Grants Awarded February 2009 Overview and Lay Descriptions

SHORT TITLE
BNP Point of Care

FULL TITLE
Cost effectiveness and Clinical outcomes of B-type
Natriuretic Peptide (BNP) Point of Care Testing
versus BNP Laboratory testing for Adults with
Dyspnea in the Department of Emergency Medicine
at Nambour General Hospital
GRANT TYPE
Emergency Medicine Trainee Grant
AMOUNT AWARDED
$13,050

Investigators

Dr David Ward Nambour General Hospital Department Emergency Medicine
Dr Logan Stuckey Nambour General Hospital Department of Emergency Medicine
Paul Negus Nambour General Hospital

Aim
The aim of this study is to evaluate how using BNP point-of-care testing in the Department of Emergency Medicine at Nambour General Hospital for adult patients presenting with acute dyspnoea impacts on patient outcomes, clinical significance, cost effectiveness and DEM patient flow when compared with laboratory testing.

Method
All English speaking patients, 18 years of age or over, presenting to the Department of Emergency Medicine at Nambour General Hospital with symptoms of dyspnoea who are capable of giving informed consent will be eligible for the research study. All patients who give their written informed consent will be included in the study sample.

Patients not consenting to participation in the research study will receive usual care and will not be included in the study. A sample size of approximately 500 participants is anticipated over a 6 month period.

The first 100 consenting participants will be ordered both BNP point-of-care testing and BNP laboratory testing to enable validation of the BNP point-of-care testing and BNP laboratory testing at Nambour General Hospital. Participants in the validation group will be randomised to have the results of either the BNP laboratory testing or BNP point-of-care testing made available to the treating medical officer to assist with assessment, diagnosis and treatment. Thereafter all other consenting participants will be randomised to have either BNP point-of-care testing as part of their diagnostic assessment or to receive standard laboratory BNP testing.

Data collection and evaluation
No additional data will be collected from participants than would normally be collected as part of usual clinical care. Time of presentation to time of initiation of appropriate medication will be recorded for both the BNP point-of care and BNP laboratory groups. All data will be collected by chart review and from the AUSLAB, HBCIS and EDIS data bases.

Data will be entered directly on to an excel spreadsheet.

Patient flow and access block will be evaluated through comparing time to decision making in the Emergency Department (ED) and Emergency Department length of stay (ED LOS) between patients who have POC and Laboratory BNP testing.

Cost effectiveness will be evaluated by reviewing treatment type given, admission rate, ICU admission rate, inpatient length of stay (IP LOS), Emergency Department Length of Stay and 30day readmission rate.

Clinical significance will be explored through reviewing probable diagnosis and severity of Congestive Heart Failure (CHF) in relation to BNP levels. Probability of diagnosis of CHF is to be recorded by the treating doctor as a percentage from 0- 100% and severity as low, intermediate and high. A cut off value of BNP<100pg/ml indicates that likelihood of CHF is low, 100-500pg/ml intermediate and >500pg/ml high. Patient outcomes will be evaluated by reviewing admission rates, 30day mortality, ICU admission rates and ICU length of stay.

SHORT TITLE
Mandatory clinical debriefing of Emergency Registrars.

FULL TITLE
Will a mandatory clinical debriefing program affect levels of psychological distress in Emergency Registrars.
GRANT TYPE
Emergency Medicine Trainee Grant
AMOUNT AWARDED
$9,050

Investigators
Dr David Ward Nambour General Hospital Department Emergency Medicine
Dr Bethany O’Neill Nambour General Hospital Department Emergency Medicine
Paul Negus Nambour General Hospital Emergency Department

Emergency doctors have been shown to exhibit higher levels of psychological distress and burnout than both their medical colleagues and the general population. One study showed that 51% of Emergency SHO's (1) and 44% of Consultants showed significant levels of psychological distress while the level in the general population was 18% (2).

This study aims to investigate whether the implementation of a mandatory clinical debriefing program affects the levels of burnout and psychological distress amongst Emergency Registrars at Nambour Hospital.

Consent will be sought from the subject group which consists of Emergency Registrars at Nambour Hospital. The registrars will be identified by a number to enable paired data correlation. This code will not known to the investigators and will be held securely by a source not involved in the study.

The two surveys taken will be the Maslach Burnout Inventory and the Brief Cope. These will be first completed in the first month of a six month rotation, after which a debriefing program will be implemented. The surveys will be repeated at the end of the term. At the time of survey, an additional questionnaire will be completed for the purpose of gathering epidemiological data but also to ascertain the occurrence of major stressful life events outside of the working environment during the study period.

