Drug Overdose with Reduced Consciousness: Patient and Staff Perspectives. A Mixed Methods Study

Drug overdoses are a common reasons for Emergency Department (ED) presentation. Overdoses may be intentional (self-harm), recreational, or accidental and often lead to reduced consciousness. Patients often need extra attention to their airway and breathing. They can be managed conservatively with oxygen, observation and regular nursing assessments. However, some require intubation: insertion of a breathing tube under sedation.

There is practice variation between doctors as to which overdose patients require intubation. Thus, the patient’s perspective becomes paramount, as their experiences influence management. We also need to understand clinician thought processes to ensure that care is standardised where possible.

This qualitative research is innovative in being the first to assess the patient experience around airway and breathing management for drug overdose with reduced consciousness, and assessing clinician attitudes. This will be done through patient and clinician questionnaires and semi-structured interviews.

AIM 1: To investigate the patient experience for an ED presentation with drug overdose and reduced conscious level. To understand the impact that interventions such as intubation can have on patients.

AIM 2: Explore clinician attitudes to the management of airway and breathing for these patients. Barriers to a conservative approach, triggers for intubation, departmental pressures and existing frameworks of care.

The research will provide insight into how this vulnerable patient population experience their care, and how clinicians reach critical decisions. It will inform development of a pathway of care to be used in the ED assessment of airway and breathing management for patients with drug overdose and reduced consciousness.

QuED HEAT: Queensland Emergency Departments: Exploring the Impact of Heatwave Exposure And Temperature

In Queensland, extreme heat and heatwaves lead to increased demand for public health services. Predicted increases in the frequency, intensity, duration, and spread of heatwaves necessitate urgent action to mitigate their impact and protect vulnerable populations. Queensland Health has recognized this threat, and in response are developing evidence-based policy to protect the health of Queensland residents. This study aims to explore the impact of heatwaves across different ages and medical conditions in Queensland emergency departments.

Using statewide data from Queensland Health and the Bureau of Meteorology, we will compare the incidence of emergency department visits during extreme heat and heatwave periods to normal periods by age and medical conditions. To date, no research has explored the impact of heatwaves and extreme heat periods on emergency department demand by age and medical conditions across Queensland. This research will extend our knowledge about the impact of heatwaves on emergency departments, which have shown to have increase by 9% according to preliminary results. This information will allow for forecasting and preparedness surrounding extreme heat events.

Cultural Safety in the Cairns Hospital Emergency Department

The overall aim of this doctoral research is to transform the Cairns Emergency Department into a place of cultural safety, as determined by Aboriginal and Torres Strait Islander community. This research centres the voices of Aboriginal and Torres Strait Islander peoples in articulating cultural safety in the Cairns Hospital Emergency Department, positioning the community as expert knowers and teachers, to inform the delivery of emergency care across the country.

This study involves a research process, through Indigenous Storywork and Narrative Practice. Using Narrative therapy and community practice, stories of wisdom, skill and know-how of the community will be shared into the Cairns Hospital ED through focus groups and in-depth interviews. Cairns Hospital ED staff will bear witness to these stories, learning from them, then taking action within their practice. Alongside this, the study will gather, through review of minutes and researcher reflections, stories behind the action register of the Cairns Hospital ED Cultural Safety Reference Group (CSRG) to document historical change, and change as it occurs within the time frame of the study.

This research grant is sought, specifically to facilitate critical knowledge translation of research findings; translating the important wisdom, skill and know-how of the First Nations community into practice and policy transformation in the Cairns Hospital ED.

