotics which should be used in the early treatment of the most severely ill patients with infection.

The cornerstone of this project is a large database which will capture detailed information on all patients presenting to the Emergency Department of a typical large Australian hospital who are subsequently admitted with infection.

Cost effectiveness and Clinical outcomes of B-type Natriuretic Peptide (BNP) Point of Care Testing versus BNP Laboratory testing for Adults with Dyspnoea in the Department of Emergency Medicine at Nambour General Hospital.

Patient flow and access block will be evaluated through comparing time to decision making in the Emergency Department (ED) and Emergency Department length of stay (ED LOS) between patients who have POC and Laboratory BNP testing. Cost effectiveness will be evaluated by reviewing treatment type given, admission rate, ICU admission rate, inpatient length of stay (IP LOS), Emergency Department Length of Stay and 30day readmission rate.

This study will build upon the findings of a similar concurrent study. Both studies demonstrate a poor utility in BNP testing in patients presenting with shortness of breath in reducing Emergency Department length of stay. While this limits the potential for BNP Point of care testing within the ED, the validated Abbott Point of Care BNP cartridge will have the good potential for improving patient care in rural and remote cardiac outpatient locations where current BNP testing results take several days to obtain.

The effect of consecutive night shifts on the psychomotor performance of registrars working in the emergency department.

The objective of this research was to evaluate the effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and psychomotor performance in a group of Australian emergency registrars. A prospective observational study with a repeated within-subjects component was conducted. Sleep time was determined using sleep diaries and activity monitors. Subjective fatigue levels and reciprocal reaction times were evaluated before and after day and night shifts.

ABC (Arm-banding, Barcoding, Compliance) of Patient Safety – Arm-banding the Emergency Patient – Does technology reduce patient misidentification of pathology specimens.

Accurate identification of patients is critical to their safety and to the efficient management of health services. Without accurate identification incorrect procedures may be performed, patients may have unnecessary tests performed on them or there may be delays in their care as pathology or other tests must be repeated. We plan to study the process of patient identification during blood collection in the Emergency Department. This is the most common procedure performed in the Emergency Department. Mislabeling of pathology specimens can lead to fatal adverse events, such as incompatible blood transfusions. Results attributed to the wrong patient can lead to incorrect diagnosis and inappropriate future management.

In the chaotic Emergency Department environment, identification of critically unstable patients who require time critical treatment is even more important. These factors lead to increased risks associated with misidentification. Recently arm banding has been recommended as part of a new national standard to improve the patient identification process in Emergency Departments.

Procedural sedation in the Emergency Department; A comprehensive analysis of a prospective registry of consecutive procedural sedations and telephone follow-up

Patients frequently present to the Emergency Department (ED) requiring brief but painful procedures as part of their medical treatment. Completion of these procedures in a safe and timely manner should be a core competency of an Emergency Physician. Insufficient data currently exists to guide the Emergency Physicians in the conduct of these procedures. A specific and highly comprehensive registry of patient related parameters, patient and physician satisfaction with the sedative episode is required.

Regulatory systems for occupational exposures in emergency care: Contemporary challenges for the emergency physician in prevention, control and management.

Healthcare workers in emergency departments are at high risk of exposure to blood-borne infections from occupational exposure. The financial and human costs of these injuries are significant. The risks such health care workers face are made more difficult in recent times because of three interconnected reasons. First, emergency care workers are at high risk of occupational exposures because of the nature of their work and the environment they operate in. They work in highly volatile and high-stakes situations. Second, emergency departments face unprecedented demands for emergency medical care. With increased numbers of patients, waiting times for medical treatment inevitably increase, leading to patient dissatisfaction, aggression and violence, larger and heavier workloads, decreased patient and staff satisfaction, and higher staff turnover and burnout. Third, emergency physicians are routinely called upon to manage healthcare workers who have sustained these occupational exposure injuries. The more patients there are, the more at risk emergency physicians and others are at risk of occupational exposures.

