The Crystalloid versus Albumin in tThe Resuscitation of Emergency Department Patients with Septic Shock (CARESS) trial inflammatory marker pilot study.

The aim of this study was to determine whether 4% albumin solution is superior to saline for fluid resuscitation of patients presenting to the emergency department with septic shock.

Noel Stevenson Research Scholarship: Prof Louise Cullen

This study is important because it will more rapidly move patients out of acute beds. It will do this by diagnosing patients with heart attacks up to four hours earlier and allowing earlier testing of patients without a heart attack but with potential heart disease, thus preventing overnight admissions. Approximately 80 per cent of patients who present to our ED each year with chest pain do not have a heart problem. Therefore, early discharge or admission of these patients would free up significant hospital resources, improve hospital flows and reduce the economic burden on the health care system. It may also reduce mortality associated with overcrowding. Given that overcrowding is associated with an excess of approximately 1,500 deaths per year one, the potential decrease in mortality may be significant.
Testing very low-risk patients frequently wastes time and resources and subjects patients to unnecessary provocative testing (e.g. treadmill testing). Provocative testing carries a risk of life-threatening heart rhythms or heart attack and if the test gives a false positive result further tests may be unnecessarily performed each with their own risk and complications. Identifying a very low risk cohort, who do not require extensive investigation, is the key.

Describing health care use in a cohort of children 0-5 years in South East Queensland

Emergency Department (ED) presentations are disproportionately greater in young children than all other age-groups. Young children are a vulnerable population and are at risk for injury and serious medical illness. In Australia, 13 per cent of all ED presentations were from children less than 5 years of age. Factors that lead to greater ED presentation rates in young children are incompletely understood and need further investigation.

This project has access to unique data from another existing study, the Environments for Healthy Living study (EFHL), run by the School of Medicine, Griffith University. EFHL recruited pregnant mothers in the Logan, Tweed and Gold Coast region and collected data since 2006 on more than 3000 children from birth with follow-up at 1, 3 and 5 years. Based on this fundamental initial work, the researchers will develop further research that aims to improve health care access and health care quality for this vulnerable population. This will better inform health care policy and education and reconfiguration of ED models of care that will enable more appropriate and efficient use of the ED to better meet the needs of the populations they serve.

This study aims to describe health care use by children aged 0-5 years living in the Logan, Gold Coast and Tweed regions. It will link the EFHL data with routinely collected data by Queensland and NSW Health (ED, inpatient and cost data) and Medicare Australia data (includes data on GP visits, medications prescribed and vaccination status). The project will focus on describing the health care use of these young children. This will include ED visits, hospital admissions, GP visits and medication use. It will aim to describe any associations between social, demographic, geographic and economic patient characteristics and common ED presentations and diagnoses (such as fever, asthma and injuries).

Decimalate: Use of an on-line Smart Test and survey to determine whether comprehension of decimals is a barrier to interpretation of clinical chemistry results among Emergency Department staff.

Recognition of the extent of medication errors resulting from misinterpretation of instructions have resulted in a multitude of recommended practices to reduce the likelihood. One area which may contribute to error, but one which has received less attention, is that of accurate interpretation of clinical chemistry results. It is well recognised that numbers containing decimal places can lead to error in medications with decimals overlooked or misplaced. Anecdotal evidence from Emergency Physicians indicates difficulty in interpreting clinical chemistry results which are presented with leading decimals (e.g. 0.0095 g/l).

Misconceptions about decimals have been the subject of extensive study. Half of student teachers were unable to place 0.606, 0.0666, 0.6, 0.66 and 0.060 in correct sequence and 40 per cent of nurses demonstrated a lack of basic computational ability with, and incomplete or incorrect conceptual understanding of, decimals. No research has been found to-date with medical staff. Whilst remedial teaching is beneficial it may not be a practical solution to the identified problem within the Emergency Department. Rather a change in the presentation of results may provide a simple and practical solution; for example the presentation of Troponin 1 as 40 pg/ml rather than 0.04 ng/ml. Such change will not be effected however without evidence of need.

The goal of the research is to provide recommendations which ultimately could lead to improvements in patient safety. The more modest project objectives are to increase user friendliness of results and reduce the potential for errors.

To determine what factors inhibit interns from developing and/or recording their clinical impressions (diagnoses) and management plans following patient assessment.

A hand written chart or clinical record is the most widely used method of patient care documentation in emergency departments. Research demonstrates that medical note taking responsibilities are frequently fulfilled to less than optimal standards by clinicians in many care settings including EDs (Gordon et al., 2010, Stetson et al. 2008). This has major implications for patient safety because communication between colleagues at shift change and patient handover can be compromised by poor record keeping. In addition, without accurate documentation of what has occurred in the emergency department, other professionals are unable to learn what care has been delivered. Furthermore, poor documentation can lead to legal complications years into the future and long after actual events have been forgotten by clinicians and other stakeholders.