The Utility of POCUS by Novice Clinicians in Diagnosing Heart Failure Project

Acutely decompensated heart failure is a significant cause of morbidity and mortality worldwide. In 2020-21, it is estimated that around 34,400 presentations to the emergency department were due to heart failure. One of the most common ways in which patients present to the Emergency Department with this end diagnosis is with acute dyspnoea secondary to acute pulmonary oedema. Traditionally, acute pulmonary oedema is detected using a combination of history, physical examination findings and Chest XR (CXR). The recent widespread availability and use of point of care ultrasound (POCUS) has drastically changed the way patients are assessed in the emergency setting. Delays in completing X-rays and awaiting formal laboratory results (such as BNP) can result in delays in the diagnosis and management of patients in acutely decompensated heart failure. POCUS offers a bedside alternative that may be able to fast track a patient’s assessment in the emergency department. This study aims to determine the utility of POCUS by novice ultrasound users, to assist in detecting acute pulmonary oedema and to assist with diagnosing acutely decompensated heart failure in the emergency department. The outcome of this study may support the widespread training of medical officers working in emergency departments in the use of POCUS for detecting acute pulmonary oedema. If proven to be non-inferior to CXR and BNP, POCUS LUS will have a significant impact on the way patients with acutely decompensated heart failure are assessed.

The feasibility of point-of-care ultrasound conducted by physiotherapists for the diagnosis of ankle syndesmosis injuries in the acute care setting: A diagnostic study and budget impact analysis study

Syndesmosis injuries, also known as a high ankle sprain, due to ligamentous injury are relatively uncommon but can have devastating outcomes when missed. This includes chronic pain, instability and osteoarthritis. Early surgical fixation of these injuries is recommended in some cases. Magnetic Resonance Imaging (MRI) is the most accurate way to diagnose these, but not ordered in the emergency department (ED) due to its cost and poor availability. Although clinical tests can help to narrow down who needs an MRI, they are often inaccurate in the acute phase. Ultrasound performed by sonographers can visualise ligament to components of the syndesmosis complex to streamline MRI referrals but is under demand during the day and not available afterhours. Point of Care Ultrasound (POCUS) performed by clinicians is an alternative option for imaging.

Emergency physiotherapy practitioners (EPP) typically manage patients with musculoskeletal injuries in the ED and are well placed to perform musculoskeletal POCUS. This study will evaluate the feasibility and accuracy of ED physiotherapist-performed POCUS for the diagnosis of ligament injury in the ED, indicative of a syndesmosis injury, against radiology-performed ultrasound. This could guide MRI patient selection to allow for earlier detection of unstable ankle injuries and expedite outpatient orthopaedic expert review and management. If POCUS by ED physiotherapists is demonstrated to be feasible and accurate for these syndesmosis injuries, the results of this study could inform the development of a diagnostic pathway that could be implemented in EDs locally and throughout Australia.

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.

Innovative Corrective Services and Ambulance Response Evaluation (ICARE): A Queensland Ambulance and Queensland Corrective Services initiative to improve the management of prisoners with minor orthopaedic injuries.

The Queensland Ambulance Service (QAS) provides out-of-hospital medical services to approximately 900,000 patients annually, and as the publicly funded provider of prehospital emergency care is called to respond to persons incarcerated within correctional facilities. The primary complaint of patients attended by QAS in this setting are minor orthopaedic injuries to the upper arm and hand. In current practice, paramedics provide short-lasting analgesia and temporary limb splinting or bleeding control, before conveying the patient to an emergency department for further management. Transport of patients from correctional facilities to public hospitals is complex, presenting potential risks to staff and the public, and is time consuming and resource intensive. As these injuries are predominately uncomplicated fractures or simple lacerations, it has been postulated these patients may be more appropriately managed by enhancing the care that can be provided onsite by the QAS, with the patient subsequently managed through an outpatient clinic and thereby avoiding an unnecessary presentation to hospital. This project proposes developing a new collaborative treatment pathway involving the QAS, QLD Health and QCS for patients with minor orthopaedic injury. The aim is to reduce unnecessary, time and resource intensive transports to hospital emergency departments for this cohort of patients. Grant funding is sought to undertake an evaluation of this initiative. This model of care provision, if proven effective, could potentially be considered for implementation in other correctional facilities or austere healthcare settings where primary health care resources are stretched, and consequently additional demands are placed on emergency care settings.

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.

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.