Lessons from surge disaster response simulation activities

Purpose: Emergency Departments (ED) play a sentinel role in disaster responses, from decontamination and triage to stabilisation of patients, while continuing to provide routine medical care for existing and new patients. However, the low frequency of disasters and patient surge and major internal catastrophes limits preparedness among emergency personnel. Aims: The aims of this study were to report how Patient Surge Disaster Response simulation activities impacted interagency preparedness and informed future planning of disaster preparedness training. Methods: We developed and delivered two tabletop ED reception activities and one in-person chemical, biological, radiation (CBR) decontamination scenario for a multi-disciplinary group of clinicians and senior administrators. Data were collected from participants and faculty via preand post-questionnaires and notes from debriefings and verbal feedback from faculty. Descriptive statistics were used to summarize numerical data and thematic analysis for textual data. Results: From around 100 participants, the preand post-questionnaires were completed by 73 (pre-PSDR) and 56 (post-PSDR). Participant professions in the pre-intervention and post-intervention questionnaires were similar. Participants' self-assessment demonstrated significant improvements in understanding and identifying roles, teamwork and confidence in disaster responses (p<0.001 for all outcomes). The key theme from qualitative data was that the capability of the response will influence future preparedness activities, including staff training, interdisciplinary collaboration, and equipment maintenance. Conclusion: Inter-agency simulation learning events were associated with improved confidence in preparedness and team response. These findings indicate the need for regular activities to ensure frontline staff are familiar with and prepared for disaster responses

The Australasian Resuscitation In Sepsis Evaluation : fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. Results: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy

Potentially preventable trauma deaths: A retrospective review

Reviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths. We conducted a retrospective review of prehospital and early in-hospital (<24?h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded. Of the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation. The number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved

Time to analgesia for care delivered by nurse practitioners in the emergency department: a retrospective chart audit

Objectives To evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by measuring: 1) Evaluate time to analgesia from initial presentation 2) Evaluate time from being seen to next analgesia 3) Pain score documentation Background The delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance. Methods A retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED Patient Information System (Cerner log) and data were extracted from electronic medical records Results Pain scores were documented in 67 (52.3%; 95% CI: 43.3-61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30-87) minutes, with 34 (26.6%; 95% CI: 19.1-35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1-24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients that received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12-50) minutes, with 65 (61.3%; 95% CI: 51.4-70.6) patients receiving analgesia within 30 minutes of assessment. Conclusions The majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research

Acute traumatic coagulopathy

Massive haemorrhage remains a leading cause of mortality post injury worldwide. Traditional methods of resuscitation that used large volumes of crystalloids followed by packed red blood cells with delayed consideration of impaired coagulation may be harmful. In response, trauma centres have initiated massive transfusion guidelines or protocols to guide resuscitation of haemorrhagic shock. This thesis starts with an evaluation of the effectiveness of massive transfusion guidelines to guide initial trauma resuscitation. A weak association of massive transfusion guidelines with improved patient outcomes is demonstrated, with reasons behind any improvement remaining elusive. To define this problem further, a standardised definition of massive transfusion has been developed, one most applicable to the acute care setting. Using this clinically useful definition, the subgroup of patients requiring massive transfusion remained difficult to predict and the level of evidence for current guidelines was shown to be low, incorporating multiple biases and confounders. Upon attempting to correct for these limitations, conclusions different to those guiding the composition of current massive transfusion guidelines were evident. A small proportion of major trauma patients have impaired coagulation- most likely commencing at the scene of trauma and well established upon presentation to hospital. The implications of this acute traumatic coagulopathy (ATC) during trauma resuscitation in being associated with early death are highlighted and despite overall improvements in patient outcomes post trauma in the last decade, outcome in the critically ill subgroup of patients with ATC remain relatively unchanged. Trauma patients most likely to benefit from massive transfusion guidelines are those with ATC and in the absence of ATC, proactive administration of high volumes of plasma, as guided by current massive transfusion guidelines, were not associated with any survival benefit, while exposing patients to the adverse effects of plasma. One of the reasons for this lack of progress in improving outcome in patients with ATC has been the inability to select a sufficient sample of patients with ATC into a study population. As ATC is relatively uncommon (about 8% of all major trauma patients), inclusion criteria of previous studies had selected only a small proportion of those with ATC resulting in studies being underpowered for the effect size being measured. To bridge this gap, a pre-hospital physiological scoring system to enrol patients into prospective trials with a high specificity is presented and subsequently prospectively validated. The usefulness of the score to recruit a high proportion of patients with ATC is further demonstrated in a prospective comparative study. In planning for future studies, this thesis discusses the limitations of current randomised controlled trials in directing management of ATC and highlighted reasons as to why, despite level I evidence, the uptake of these agents into massive transfusion guidelines have been poor. Acute traumatic coagulopathy is a complex entity, increasing in complexity through new discoveries, and is unlikely to be reversed by a single treatment. Rather, development of effective trauma systems and management guidelines that incorporate multiple agents evaluated through robust clinical trials should be the target of further research. The research design of a multi-centre prospective randomised controlled study, developed using the findings of this thesis, is presented