Can interactive online learning using enhanced technology adequately teach trauma-based procedural skills to emergency nursing clinicians?

Injury and trauma are common presentations to Queensland Emergency Departments. Clinicians caring for trauma victims must maintain competency with trauma procedures and interventions to apply them in a time-critical context, accurately, and therefore achieve the best outcome for individual patients. Engagement with traditional educational approaches, such as face-to-face training, is challenged by workload, shift patterns, clinician location and lack of opportunity to attend dedicated training events. A previous learning needs analysis of trauma education programs has highlighted that the greatest challenges are often faced by clinicians in rural and remote locations. One solution is to include the use of online learning platforms, to connect and assess clinician knowledge, with positive feedback regarding the engagement and experience for the learner. This study aims to use high-fidelity interactive online education, using a range of technologies including 360 videos with user interaction capabilities to design and develop a scalable model for future-proofing trauma education across Queensland. The research will test the effectiveness of (1) the approach to design and development in terms of scalability and (2) the online resources and assessment procedures in terms of the impact on knowledge and skill development.

Treatment for nausea and vomiting: A multi-arm double blind, placebo-controlled trial comparing the efficacy of droperidol, metoclopramide, and ondansetron for patients in the prehospital setting.

Nausea and vomiting are common reasons for people to call an ambulance. In Queensland, paramedics can provide a medication called Ondansetron to reduce the severity of nausea and vomiting. Alternative medicines, such as metoclopramide and droperidol, are also used in the emergency department or by ambulance services in other states. Despite the widespread use of medications for nausea and vomiting, little is known about their effectiveness in the prehospital setting. The limited evidence that exists comes from small studies in the emergency department setting, and indicates that medications may be no more effective than placebo for reducing nausea and vomiting. In this study, we aim to determine the effectiveness of medicines for nausea and vomiting in the prehospital environment. We will randomly assign patients who have nausea and/or vomiting to receive either ondansetron, metoclopramide, droperidol or a placebo as a prehospital treatment. Patients will rate the severity of their symptoms before and after receiving the medication, and we will compare these symptoms between groups to identify the most effective medicines. The study will help to optimise the treatment provided to the large number of patients who call an ambulance for nausea or vomiting.

Pharmacological Emergency management of Agitation in Children and Young People – randomised controlled trials of Oral and intraMuscular medication: PEAChY-O and PEAChY-M

Acute severe behavioural disturbance (ASBD) is an emergency situation where a patient experiences severe agitation or aggression. These individuals commonly present to the emergency department (ED) for treatment. Medications are often provided to assist the person to feel calmer. In most instances, oral medications are used. When the patient is extremely agitated, an intramuscular (IM) injection will be given.

In individuals less than 18 years, there is minimal available evidence to guide doctors about which medications work best. It is also not known how well these medications are tolerated by these young people. Therefore, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network is running two trials across a number of Australian EDs to create evidence to be used to guide the treatment for these young people.

The first study (PEAChY-O) compares two oral medications - olanzapine and diazepam - to determine which medication works better. The second study (PEAChY-M) compares two IM medications – olanzapine and droperidol. These medications were chosen because they are used as standard of care in Australian EDs and are recommended on current Clinical Practice Guidelines (CPGs). These are important studies because they will be the first trials to compare any medications head-to-head in a randomised trial across either the oral or IM routes.
Once the results are available, they will be used to guide future clinical practice including influencing the recommendations made in Australian guidelines, ensuring that these young people receive evidence-based treatments.

Prothrombinex-VF® for coagulopathy of liver disease in acutely bleeding patients; Too much of a good thing?

Chronic liver disease (CLD) is prevalent in Australian society and is the 11th leading cause of premature death (1). Thirty eight percent of patients experience gastrointestinal bleeding (GI) as a complication(2). The underlying balance between bleeding and clotting tendency is altered in chronic liver disease, making management of acute bleeding challenging in the emergency setting(3). There is a lack of high-quality evidence to guide the best combination of blood products and other medications to stop bleeding(4).

