L-EMeRG - Newsletter

The specialty of Accident and Emergency Medicine is a small fish in the large pool of academic medicine. A well-known Anaesthetist is fond of pointing out that the U.K. has more Professors of Oral Hygiene than Emergency Medicine. However the opportunities for research offered by the volume and spectrum of clinical material passing through A&E departments is unrivalled and the existing evidence base for many of the investigations and treatments used in clinical practice is poor.

The reasons for the specialty's weak research base have been well documented. Heavy service commitments, the practicalities of conducting rigorous research in emergency situations and the lack of an established group of researchers to provide support and advice are all barriers to research success. Yet developing a credible track record in research is fundamental to the acceptance of Accident and Emergency Medicine and Nursing by peer specialties as an equal. It is also vital to ensure that patients receive proven and effective treatments.

Leeds has the potential to become the leading centre in the U.K. in Accident and Emergency Medicine and Nursing. A reputation for excellence in clinical care already exists however with a few notable exceptions Accident and Emergency research in the city has been sporadic and disjointed. L-EMeRG has been founded by a group of nurses and doctors to provide leadership in A&E research in the city. The group hope to achieve this by encouraging and supporting the ideas and energy of all those in the health community with an interest in the wide spectrum of Emergency Medicine and Nursing. A track record of excellence and success in research will take many years to achieve, however we hope that in future years L-EMeRG will be seen as having played a role in establishing Leeds as a leading centre of UK A&E research.

Graham Johnson, Chairman

Mr Graham Johnson, Chairman,

Consultant in Accident and Emergency Medicine,

St James's University Hospital and Medical Director, West Yorkshire Metropolitan Ambulance Service

Dr Taj Hassan, Secretary,

Consultant in Accident and Emergency Medicine,

Leeds General Infirmary

Mr Bob McMaster,

Lecturer in Nursing,

University of Leeds and Nurse Consultant in Accident and Emergency Medicine, Leeds Teaching Hospitals Trust

Dr Steve Crane,

Research Registrar,

St James's University Hospital

Dr Alasdair Gray,

Consultant in Accident and Emergency Medicine,

St James's University Hospital

Sister Heather McClelland,

Accident and Emergency

Department, Leeds General Infirmary

Dr Julen Gomez,

Staff Grade in Accident and Emergency Medicine,

Leeds General Infirmary

Dr Paul Gaffney,

Specialist Registrar,

Accident and Emergency Department,

Pinderfields General Hospital

The formation of the Leeds Emergency Medicine Research Group in November 1999 was the result of a critical need identified by doctors and nursing staff in the city. One year later it is important to record what has been achieved.

The needs of the staff in Emergency Medicine as well as on-going research activity was evaluated using a questionnaire study design. I am especially grateful to Dr Alison Walker for all her hard work in this regard. We hope that L-EMeRG will be able to fulfil these needs over the coming years.

The L-EMeRG Committee was formed to develop a strategy to meet the needs identified by the questionnaire. This group consists of doctors and nurses with representatives from both sides of the city. The group identified core objectives :

• To develop a clear and co-ordinated research agenda for Emergency Medicine in Leeds.
• To provide multi-disciplinary support for all those interested in research in Emergency Medicine in Leeds.
• To develop and enhance staff capabilities to define, perform, present and publish high quality research at a regional, national and international level.
• To significantly increase the quantity and quality of research publications produced by the Departments of Emergency Medicine in the Leeds Teaching Hospitals.

A number of other projects are also on-going.

During the first year we held 4 Forum meetings on both sides of the city. These provided an opportunity for research ideas to be discussed (in a relatively non -confrontational environment!), information of on-going research activities and a number of invited guest lecturers to stimulate ideas for further research activity. We look forward to suggestions for future meetings from all members of staff.

With data derived from the initial questionnaires we were able to develop and set up a database of ongoing research activity within the city. This information will be useful to individuals as well as providing good quality data to the Trust of the speciality's research output within the city. We hope that in the near future this database will be accessible on an intranet site being developed.

The L-EMeRG intranet site will be part of the Emergency Medicine Information Bank (EMIBank) which it is hoped will go 'live' in April 2001. This site will give information on :

• the group's strategy
• what to research
• funding opportunities
• how to convert an idea into a protocol
• on-going research activities
• an on-line submission form for research ideas.
• the newsletter

The Group is keen to provide a service where doctors and nurses have an opportunity to submit their ideas for initial critique and feedback prior to full submission to the Ethics Committee and the Trust's R&D.

