Evaluating the effectiveness of pre-hospital fibrinogen concentrate administration for major haemorrhage

Fibrinogen is a component of blood that is vital in the formation of blood clots, and low levels are often found in trauma patients who are bleeding. Low levels of fibrinogen cause problems with blood clotting and result in ongoing bleeding. Replacement fibrinogen has only been available in major hospitals which has been a problem given that the majority of trauma patients (most from the result of road accidents) treated by pre-hospital medical services are in rural and remote areas where this has not been available. Fibrinogen concentrate (FibC) is being introduced into Queensland’s pre-hospital and retrieval services to improve equity of access and facilitate early administration to patients that are critically bleeding. This study aims to evaluate the effectiveness of early FibC administration for bleeding trauma patients in the pre-hospital and retrieval setting and is the first study of its kind to do so. Should the study find a significant benefit of this early administration it will result in improved outcomes for such trauma patients, and has the potential to modify international medical practice in the management of bleeding trauma patients.

Comparison of pressure points versus tourniquet application for first aid control of arterial bleeding in beachgoers: a randomised controlled cross over trial

Arterial injuries to the lower limb, such as from a shark bite or deep laceration, can lead to catastrophic bleeding and death. Current first aid measures involve trained personnel applying an arterial tourniquet. However, even a short delay in haemorrhage management can lead to significant blood loss, brain injury or death. There is growing evidence that the simple technique of applying pressure to the groin can effectively occlude blood flow through the femoral artery, buying time for medically trained personnel to attend. One potential application of this technique is the treatment of shark attack victims with lower limb injuries, where beachgoers without medical training who have only seen a sign on a beach could apply life saving first aid. There is plethora of other potential applications outside marine encounters where this technique could be critical in reducing blood loss such as limb trauma from motor vehicle accidents, workplace injuries or military settings. The benefits are the simplicity of the technique which may be both easily and effectively performed by bystanders with no medical training. Using a non-clinical environment, we intend on performing a randomised trial to evaluate the efficacy of non-medically trained beachgoers performing pressure points compared with the application of a commercial arterial tourniquet after reading an infographic. We will measure the reduction in arterial blood flow using doppler ultrasound. The project aims to generate translatable research with the goal of influencing local, national, and international first aid guidelines.

Biomarkers for rapid diagnosis of paediatric sepsis

Sepsis is a time critical medical emergency that arises when the body starts to attack its own tissues and organs in response to an infection. Sepsis can result in organ dysfunction, multi-organ failure and death if not treated promptly, and is a leading cause of death in children worldwide. Sepsis often presents with non-specific signs common to many mild infections, making it difficult to detect early and accurately, leading to delaying appropriate treatments and resulting in severe sepsis. Therefore, it is vital to identify new approaches to rapidly identify the type of infection and predict the severity of the condition in patients presenting with suspected sepsis to enable early initiation of appropriate treatments.

Recent advances in genomic technologies have shown that gene expression based infection testing has the potential to provide much faster and more precise results. This results in more accurate diagnosis of infections and appropriate timely treatments. Our study will utilise an advanced gene expression analysis approach named single-cell RNA sequencing to identify new approaches for sepsis diagnosis. This could lead to development of a rapid testing method which can predict the type of infection (bacterial or viral) and the severity of the condition with a quick turnaround time for results, improving patient outcomes, reducing unnecessary antibiotic use, and shortening hospital length of stay.

The Kids Pain Collaborative: A collaborative implementation study of acute paediatric pain care in an outer metropolitan, mixed emergency department

Although pain is the most common reason for children to come to the emergency department (ED), it is frequently under-treated and under-recognised. We know children are particularly vulnerable to inadequate pain care, relying on adults to interpret their pain and act as advocates. A recent audit of children presenting in pain at Redcliffe ED found that many children with broken arms waited for prolonged periods (48 – 174 minutes) for pain medicine. The Redcliffe ED team identified significant barriers to pain care: staff’s inability to identify pain in children, lack of parental/clinician advocacy and lack of knowledge around paediatric medicines. To address this deficit in pain care, the Kids Pain Collaborative (KPC), an interdisciplinary collaboration of experienced ED clinicians, academic nurse researchers and ED consumers, has been established to transform paediatric pain care in Redcliffe ED.

The KPC is committed to optimising ED pain care at the systems level so that no child has to wait in pain. Our aim is to co-design, implement and evaluate an innovative evidence-based model of paediatric pain care which will begin with the child and family at triage. Engaging families in pain care assessment, optimising pain care processes and facilitating a workplace culture of prioritising pain is key to the success of this project. This project aims to reduce suffering for children and their families and inform paediatric pain care practice and policy at a State level. Research design draws on recent successful implementation research undertaken at the Queensland Children’s Hospital ED (1).

A structures, process and outcome evaluation of the Residential Aged care District Assessment and Referral Rapid Response (RADAR RR) model

Older persons from residential aged care homes (RACF) have unique needs that are often overlooked in our traditional emergency departments (EDs). This can lead to under triage, prolonged length of ED stays, unnecessary investigations and iatrogenic hospital acquired complications (1). The Residential Aged Care District Assessment and Referral Rapid Response (RADAR RR) model is a pre-hospital Queensland Ambulance Service (QAS) co-responder model providing ED equivalent care in the resident’s home for acute illness and injury. RADAR RR model operates between 0800 and 2000, 7 days a week. We hope to evaluate the clinical and cost outcomes of the RADAR RR model and determine if it is equivalent to the care provided by traditional ED models of care in an urban setting. We will also review the structures and processes required for effective service delivery which will in turn guide the development of a toolkit to assist other hospitals in adopting the RADAR RR model if appropriate for their area. Finally, given increasing pressure for high value models of care we will undertake an economic evaluation to determine if the RADAR RR model is more economically efficient than the traditional ED model of care.