Clinical cases for clinical debriefing will be flagged by the following criteria
1. Category 1 presentations
2. Trauma calls
3. Deaths in the department
4. Registrar flagged cases of concern

The clinical debriefing session will be held within 72 hours of the incident and will involve a sit down discussion including the treating registrar, the supervising consultant for that case and the principal investigator. The discussion issues will include -

1. Clinical presentation, investigations and interventions
2. Aspects of assessment and management done well
3. Aspects of assessment and management that could have been done differently
4. Specific concerns about the case and formulation of learning objectives
5. Identifying and referring those who need further support

Concurrently, consent will be sought from a control group of registrars at similarly sized Toowoomba Hospital who will be surveyed at the same points in time, with no intervention. The results will be compared and analysed for statistical significance.

SHORT TITLE
Placement of equipment as a factor influencing hand hygiene In the emergency department (Hand washing equipment).

FULL TITLE
Placement Of Equipment As A Factor Influencing Hand Hygiene In The Emergency Department (Hand Washing Equipment).
GRANT TYPE
Emergency Medicine Trainee Grant
AMOUNT AWARDED
$16,300

Investigators

Dr Michael Sinnott Princess Alexandra Hospital Department of Emergency Medicine
Georgia Livesay Princess Alexandra Hospital Department of Emergency Medicine
Ramon Shaban Princess Alexandra Hospital Nursing Practice Development Unit, Griffith Institute for Health & Medical Research, Griffith University

Effective hand washing and hand hygiene are universally recognised as the simplest ways to prevent the spread of infection. As well as limiting the spread of disease, hand washing is one of the few effective ways to reduce the development of antibiotic resistant infections. Despite this, many studies have shown that hand hygiene and compliance best-practice standards is universally poor amongst doctors and nurses working in hospitals. Previous studies have identified many factors reported to affect hand washing compliance. The time to undertake hand hygiene, the individual’s knowledge of hand hygiene techniques, their attitudes towards its importance, workloads, and the context in which they work are all known to influence hand hygiene practices.

One important factor known to influence hand hygiene factors is the availability and accessibility of equipment to carry out effective hand hygiene, such as antiseptic solutions. It is well-documented that compliance with hand hygiene is directly proportional to the accessibility and availability of products to decontaminate hands. In the context of the emergency department, where there are significant time and resource pressures, the time it takes to undertake hand hygiene and the accessibility of products to do so are important. Despite this, little evidence exists that examines the relationship between the positioning of hand hygiene solutions relative to the sink and its effect on hand hygiene compliance.

The site chosen for data collection, Princess Alexandra Hospital Emergency Department, has 21 sinks located in the patient care areas. All have a hand wash solution on one side of the sink and a moisturising solution on the other. Of these, 15 sinks have the hand wash solution on the left of the sink, and 6 have the hand wash solution on the right side. There is no consistency of hand wash solutions within the department, and as such the colour of the solution, the size and shape of the container, and their location relative to other resources is not consistent throughout the department. Figure 1 below illustrates a sink within the ED where hand lotion and hand wash are co-located.

SHORT TITLE
ABC’s(Armbanding, Barcoding, Compliance) of Patient Safety – Armbanding the Emergency Patient

FULL TITLE
ABC's(Armbanding, Barcoding, Compliance) of Patient Safety - Armbanding the Emergency Patient - Does technology reduce patient misidentification of pathology specimens - a prospective interventional observational trial in a large tertiary emergency department.
GRANT TYPE
Emergency Medicine Staff Specialist Research Grant
AMOUNT AWARDED
$42,200

Investigators

Dr David Spain Gold Coast Hospital Department of Emergency Medicine
Dr John Pierce Gold Coast Hospital Department of Emergency Medicine
Dr Julia Crilly Gold Coast Hospital Department of Emergency Medicine
Dr Gerben Keijzers Gold Coast Hospital Department of Emergency Medicine

Accurate identification of patients is critical to their safety and to the efficient management of health services. Without accurate identification incorrect procedures may be performed, patients may have unnecessary tests performed on them or there may be delays in their care as pathology or other tests must be repeated. We plan to study the process of patient identification during blood collection in the Emergency Department. This is the most common procedure performed in the Emergency Department. Mislabelling of pathology specimens can lead to fatal adverse events, such as incompatible blood transfusions. Results attributed to the wrong patient can lead to incorrect diagnosis and inappropriate future management.