It is hoped that the EMIBank will by the end of the year go onto the World Wide Web with limited access to certain aspects of the site.

The L-EMERG committee have put much effort into the Group's first year and I am grateful to all of them for their help and support. The achievements listed above are a solid platform from which we hope we will succeed in raising the research profile of Leeds and Yorkshire both nationally and internationally. Informal feedback suggests that the changes made thus far have been significant first step in this process.

We hope that in the coming year you will choose to contribute with your ideas, perform studies which lead to completed research and publications, suggest and co-ordinate collaborative research with other specialities or at the very least, support the Research Forums with your attendance. We also look forward to support and contributions from other Departments of Emergency Medicine within Yorkshire.

If you are interested in your speciality and want to see it flourish then that is what is needed!

Dr Taj Hassan,

Secretary - L-EmeRG

Research School and Faculty of Medicine, Dentistry, Psychology and Health, University of Leeds

Dr David Owens, Course organiser, Lesley Patchett, Secretary

This course was formally launched in February 1999 and all who work in the health care arena are eligible to apply.

It is based on individual modules covering topics relevant to health research (introduction to research, capturing data, handling data, writing and disseminating, analytic research, and intervention research). The six modules included in the certificate level are covered in approximately 5 months. The teaching element of each module is spread over 2, 3 or 4 days depending on the number of credits available for that particular module (for example, a 5-credit module will usually necessitate 2 days of attendance). The emphasis is on active forms of learning such as problem-based classes, workbook exercises, computer use and group participation. Formal assessment is based on the quality of submitted homework (a 5-credit module may necessitate 40 hours of a student's private study time).

Alasdair Gray, Steve Crane and Paul Gaffney have attended this course so far and their feedback has been largely positive. It is planned to extend the course to diploma level and ultimately to MSc level.

To date R&D have helped secure funding ('training bursaries') for those who have attended this course. Further details available from Nancy Lester, R&D, Clinical Sciences Building, St James's University Hospital.

Contact l.a.patchett@leeds.ac.uk

0113 - 2332728

Health care practitioners can no longer ignore the challenges & centrality of research in practice.

Nursing needs to be dynamic to meet the changing needs of the patients but so too must the education & preparation of Nurses.

R&D strategy for the NHS Est. 1991 has addressed the need to know outcomes from patient's care and treatment. It is not good enough just to say we do it this way because we always have! We need to know what we are doing is being effective.

There are increasing numbers of health care professionals who are resolving their own uncertainties about research by undertaking research appreciation courses in which their insight and knowledge of the subject can be increased.

Research awareness is all about being prepared to ask questions and look for answers and whilst not all of us will be researchers, we should all be aware of research relevant to our practice and be able to use that knowledge within our work.

Undertaking Research Roles, whilst demanding are also extremely rewarding. There is a huge scope for personal and professional growth encompassed within the Role.

. Development of Research Awareness and Skills

. Development of Leadership Skills

. Development of I.T. skills

. Increased confidence in managing difficulties

. Opportunities to increase your presentation skills

. Academic opportunities

Research based practice is fundamental to the development of Nursing. In order to enhance the service we provide, the ways in which care is delivered must be explored.

I consider there a real need for Research-practitioner roles within the Nursing Profession.

Combining a Clinical role with a Research role whilst having responsibility for:

. Development of Research awareness

. Fostering a Research culture within their department/ ward/ unit

. Undertaking Research projects within the department/ward/unit with questions generated from issues important to all clinical staff.

There is a real need for more opportunities for nurses to become proactive and involved in Research work.

Seconded placements for Nurses in to Research are a huge investment all round, not only for the individuals and their projects but also for research work in the Trust as a whole.