How are hypertensive urgencies managed in emergency departments in Queensland?

Hypertension is a highly prevalent, chronic cardiovascular disease with considerable impacts to population health. Although hypertensive urgencies are common encounters in emergency departments (ED), there is a lack of clear guidance for their clinical management. A poorly managed hypertensive urgency can leave the patient with continuing severe hypertension and at increased risk of end-organ damage. The objective of this study is to determine the current management strategies for hypertensive urgencies in Queensland EDs, and to better understand the reasons for their use. We will survey Queensland ED physicians about their use of and opinions about current management strategies for hypertensive urgencies. We will also conduct a pilot single-site observational study of management strategies for hypertensive urgencies. The findings of this study will inform the design of future research to improve management of hypertensive urgencies in EDs.

Retrospective analysis of GEDI impact on older adult patients presenting to the emergency department with a positive delirium screen (4AT)

Delirium in the older adult population is a common hospital complication linked to multiple adverse outcomes including longer lengths of stay, increased morbidity and mortality, greater cognitive and functional decline, and increased risk of re-presentation to the emergency department (ED). Patients with delirium can increase healthcare expenses by up to $30,000 extra per patient. This places a significant burden on the patient and the health system. The Geriatric Emergency Department Initiative (GEDI) has shown benefits in the ED management of older patients including reduction of re-presentations to the ED. However, the effectiveness of GEDI for older patients with delirium remains unclear. The aim of this research project is to compare clinical outcomes of older patients presenting to the ED with positive 4AT scores who received GEDI input versus those who did not, across a six-months period. The outcome measures will include ED length of stay and time to geriatric review.

Application of the HEART score to the “intermediate risk” patient group may help identify those who are at lowest risk of cardiac events, therefore, not benefit from further testing

Chest pain is a very common presentation to emergency departments and has wide variety of causes including life threatening conditions such as a heart attack and benign causes such as a muscular strain. Often the biggest challenge is to appropriately identify an individual's risk of suffering a heart attack, while ensuring that the harms associated with potential over-investigation are minimised. This requires an efficient and systematic risk stratification process, and has been the focus of a lot of research. Currently, in Queensland the approach to this challenge is to use a blood test called troponin, along with ECG, to determine an individuals level of risk. This allows a large number of patients to be discharged quickly, but also results in many people falling into an intermediate risk group. The Sunshine Coast Health Service has recently started using the internationally validated HEART Score to further risk stratify this intermediate risk group, to identify those who do not require further testing and those that are at a level of risk that do require further investigation. These patients are then seen in a rapid access chest pain clinic. This study assesses the safety of this pathway which is unique in the way it combines the two approaches, and in that it assessing patients who are intermediate risk by HEART Score in an outpatient setting when normally they would be admitted to hospital.

Contactless vital sign monitoring to improve Patient Safety in Emergency Department Waiting Rooms: A prospective, single-site, pilot study

Emergency Departments are experiencing an ever increasing volume of patients presenting for medical care. At times, the number of patients in Emergency Departments can exceed the number of available beds. When this happens, sicker patients are allocated to treatment areas while those less unwell are required to wait in the waiting room. Some waiting room patients will inevitably become more unwell before being seen by a doctor. Measuring vital signs - blood pressure, heart rate, breathing rate, blood oxygen levels, temperature - is a proven method for early detection of deterioration in unwell patients. Emergency triage clinicians endeavour to measure vital signs of waiting room patients, however, their ability is significantly limited during period of insufficient staffing and overcrowded waiting rooms. Innovative, camera-based advanced sensor technology could facilitate automatic, contactless, vital sign measurement during periods where available resources are limited or overwhelmed. Contactless vital sign measurement could thus enable early detection of patient deterioration and improve patient safety in emergency department waiting rooms. Such technology has shown promise in recent studies but has not been rigorously tested in an Australian Emergency Department. This project will study one such technology to determine its reliability and accuracy in measuring vital signs in waiting room patients at Townsville University Hospital Emergency Department. If this technology is found to be reliable and accurate, this study will improve quality of care and safety for patients in emergency department waiting rooms.

A retrospective cohort review study of patients with Primary Immune Deficiency (PID) who have presented to the emergency department (ED) with a fever

Primary Immune Deficiency can develop into frequent and in some cases severe infections, and inflammation. With this cohort of patients being so vulnerable, they should be treated and assessed promptly when presenting to an emergency department with a fever. There remains a critical need in this specific population to optimise strategies aiming to improve the recognition as to which febrile patients require immediate intervention, and to identify if treatment can be withheld/de-escalated safely.

Currently there are limited guidelines and knowledge surrounding this specific population when they present to an ED creating a gap in research. This dissertation will aim to address this via:

1. A scoping Review of global standards and practices of febrile PID children presenting to ED, and
2. A retrospective review, of all paediatric patients with a PID who present to an ED with a fever. Data will include demographics, PID characteristics, ED diagnosis, procedures and disposition.