The Foundation has improved Emergency Health Care through education, innovation and research.
Education
The Foundation provided training mannequins for doctors and nurses at Christchurch Hospital to learn and practice resuscitation of adults and children. The mannequins are computerised life-like models, allowing rehearsal of difficult resuscitations, just as a pilot might practice difficult landings in a flight simulator.
Innovation
The Foundation has helped implement new practices, such as using clinical decision tools to aid the diagnosis of some serious conditions, and the provision of pathways for ensuring good and efficient care of patients. These tools and pathways are outcomes of some of the research the Foundation has funded and consequently more detail is provided in the `Research' section, below. In addition, the Foundation assisted with the development of electronic transfer of ECGs (heart tracings) from the ambulance to the Coronary Care Unit, so that suitable patients could be `fast-tracked' to a definitive procedure called angioplasty.
Research
Most of the achievements of the Foundation have been related to the provision of staff salaries and equipment for the performance of research. The Emergency Care Foundation doesn't do research itself, but it funds New Zealand's only Emergency Nurse Researcher, and the activities of the Emergency Research Group based at Christchurch Hospital and the University of Otago, Christchurch.
Research success is often measured in terms of numbers of publications in journals and papers presented at conferences. Since the foundation began in 2003, and the Emergency Research Group was founded, its members have published more than 50 papers, abstracts or letters in medical or nursing journals. In addition, its members have presented at dozens of conferences throughout New Zealand and overseas.
This research has been mostly around three principle themes; access, accuracy and ethics.
`Access' research includes 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.
An extensive survey of patients attending the ED has been completed, resulting in the biggest dataset ever constructed, about who attends and why. This survey was a collaboration with the Canterbury District Health Board. The data is currently being evaluated and a report is being written.
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.
`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 of 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 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, and to a potential relationship with the manufacturer of the test. In Christchurch this has allowed the reassurance and discharge of patients with confidence.
Research into abdominal pain, syncope (collapse), and chest pain has led to preliminary plans for structured diagnostic and management pathways for such patients, which may include follow-up in acute clinics, rather than admission to hospital.
`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;
ß 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, the Foundation has provided equipment for education, and equipment and staff for innovation and research. Consequences of the research include many improvements in patient care and greater efficiencies in resource utilisation.