Prothrombinex®-VF is a blood product which can help to improve the level of clotting factors in the body thereby reducing bleeding tendency. It is indicated for anticoagulant reversal in acute bleeding(5). In practice many emergency physicians have used the product for patients with chronic liver disease who present with acute bleeding, although it is not licensed for this indication(6).

A retrospective Queensland study performed by this author showed that half of Prothrombinex®-VF usage for liver disease was in the emergency department by emergency physicians. It suggested that the product makes little impact on reversal of laboratory blood clotting tests and it raised important safety concerns regarding the develop of a syndrome of accelerated bleeding and clotting concurrently(6).

This expanded statewide audit of Prothrombinex®-VF in chronic liver disease in Queensland seeks to define efficacy and safety of the product. There is no statewide guideline for Prothrombinex®-VF and this data will contribute valuable information to developing future guidance for clinicians.

National Emergency Department Stress, Coping and Intention to Leave Survey: DESTRESS

The emergency department (ED) is a stressful workplace. The stressful work environment has resulted in high levels of psychological distress with some using mal-adaptive coping strategies. High staff turnover is evident in some EDs. To guide the development of strategies for clinicians, health services, policy makers, and emergency colleges, this research will provide a national picture regarding the impact of stressors on health and performance.

The well-being of staff is a priority for Emergency Medicine and Nursing colleges in Australia. Research reports have emerged highlighting concerns with post-traumatic stress, sleeping problems, cardiovascular disease and increasing rates of suicide among healthcare staff. This research is critical to address such concerning trends.

This multi-disciplinary research collaborative is new, consisting of expert clinical and academic leaders from emergency nursing and medicine coming together to provide a robust approach to understand, from a national perspective, where opportunities exist to enhance clinician wellbeing and the effectiveness of local, state, or national practice or policy measures, through the longitudinal design.

This research will provide a comprehensive Queensland, as well as a national understanding of the impact of stressors on the health and performance of ED staff. When applied longitudinally, the questionnaire can be used to evaluate the outcomes of interventions and policies that seek to promote positive coping strategies for ED clinicians.

Deadly Steps in the Emergency Department with Aboriginal and Torres Strait Islander Consumers: an evaluation of a co-design cultural safety improvement and awareness tool

Aboriginal and Torres Strait Islander (A&TSI) people presenting emergency departments are more likely to experience difficulty in communicating with healthcare providers, feel isolated, and experience shame and distress. These feelings lead to them leaving before they have been seen, or leaving before their treatment is completed, and they experience poorer health outcomes. Cultural safety is the ability of an organisation to meet the cultural needs of a group of people, and improved emergency department cultural safety has been shown to reduce rate of Aboriginal and Torres Strait Islander people leaving without being treated or before their treatment is completed. The 15 Steps Challenge Toolkit was developed in the NHS and is effective in assisting healthcare providers to see a clinical space “through the eyes of consumers”. This project aims to adapt the NHS 15 Steps Challenge toolkit to make it relevant to the experience of Aboriginal and Torres Strait Islander peoples using co-design methodology based on the “Yerin Dilly” model, which outlines values and processes to make research culturally safe. The project will be conducted in three phases to develop, trial and evaluate the Deadly Steps process. It will use both qualitative and quantitative methodologies to evaluate the process. The impacts of this project will be an improved process for evaluating and identifying opportunities to improve cultural safety, new cultural safety educational materials for healthcare providers, and improved experiences for Aboriginal and Torres Strait Islander people attending emergency departments in the Redcliffe, Caboolture, Sunshine Coast University, and Nambour hospitals.

