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.

Exploring the relationship between psychological safety in the workplace and in simulation based educational sessions for emergency department doctors and nurses

Emergency department teams need to perform urgent and high stakes patient care. This requires individual expertise and effective teamwork underpinned by trust, respect and shared values.

Psychological safety is a “shared belief held by members of a team that the team is safe for interpersonal risk taking”. The factors affecting the development of psychological safety in emergency department teams are not well understood and we aim to explore this within the emergency departments at Gold Coast Health.

Learning more about how to develop psychological safety in teams will inform team training strategies, including but not limited to simulation-based training, and subsequently better care for patients presenting to emergency departments where high performing teams are critical.

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.

D.dimer adjusted to low clinical probability in the diagnosis of suspected pulmonary embolism – is it safe in the urban emergency department?

Pulmonary embolism (PE) is the third most common presenting acute cardiovascular syndrome behind myocardial infarction and cerebral vascular event, resulting in significant harm and death. Different clinical decision-making rules exist to guide clinicians investigating PE, to risk stratify patients based on presenting signs and symptoms; into low, moderate or high-risk. This helps direct further investigations and imaging, such as blood tests (D.dimer), computed tomography pulmonary angiogram (CTPA), and ventilation/perfusion scan (V/Q).

Currently, a blood test is a first line test used to help identify which lower risk patients might require further investigation with medical imaging. Medical imaging adds cost, prolongs hospital stay and exposes the patient to radiation and IV contrast. This retrospective study will determine in the Australian context, whether applying a higher cut off D.dimer to low risk patients who present to an urban emergency department is a safe strategy in ruling out PEs. An Australian study is important due to significant contextual issues in the D.dimer testing across different countries despite decision rules currently available.

Interaction of hyperdynamic septic shock and sepsis endotypes: a new paradigm

Sepsis is an emergency medical condition that is caused by an abnormal response of the body to the presence of harmful microorganisms in the blood. It can lead to injury of body organs, shock and loss of life. Every year, 11 million people worldwide die due to sepsis.

Despite advances in the treatment of infections, management strategies for sepsis remain suboptimal. Inadequate understanding of immune system response to severe infection is partly to blame. Patients present to hospital with different signs that may include having warm peripheries and low blood pressure (hyperdynamic shock). Critically ill patients with sepsis who present with these signs, commonly receive medications to support blood pressure (vasopressors) but it is unclear whether starting vasopressor early, will result in better patient response or outcomes.

This study will investigate whether starting early vasopressor is better compared to delayed initiation. As clinicians working in the emergency department and intensive care, researchers will be able use study findings to develop better ways of treating septic patients.

Emergency department treatment of the drowning victim

Drowning has a major global impact, with approximately 300,000 deaths each year. Yet the treatment of drowning victims has received limited investigation. This lack of evidence means that guidelines for the treatment of drowning victims are largely based on case reports or on other conditions such as acute respiratory distress syndrome (ARDS), on the premise that there may be similarities between the two conditions.

We are proposing to create a comprehensive database of information on drowning patients presenting to the emergency departments at the Sunshine Coast Hospital and Health Service. We will utilise a standardised list of data (Utstein-style guidelines for Drowning) to explore the treatment and outcomes for drowning patients over an eight-year period 2015-2022 inclusive. This will allow us to answer questions on the best ways to assist the breathing of drowning patients, if the treatment and outcomes in female drowning differ from males and why (there is some evidence females have better survival outcomes after being admitted to hospital), and to determine if the classification of drowning severity in common use around the world is useful in an Australian population.

PaNURAMA Inter-facility Transfer Tool: a validation study of the Paediatric Non-Urgent, Risk Assessment, Management and nurse escort Assessment Tool for safe children’s inter-facility Transfer

Most paediatric inter-facility transfers within Australia are for children that do not qualify for specialist paediatric retrieval services but still require access to specialised paediatric care not offered at the local healthcare facility.

Evidence-based transfer guidance for children requiring retrieval are well established. However, for children who do not meet retrieval criteria, there is little guidance for referring and accepting clinicians on how to coordinate safe transfer. Nurse escorts are often deployed but may not be trained sufficiently to deal with arising complications during transfer. Additionally, with the availability and scope of paramedics, the deployment of nurse escorts may not be required, and unecessarily deplete valuable resources at referring facilities.

A risk stratification tool has been developed to determine which non-urgent transfers require higher level consultation and management prior to and during transfer, and nursing escort. The validation of this tool may assist to accurately identify higher-risk children, enabling application of appropriate safeguards, an appropriate level of consultation and escort, and supporting clinician decision-making surrounding transport Australia-wide.

Relief of chest pain in the emergency department (RELIEF)

Many emergency department (ED) patients with painful conditions have extensive delays to receive pain relief, which may result in unnecessary discomfort and an extended length of stay.

This study will focus on how long patients who present to the ED with chest pain wait for adequate pain relief. This study is important for improving patient comfort and health service outcomes.

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.