The information obtained will be utilised to modify the education program known as More Learning for Interns in Emergency (MOLIE) for incoming rotations of Princess Alexandra Hospital (PAH) ED interns to increase their focus on documentation. The study also aims to establish the actual current standard of medical records by current junior Princess Alexandra Hospital (PAH) emergency medicine interns by reviewing their written patient records using an Intern Note Score Sheet. A subsequent review of medical records will be undertaken to examine notes written by interns who have experienced the new educational approach. It is anticipated that, if interns commit to paper what they are thinking, it will be a more productive learning experience for them. Ultimately this will lead to better patient care. Both of these aspects of the study will be grounds for further research.

Single palmar injection versus double injection dorsal digital nerve block for finger injuries in the Emergency Department: A Randomised Clinical Trial.

Patients with finger injuries often require their finger to be numb to allow their injury to be assessed properly and treated.
There are several methods available to numb the finger. Our study aims to compare two methods for numbing the patient’s finger to see which one of these methods is least painful for the patient. The first method is a single injection in the palm of the hand and the second method is two injections in the back of the hand or finger. The second method is the most commonly used method in our emergency department. Our hypothesis is that the single injection into the palm is less painful than the double injection in the back of the hand or finger.

Patients who present to the emergency department with finger injuries that require their finger to be numb for treatment or assessment of their injury will be given a study information sheet and consent will be obtained for participation in the study. Participants will then be randomly assigned to receive either the single injection in the palm or the double injection in the back of the hand or finger. A medical officer will perform the injection to numb the finger and a separate medical officer will then ask the patients to rate the pain of the injection to numb their finger. Participants will also be asked to rate their pain level before and five and ten minutes after the injection. The patient’s finger injuries will be treated as per standard care for their injury. Patients will be contacted at one week following the injection to ask them if they have any pain or signs of infection such as redness or swelling.

IVL-Gone: Assessment of the effect of skin glue on the function of a peripherally inserted intravenous line.

Intravenous lines are placed in the majority of patients admitted to hospital. Unfortunately they often fall out, become infected, cause irritation & pain or become blocked. Occasionally this can cause a life threatening illness. Blood can leak from the intravenous line onto the patient’s skin, clothing or bed linen. This causes patient distress. It can also be dangerous for hospital staff if they accidentally come into contact with the blood.

The insertion of a replacement intravenous line is generally regarded as an unpleasant experience that would be nice to avoid. The IVL-GONE research team are researching the use of common skin glue (think super-glue) to ‘stick-on’ the intravenous line. Other benefits are thought to include keeping the bugs out, improving patient comfort & helping to protect hospital staff from blood. If the skin glue works as well as preliminary studies indicate, this could be a simple solution for a worldwide problem; Queensland research leading the world.

A randomised controlled trial of interventional versus conservative treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) is defined as a collapsed lung with air in the pleural cavity that occurs in the absence of clinically apparent underlying lung disease. PSP is a significant global health problem affecting adolescents and young adults. Throughout the 20th century the treatment of PSP was predominantly bed rest, with invasive treatment reserved for severely symptomatic episodes. A study in 1966 suggested that managing large and small PSP in the community was safe. Despite this, rates of intervention have steadily increased over the decades. The reasons for this are unclear and this approach has recently been questioned in the scientific literature. Preliminary data suggests that a conservative approach to management may allow faster healing and reduce the risk of recurrence from around 25 per cent to 5 per cent in the first year. Conservative management is also likely to reduce the risks of prolonged admission due to persistent leak from approximately 30 per cent to less than 10 per cent and of other complications related to interventional management. Clinicians are, however, unlikely to change a practice entrenched for decades and re-enforced by current international guidelines without robust evidence.

This study will significantly increase our understanding of Primary spontaneous pneumothorax and its optimal management. If allowing the lung to remain collapsed initially results in improved healing of the pleural defect and lower recurrence rates then this study will contribute to improve outcomes and a reduction in the morbidity associated with current treatment.

Adding “insult to Injury” – The Effect of fresh and aged blood to oxygenation metabolisms and organ function in a clinically relevant trauma/sepsis model.

The World Health Organization reports that trauma will be the major contributor to the 49.7 million annual deaths globally from non–communicable disease in 2020. Trauma and sepsis are the two leading causes of death worldwide. This project aims to examine the effects of trauma and severe infection on oxygen supply to various tissues and organs.
We will study what infection does to metabolism and the degree of inflammation in these tissues. The effects of resuscitation on these tissue parameters while using stored and fresh blood will also be studied.

SWAMPED: Linking best practice workforce models to Emergency Department funding

The aims of this research are to link best practice ED workforce models to available ED funding under an activity-based funding (ABF), while contributing to the development of an improved national activity and outcome-based ED funding model. This research will identify the current status of funding of EDs, identify and critically appraise models for funding of EDs and identify the workforce implications of those funding models and propose a State-wide ED clinical workforce framework.