Emergency Research - Emergency Department

The Emergency Medicine Research Group

Background
Areas of Research Interest of EMNRG
Research Group : Terms of Reference
Improvements in Patient Care Consequent to EMNRG Activities
The Emergency Care Foundation

Background:

The EMNRG was formally established in July of 2002, building on existing systems and personnel.
The need for a research group to co-ordinate and oversee departmental research was evident in the number of projects already running and in the expressions of interest from other areas wanting to conduct research in the ED.
The members of the group represent various elements and interests within the ED and include:

Prof. Mike Ardagh, as the Professor of Emergency Medicine at the Christchurch School of Medicine and Health Sciences, based in Christchurch Hospital, was responsible for developing the research group. He has longstanding interests in research and an expertise in the areas of ethics and resuscitation. Emergency Medicine is an emerging academic speciality and his research output in this area is among the greatest in Australasia.

An innovative step was the creation of a clinical Nurse Researcher position, with a view to co-ordinating research opportunities and to develop nursing research projects. Sandy Richardson was appointed to this position in July 2002, and has been enthusiastic in the development of the role and scope of practice associated with this. She has a commitment to the integration of research and practice, and to ensuring the expansion of a strong nursing knowledge base.

Dr Martin Than, Emergency Department Consultant, has a strong interest in evidence-based practice, and in developing research based around clinical care protocols and investigations. In addition to his research interests, he has proved tireless in seeking funding and support for the work of the research group.

Dr Phil Hider, senior lecturer in clinical epidemiology in the Christchurch School of Medicine and Health Sciences, has research and undergraduate/postgraduate teaching expertise in evidence-based practice and quality improvement. He brings a wealth of expertise and his work within the Christchurch School of Medicine and Health Sciences (CSMHS) brings new insights and approaches.

Given the collaborative nature of Emergency Medicine, and the developing focus on post-graduate education and research amongst nursing practitioners, a strong nursing representation was sought. Anne Esson is the Nurse Manager for the Emergency Department, and encourages the development of research-based practice, and further education for nurses working in the area of emergency nursing.

Kristi Calder joined the group in 2004, bringing with her experience in recruitment and follow-up of study participants. She has created and maintained databases for a number of current research projects.

Areas of Research Interest of EMNRG

Areas of research interest can be grouped into four main categories:

‘Access’ research explores issues related to ED attendance, appropriateness, overcrowding and access block.
‘Accuracy’ research explores clinical predictors of disease, and the development of clinical decision-making tools. Projects in this regard include Acute Coronary Syndrome, Pulmonary Embolism (clots in the lung), deep venous thrombosis (DVT) and abdominal pain.
‘Ethics’ research.
‘Other’ research, including poisoning, and trauma imaging.

Research Group : Terms of Reference

Rationale
Purpose Statement

Rationale

In order to ensure that research resources and efforts are used to their maximum effect, it is necessary to clearly formulate a purpose statement encapsulating the aims and objectives of the Emergency Medicine and Nursing Research Group (the Group) with regard to research to be carried out in the Emergency Department of Christchurch Hospital. In association with this, a number of research strands will be identified to help focus the use of the available resources. It is envisaged that these strands will encompass the existing interests of the department, but will be aligned to reflect government priority health objectives and to relate to funding priority objectives. This is not to imply that these guidelines will necessarily be exclusive, as worthwhile research that falls outside these boundaries will still be considered by the Group.

Purpose statement

Research is recognised as both a formal requirement for some staff and an anticipated academic and professional strategy for all. The Christchurch Hospital Emergency Medicine and Nursing Research Group has been established to:

facilitate the ongoing research endeavours of individuals and groups, which relate to the provision of emergency care

promote and educate staff regarding Evidence Based Medicine (EBM) and Evidence Based Nursing (EBN)

guide and support staff in their research efforts

co-ordinate research activities in the Emergency Department (ED)

monitor and audit the progress of research in the ED

maintain appropriate professional practice with regard to research

The aim of the group is to facilitate the recognition of the Christchurch Hospital Emergency Department as a Centre of Excellence for Emergency Research.

Improvements in Patient Care Consequent to EMNRG Activities

The research of the EMNRG was varied but mostly consistent with three principal themes: access, accuracy and ethics. ‘Access’ research included work related to waiting times in Emergency Departments, Emergency Department Overcrowding and alternative forms of care.

Research does not, in itself, bring about improvements in care, but it provides the knowledge so that improvements might then occur.

Specific improvements that have occurred as a result of this research area include the following:

The concept of ‘inappropriate’ Emergency Department (ED) attendance – there is a perception that ED overcrowding is largely due to people using the ED when they should have gone to a General Practitioner. Research done in Christchurch suggests this is not the case, and that there is no consensus among health care providers as to what constitutes appropriate use of the ED. This research has prompted a PhD student to embark on an extensive project to develop a consensus about who, ideally, should go to the ED and who should go to a GP. A consequence of this will be a more accurate assessment of ED utilisation, and more evidence based development of services for emergency health care. A principle underpinning this work is that lasting solutions to access to care involve lowering barriers to appropriate care, rather than raising barriers to care perceived to be inappropriate.

The ‘Cardiac Failure Analogy’ of ED overcrowding (developed by members of the Group, published in medical and nursing journals, and presented at national conferences and meetings) has allowed the development of a template for solutions to ED overcrowding. This template has been used in Christchurch and is contributing to an improvement to ED patient waits, privacy and comfort.