In the chaotic Emergency Department environment, identification of critically unstable patients who require time critical treatment is even more important. These factors lead to increased risks associated with misidentification. Recently arm banding has been recommended as part of a new national standard to improve the patient identification process in Emergency Departments.

The process of accurate identification during blood collection requires certain behaviours that act as checks and balances to ensure accuracy and safety. Patient identification requires several identifiable steps (see table).

Steps in Patient Identification during blood collection

Error theory, classically represented by the “Swiss Cheese Model” shows failure of a single step rarely results in a poor outcome, but the failure of a succession of steps increases the risk. Identification during pathology collection has several critical tasks.

The first aim of this study is to examine in detail the behaviour of staff during the identification process of patients during blood collection in an Emergency Department. Secondly, it aims to identify whether the introduction of bar-coded arm banding and bar code readers improves the level of identity checking by emergency department staff during blood collection.

We will observe the management of a group of patients (approximately 100) to identify the steps taken by staff to identify them. We will then introduce a small number of bar-code readers and examine another group of 100 patient interactions. We want to see if the introduction of the technology along with an associated education program improves the identification process during blood collection.

FULL TITLE
End-of-Life Issues – Withdrawal of treatment / Decision not to treat in the Emergency Department: A prospective multi-centre study.
GRANT TYPE
Emergency Medicine Staff Specialist Research Grant
AMOUNT AWARDED
$50,000

Investigators

Dr Philip Richardson Royal Brisbane and Women's Hospital Department of Emergency Medicine, School of Medicine, University of Queensland
Dr Kevin Chu Royal Brisbane and Women's Hospital Department of Emergency Medicine Dr Jaimi Greenslade Royal Brisbane and Women's Hospital Department of Emergency Medicine, School of Medicine, University of Queensland

Not infrequently, doctors working in the Emergency Department (ED) have to decide on how they are to provide treatment to dying patients. Specifically, they have to decide whether to actively treat or whether they should limit or withdraw treatment on patients who are not anticipated to live. Such decisions should be governed by legislature as well as standards set by the Australian Council on Health Care Standards (ACHCS). However, research conducted in our hospital has indicated that doctors consider a wide variety of factors including patient’s and family’s wishes when making such end-of-life decisions. We therefore raise the following questions. First, what factors do doctors take into account when they withdrawal or withhold treatment in the ED? Second, are such decisions made in accordance with legislative requirements? To date, no research has examined this issue.

This study addresses this gap by focussing on the decisions leading to withdrawal of treatment in the ED. It is a multi-centre review of patients who die in 2009 in a number of Australian and New Zealand hospitals. The primary aim is to describe the factors that doctors consider when making the decisions to withdraw or withhold life-sustaining treatment. The secondary aims are to determine 1) whether Australian doctors are conducting such processes in line with ACHCS guidelines and 2) whether Queensland doctors are making such decisions in accordance with Queensland legislation.

SHORT TITLE
Improving detection on abusive injury in young children presenting to Queensland Emergency Departments; A comparison between 2 Paediatric Emergency Departments.

FULL TITLE
Comparison of the quality and completeness of the medical record and the proportion of appropriate referrals for suspected abusive injury of young children presenting to two representative Qld Paediatric EDs using traditional ED worksheets and purpose designed pre-printed worksheets both computer generated in EDIS and manually distributed
GRANT TYPE
Emergency Medicine Staff Specialist Research Grant
AMOUNT AWARDED
$24,898

Investigators

Dr Ronald Clark Royal Children’s Hospital Department of Emergency Medicine
Dr William Robert Pitt Mater Children’s Hospital Paediatric Emergency Department
Jennifer Crimmins Royal Children’s Hospital Children’s Advocacy Service
Dr Robyn Brady Mater Children’s Hopsital Paediatric Emergency Department

This study examines the data gathered and documented in patient charts with respect to the possibility of abusive injury in presentations by injured children under 2 years of age, as well as conclusions made by the treating doctor with respect to the possibility of abusive injury, and whether or not a consultation with an emergency or child protection specialist was made in reference to this issue.

These data are compared:
1/ Between two sample periods at the Mater Children’s Hospital before and after the introduction of an electronically generated proforma to prompt such data collection
2/ Between these samples and a matched sample from Royal Children’s Hospital which uses the prompting proforma but generates this manually.