Aeromedical Retrieval of people with Acute Behavioural Disturbance in Queensland – ELEVATE Study

The burden of mental illness on the Australian community and public health care system is substantial. (1) Every year in Queensland, approximately 300 people who present to a rural or remote ED location with acute behavioural disturbances (ABD) require aeromedical retrieval to an Authorised Mental Health Service (AMHS). ABD is “combined physical actions made by an individual which are in excess of those considered contextually appropriate and are judged to have the potential to result in significant harm to the individual themselves, other individuals or property” of rapid onset and a severe nature.(2)The transfer of people experiencing ABD is challenging due to difficulties in balancing patient rights and safety against that of the retrieval team. The aeromedical retrieval environment is restrictive, both in physical size and in relation to resource access, necessitating a heavy emphasis on risk-mitigation. Whilst research has established a safe approach to the sedation of people with ABD, other aspects of their retrieval remain lacking in evidence, and may contribute to suboptimal care and delayed access to specialist mental health services. This programme of research aims to explore those areas to ensure the management of people with ABD requiring aeromedical retrieval is optimal. Should changes in practice be required as a result, operating procedures and policies with Queensland's aeromedical network will occur.

Composition, Quality and Delivery of Major Haemorrhage Protocols (MHP) and critical bleeding clinical practice guidelines in hospitals across Queensland Health

Major bleeding is a leading cause of death in trauma patients. Blood product replacement is a key component of damage control resuscitation aimed at limiting coagulopathy until definitive control of bleeding is achieved. Although Major Haemorrhage Protocols (MHP) are now widely used in the initial resuscitation of traumatically injured patients (1), protocols can vary based upon individual institutions' capabilities and processes.

Within Australia, the National Blood Authority 2011 Patient Blood Management Guideline Module 1: Critical Care/ Massive Transfusion (2) recommended institutions develop standardized MHP to guide clinicians regarding the dose, timing and ratio of blood component therapy for bleeding trauma patients. However, it is currently unknown if these guidelines are implemented and if so, what institutional variations occur. While the guidelines provide a robust review of the evidence base for MHP, there is little information about the logistics of MHP implementation.

Our project aims are firstly to compare the available trauma bleeding protocols across Queensland for content and quality. Secondly, we wish to understand the institution's capabilities of delivering an MHP in terms of the structure and processes available to them. Thirdly we want to explore the experiences of clinicians involved in delivering an MHP for trauma patients in both tertiary, rural and remote hospitals within Queensland.

Expected benefits are to identify potential disparity of care for trauma patients in terms of MHP content, availability of resources and access to blood products. This information can help guide improvements in education, blood products availability and cost-effective care across Queensland.

Identifying RNA-based blood markers in ED patients with suspected acute ischaemic stroke arising from large vessel occlusion

Each year 40,000 Australians suffer a stroke, most of which arise from interruptions in the blood supply to the brain. Treatments for stroke focus on restoring the brain’s blood supply to limit the number of brain cells which die. Patients who suffer stroke due to a blockage of the arteries supplying the brain (LVO-stroke), benefit from surgical restoration of the blood supply (known as endovascular clot retrieval, ECR), but this is only effective if performed within 24 hours of stroke onset.

Rapid detection of patients with LVO-stroke is key, however many unrelated conditions can mimic stroke symptoms. Patients suspected of suffering a stroke therefore require intensive examination and brain scans to confirm diagnosis before treatment can begin. This delays care provision, particularly for patients in regional areas who must travel to access specialist equipment. Furthermore, the sensitivity of brain scans during the early stages of stroke is poor, increasing the potential for misdiagnosis.

Researchers propose developing a blood test to rapidly screen patients for stroke. Previous research identified 11 new markers in the blood of stroke patients, suggesting diagnostic potential. In this study, researchers we will screen blood samples collected from patients with LVO-stroke to discover markers specifically associated with ECR requirement. The study will also compare the diagnostic performance of identified markers to the screening tool currently used by emergency teams to assess clinical usefulness.

LOVE-DIVA

Peripheral intravenous catheters (PIVCs) are small plastic tubes placed in a patient’s vein for the delivery of intravenous fluid and medications. In the emergency department, many patients present with difficult intravenous access and require multiple insertion attempts to successfully place a PIVC. This can be time consuming for clinical staff, costly for hospitals, and painful for patients. Correct device selection is a key strategy to ensure first-time insertion success.

This study will recruit 406 adult participants at two emergency departments in order to test if novel PIVCs with a retractable guidewire (AccuCath Ace™ Intravascular Cannula, BD), compared to standard care, are effective at increasing first-time insertion success for patients with difficult vascular access.