The Group is contributing to the development of an innovation in emergency health care called the ‘Emergency Practitioner Project’. This is based on research conducted in England and involves ‘up-skilling’ ambulance paramedics to perform more advanced patient assessments at the patient’s home. More patient specific interventions can then be instituted, including alternative community care options.

‘Accuracy’ research is about improving the diagnostic accuracy of health care professionals involved in Emergency Care. Meningitis is a well-publicised condition which is misdiagnosed from time to time. There are many conditions which masquerade under the guise of a more benign condition - meningitis looking like the ‘flu’, myocardial infarction (heart attack) looking like indigestion, pulmonary embolism (clots in the lung) looking like a chest infection or a muscle strain, are a few examples.

The Group has projects in the areas of acute abdominal pain, acute myocardial infarction and pulmonary embolism and intends to study meningitis when resources allow. The pulmonary embolism research is ongoing but already has an international reputation. Much of the Emergency Care Foundation’s funding has been put towards this research project. Specific improvements in patient care as a result of this research theme include:

A specific risk assessment tool has been incorporated into blood test request forms for patients with possible pulmonary embolism presenting to Christchurch Hospital Emergency Department. This tool assists doctors determining which patients can go home and which need further investigations. The further investigations in question are a form of scanning of the patient’s chest. These investigations are costly, involve a wait for the patient, and sometimes cause harm due to radiation, reaction to injected drugs or incorrect interpretation of the result. Consequently, the use of these tests should be restricted to those who really need them. This tool improves the accuracy of test ordering.

The Pulmonary Embolism research has revealed that a blood test result helps to exclude the diagnosis of Pulmonary Embolism with a very high level of accuracy. This result is of considerable international significance and has resulted in a number of presentations at conferences. In Christchurch this has allowed the reassurance and discharge of patients with greater confidence.

Research into abdominal pain and syncope (collapse) has led to preliminary plans for acute abdominal pain and syncope clinics. The research has indicated a potential benefit of these clinics for the prompt follow-up and investigation of patients with these presentations.

Ethics’ research concerns the process of ethical decision-making in the Emergency Department and Emergency Care. Professor Ardagh has a PhD in Bioethics and has continued work in this area, with the assistance of the Group.

Specific improvements in patient care as a result of this research theme include:

The ‘Ethics Toolkit’ for Emergency Care has been constructed and shared with audiences at conferences and meetings throughout New Zealand, and in Australia and the United Kingdom. It is regularly used to teach staff in Christchurch, and to assist with decision-making in individual cases. It is the subject of interest from an international publishing house as a potential book to guide Emergency Health Care providers worldwide.

Guidelines for the handling of material (clothing etc), the performance of examinations and procedures, when these things might be the subject of police investigation, have been produced as an outcome of the research regarding the Forensic Nurse Practitioner in the Emergency Department.

A further research theme relates to management of the poisoned patient and, in particular, the use of interventions to prevent the poison being absorbed into the blood stream (eg. gastric lavage, or stomach washout/pump).

Specific improvements in patient care as a result of this research theme include:

This research revealed that gastric lavage (stomach washout/pump) had limited utility in the management of poisoned patients. Consequently, (and the publications and presentations of the group made this a consequence for all New Zealand Emergency Departments), this invasive and unpleasant procedure is done infrequently now.

Further research revealed that, although the use of ‘activated charcoal’ is much better than gastric lavage, supportive care is of greatest benefit for the poisoned patient.

A consequence of the poisoning research is that admissions to hospital are greatly reduced, with most patients having short-term observation under the care of Emergency Department staff instead. This allows the patient home much earlier, as well as reducing the use of a limited hospital resource.

In summary, consequences of the research of the EMNRG include many improvements in patient care and greater efficiencies in resource utilisation.

The Emergency Care Foundation

Our Mission Statement:

To help ensure that Emergency Care is the best it can possibly be.

To date there has been limited research undertaken into the many facets of emergency care, leaving many important question unanswered of both a medical and administrative nature. Unfortunately neither hospitals nor health boards fund this. The Emergency Care Foundation was set up in December 2003 by Professor Mike Ardagh and Dr Martin Than. Its primary focus is ‘leadership’ in Emergency Care and answering unsolved question to benefit all practitioners.

While the term Emergency Care covers the practice of Emergency Medicine it also includes other aspects of the management of unwell or injured persons such as first aid, rescue and pre-hospital care and covers Emergency Care Foundation’s future research into all aspects of emergency care.

Currently the foundation is involved in research at the Christchurch Hospital. Emergency Research - Emergency Department - Christchurch HospitalThe research is focused upon five important goals.

Establish solutions to the problems of people accessing appropriate Emergency Care. This research will specifically examine methods of reducing waiting times and overcrowding in Emergency Departments.
Undertake research leading to improvements in diagnostic accuracy and decision making in emergency care, particularly in relation to conditions which can be difficult to diagnose (heart disease, blood clots in the legs and lungs and infections like meningitis).
Improve knowledge about the best way to manage a variety of emergency conditions.
Initiate research leading to advancements in relation to ethical decision-making in emergency care.
Improve access to emergency care for all those who might need it and improve the diagnostic and decision-making accuracy of doctors and nurses working in emergency care.

For more information about the Emergency Care Foundation, please visit their website www.emergencycare.org.nz