These injuries are largely preventable. Emergency physicians have key roles to play with their prevention, but lack a rigorous reporting system and sensitive data management system with a universal regulatory framework to do so. While national guidelines exist to govern the clinical management of such injuries, there is no consistency of regulatory and legislative workplace health and safety frameworks in which emergency physicians are required to operate across the country, making their prevention, control and management by emergency physicians highly problematic. This study will provide a definitive systematic review of the legislative and regulatory workplace health and safety frameworks governing the management, control and prevention of occupational exposures across Australia. Moreover, the study will provide baseline data and pilot research for a larger study that suggests the development of a culture of patient safety within the emergency department and the wider hospital environment first requires a culture of staff safety. For the true financial and human costs of occupational exposures to be known, it is critical to gauge the extent the problem. When we consider the estimated under-reporting in the United States or Australia, where it is estimated that up to 85% of occupational exposures are not reported due to the systematic under-reporting of sharps injuries, the financial and human costs associated with occupational exposures are significant.

The effects of implementation of a tertiary survey tool for multi-trauma patients.

Missed injuries in trauma patients are a well recognised phenomenon. Currently at Gold Coast Hospital there is no formalized process for review of multi-trauma patients who are admitted to the general ward. Anecdotal evidence from the emergency department’s monthly trauma review meeting suggests that there are multiple factors that contribute to missed injuries. Commonly patients with an altered level of consciousness, those that are intoxicated or those that are unstable and require immediate operation, have injuries that may not be recognized in the ED. Also at risk are patients transferred from other facilities that have been assessed and managed elsewhere. The idea of a tertiary survey has been proposed as one strategy to reduce the incidence of missed injuries in trauma patients. This involves a re-evaluation within 24 hours of admission with a complete head to toe examination, review of laboratory results and radiologic studies. This is frequently documented on a tertiary survey form that is filed in the medical record.

A randomized controlled trial comparing patient controlled versus physician controlled sedation in the Emergency Department.

Emergency Department patients are often sedated before undergoing painful procedures such as manipulation of fractures and dislocations. Propofol is a sedative drug commonly used for this purpose. Presently, the drug is always given by the doctor. However, there is evidence to suggest that the drug can be safely administered by the patient to him or herself. The patient does this by pressing a button on a pump which delivers the drug on demand in a controlled manner. This is called patient controlled sedation. There are potential benefits when the patient gives the sedative drug to him or herself including getting the dose and therefore the sedation just right, and the satisfaction of being in control. Patient controlled sedation will avoid the discomfort associated with the painful procedure if the doctor does not give enough of the drug. It will also avoid an overdose along with its associated side effects if the doctor gives too much of the drug.

This study will compare patient controlled sedation with doctor administered sedation for painful procedures performed in the Emergency Department. Eighty patients will be randomly assigned to the patient controlled sedation group and eighty patients to the doctor administered sedation group. The overall dose of propofol administered during patient controlled and doctor administered sedation will be compared. The study will also examine how deeply the patients are put to sleep, how long they are put to sleep, how satisfied they are with the sedation, and the number of adverse events, if any, between the two groups. The study has been approved the Human Research Ethics Committee of the Royal Brisbane and Women’s Hospital. Results of the study will be presented at scientific meetings and published in medical journals.

Noel Stevenson Research Scholarship: A/Prof Peter Aitken

Disasters have caused the loss of more than 12 million lives and affected more than 50 million people in the past 50 years alone. Disasters involve not just more patients, but a different type of patient in a system under extreme stress. Emergency Departments (ED), as the ‘front door’ to the health system are a key part of the disaster response and a well prepared ED is essential to save lives. Being prepared involves education and training however disaster health education is not well developed in Australia. The research program aim is the development of a disaster education framework for the health workforce in Australia. This framework will incorporate learning needs and identify strategies to meet them in a manner which is both cost and outcome effective. A key outcome will be development and evaluation of a post graduate qualification in disaster health consistent with this framework. The current state of education in disaster health in Australia will be reviewed including a comparison of strategies used, relative effectiveness and barriers to success. Common problems will be identified from literature and Australian experience to help target educational priorities. This will include ED and Australian teams deployed overseas, many of whom were ED staff. A secondary aim is development of a network to strengthen both emergency medicine response to disasters and disaster health research.