key: cord-0695389-1tw9vw1q
authors: O'Reilly, GM; Mitchell, RD; Mitra, B; Noonan, MP; Hiller, R; Brichko, L; Luckhoff, C; Paton, A; Smit, D; Cameron, PA
title: Informing Emergency Care for all patients: The Registry for Emergency Care (REC) Project Protocol
date: 2020-05-28
journal: Emerg Med Australas
DOI: 10.1111/1742-6723.13558
sha: 4f04c06e0a4b75435bb1bb5e418d8f50ed6e725a
doc_id: 695389
cord_uid: 1tw9vw1q

OBJECTIVES: In Australia, the current emergency department (ED) burden related to COVID‐19 is from ‘suspected’ rather than ‘confirmed’ cases. The initial aim of the Registry for Emergency Care (REC) Project is to determine the impact of isolation processes on the emergency care of all patients. METHODS: The REC Project builds on the COVID‐19 Emergency Department Quality Improvement Project (COVED). Outcomes measured include times to critical assessment and management. RESULTS: Clinical tools will be generated to inform emergency care, both during and beyond the COVID‐19 pandemic. CONCLUSIONS: The REC Project will support ED clinicians in the emergency care of all patients. This article is protected by copyright. All rights reserved.

The number of patients with suspected COVID-19 presenting to emergency departments (EDs) will fluctuate throughout 2020. Although the current burden of confirmed cases in Australia remains low [1] , the pandemic has prompted important changes to clinical processes in the ED. There has been a widespread increase in the implementation of infection prevention and control (IPC) procedures and the establishment of isolation zones [2] .

The ongoing impact of the pandemic is likely to be substantial, affecting the resource allocation, care pathways and outcomes of all patients, regardless of their COVID-19 status. Further, the role of EDs in the syndromic surveillance for patients with communicable diseases will continue indefinitely.

Addressing these major and ongoing challenges will require robust systems for monitoring the presenting symptoms, assessment findings, management and outcomes for all patients presenting to the ED. While efforts to inform the clinical and system-level care of patients with suspected and confirmed COVID-19 have been initiated [3] , there is now a greater need for ED clinicians to understand the indirect effects of infection containment strategies, including the impact of IPC and isolation processes to emergency care provision. The implementation of systems that monitor presentations and outcomes on an ongoing basis will increase resilience, improving the capacity of EDs to care for all patients with acute illness and/or injury, not just those patients with communicable diseases [1] .

The aim of this manuscript is to introduce the Registry for Emergency Care (REC) study protocol. The first objective of the REC Project is to determine the impact of patient isolation and IPC processes on ED length of stay for adult patients. The complete list of medium-term and specific objectives of the REC Project are provided in Box 1.

The REC Project is a prospective cohort study, with a series of nested cohort studies (each with a pre-determined primary exposure and primary outcome). The current project site is the Alfred Hospital, Melbourne, with the opportunity for other Australian EDs to participate to form a REC network. The Alfred Hospital is a tertiary, adult, Level 1 trauma centre with an ED census of approximately 70,000. This article is protected by copyright. All rights reserved.

All patients presenting to the ED, aged 18 years or more, will be included. Outcomes measured will include ED length of stay, time to emergency procedures, ED disposition destination, ICU admission, the number of ventilator free days, hospital length of stay and hospital admission.

Variables to be collected will cover the spectrum of emergency care: demographics, presenting complaint plus comorbidities, processes of care (including time to emergency procedures), measures of severity (including first vital signs and triage category) and outcomes (including those listed above). The planned initial REC dataset is described in Box 2. These variables build on the existing COVED Project and COVED Registry and are mostly consistent with the variables in the WHO International Registry for Trauma and Emergency Care (IRTEC) [4] . The IRTEC has been developed as an important resource to help deliver the recommendations of last year's WHA Resolution 72.16 globally, including across the Indo-Pacific region [5] . The REC list of variables is flexible to change as new data emerges regarding outcome predictors and treatment strategies. Up to date versions of the case report form and data dictionary will be made available on The Alfred's academic programs website at www.emergencyeducation.org.au. This will facilitate standardisation of variables across other sites interested in participating.

Administrative data will be automatically exported from the Alfred Hospital's Electronic Medical Record (EMR); the data for the additional clinical variables will be captured from the tailored clinician form embedded in the EMR. All data will be entered into the novel REC utilising Research Electronic Data CAPture (REDCap) software (licensed to Monash University) [1, 3] . Analyses will be conducted to meet the objectives listed in Box 1.

Medicine regarding research priorities during the COVID-19 pandemic [2] . Ethics approval for the This article is protected by copyright. All rights reserved.

The REC Project will inform real-time improvements in ED care; it will determine the clinical predictors of patient-centred outcomes for all patients seeking emergency care, and guide systems design, resource allocation and clinical management in order to meet current and future challenges.

In the short-term, it will help mitigate the indirect effects of COVID-19 and the impact of virus containment strategies.

 To monitor ED presentations for presenting complaints consistent with conditions of public health importance (e.g. syndromic surveillance for respiratory infections with epidemic potential) a ;

 Among all patients presenting to the ED (P), to determine and regularly monitor the impact of patient isolation (primary exposure variable (E)) during ED presentation versus no isolation (C) on clinical and system outcomes relevant to emergency care (O) (i.e. to use the REC to examine the impact of isolation for all ED presentations) b ;

 Among clinically identified subgroups of patients presenting to the ED (defined by triage category, presenting complaint, first vital signs and/or ED callout criteria)(P), to determine and regularly monitor the impact of isolation (primary exposure variable (E)) during a patient's ED presentation) versus no isolation (C) on clinical and system outcomes relevant to emergency care (O)) (i.e. to use the REC to examine the impact of isolation for selected clinical subgroups of ED presentations) a ;

 Among all and clinically identified subgroups of patients presenting to the ED (defined by triage category, presenting complaint, first vital signs and /or ED callout criteria) (P), to determine and regularly monitor additional predictors and risk factors (other than isolation in the ED) (E/C) for clinical and system outcomes relevant to emergency care (O) (i.e. to use the REC to guide and improve care for all ED patients) b .

 To use the REC to provide useful, timely and regular (minimum of monthly) reports to inform and improve clinical care and system processes in the ED b . This article is protected by copyright. All rights reserved.

Epidemiology and clinical features of emergency department patients with suspected COVID-19: Initial results from the COVID-19 Emergency Department Quality Improvement Project (COVED-1)

Clinical Guidelines for the Management of COVID-19 in Australasian Emergency Departments

Informing emergency care for COVID-19 patients

Emergency Department Quality Improvement Project protocol

World Health Assembly Resolution 72.16: What are the implications for the Australasian College for Emergency Medicine and emergency care development in the Indo-Pacific

Associate Professor Gerard O'Reilly is currently a NHMRC Research Fellow at the National Trauma Research Institute, Alfred Hospital, Melbourne, Australia, leading the project titled: Maximising the usefulness and timeliness of trauma and emergency registry data for improving patient outcomes. This article is protected by copyright. All rights reserved.Accepted Article