Sarah Gill Research Nurse , Accident & Emergency

No one said that a randomised controlled trial of non-invasive ventilation in the treatment of LVF in the A&E department was going to be easy, but the 3PO study continues to plod on and I suspect it will end up taking a year to collect all the data. So far I have identified a total of 115 patients who were probably eligible for inclusion into the study. Of these only 37 have been included. Normally a inclusion rate of only one in three would not be viewed as being particularly representative, but thankfully I have collected some data on those not included and I'm certain that these are largely similar to those randomised to the study. Twenty seven have been unable or unwilling to provide consent, 15 patients no longer fitted the inclusion criteria at the time I arrived to consent them (i.e. they got better or significantly worse) and in 8 cases it was frankly just too inconvenient for me to go and see them (e.g. I was on holiday, doing an exam or stuck in traffic!).

In 28 cases I was not phoned about the patient at all, so if I'm going to get any message across from this piece of prose its please, please continue to phone me whenever you see a potential patient!!

As obtaining informed consent for the 3PO study has been one of the most difficult aspects (apart from getting up in the early hours) I have detailed below some of the important considerations in relation to consent in emergency medicine research.

1) The Nuremberg Code (1949)

. The voluntary consent of the human subject is absolutely essential.

. The experiment should be such as to yield fruitful results for the good of society.

. The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.

. The human subject should be at liberty to bring the experiment to an end ...

2) The declaration of Helsinki (1964; amended 1975)

. In any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. He/she should be informed that he/she is at liberty to abstain from participation in the study and that he/she is free to withdraw his/her consent to participation at any time. The physician should obtain the subjects freely-given informed consent, preferably in writing.

. In case of legal incompetence, informed consent should be obtained from the legal guardian.

. Whenever the minor child is in fact able to give a consent, the minor's consent must be obtained in addition to the consent of the minor's legal guardian.

3) General rules of consent (RCP reports - 1990; GMC - 1998)

. Patients should know they are taking part in research.

. Research involving a patient should only be carried out with the patient's consent.

. The research is not contrary to the individual's interests.

. The results are not predictable.

. Potential participants must be given the fullest possible information, presented in a form they can understand. This must include information on potential risks and benefits.

. Participants must have the opportunity to read and consider the information leaflet and have sufficient time to reflect on the implications of participating in the study.

. You must not put pressure on anyone to take part in the research.

. You must obtain the person's consent in writing.

. You must obtain approval from a research ethics committee.

. You should seek further advice where research will involve adults who are unable to make decisions for themselves or children. In these cases the legal position is unclear or complex, and there is no general consensus on how to balance the risks and benefits to vulnerable individuals against the public interest.

4) Consent in emergency medicine research

In 1990 the RCP recognised 5 exceptions to the main rules of consent:

. Observational research which is totally without risk or intrusiveness,

. Innocuous research into comprehension,

. Examination of anonymous specimens,

. Research based on medical records,

. Research into the management of unexpected overwhelming emergencies.

Where the severity of the patient's illness renders him incompetent to give consent..

. There is no provision in law which provides for another individual to give consent on their behalf.

. A doctor may proceed with TREATMENT in such

circumstances, providing he acts in the best interests of the patient and in accordance with a practice which is accepted by a reasonable body of medical opinion.

. The same general rule may apply to RESEARCH but the position is very unclear.

. The decision as to whether to continue with a research study without the patient's consent should be made by the ethics committee.

. A near relative should be informed of the nature of the research and how the patient will be involved.

. The patient should be told of participation in the research when they have recovered sufficiently to comprehend.

5) Alternatives to obtaining prospective, informed consent

. "prior discussion"

. i.e. discussion of the proposed research with members of the population at risk of the adverse event before the event occurs.

. E.g. research on the resuscitation of the sick, newborn could be discussed with all expectant mothers.

. E.g. research on treatments for cardiac arrest could be discussed with all in-patients.

. "Waiver of informed consent"

. guidance issued by the FDA. No similar guidance in the UK.

. An IRB (ethics committee) may grant a waiver of the duty to obtain informed consent if certain, usually very strict, conditions apply

. Zelen's Method

. i.e. randomising all eligible patients BEFORE obtaining consent.

. Only informing those who are randomised to the treatment arm(s) to ensure they are happy with being on an experimental therapy and giving them an opportunity to withdraw from the study.

. Not informing patients who are randomised to standard therapy

. Analysing the data according to their original randomisation group and not on the treatment they actually receive.

. This method should ensure greater numbers of patients within a study but may mean an excess of patients having control treatment having being randomised to the experimental therapy.

Trying to adhere to all the rules of consent is very difficult in emergency medicine trials, particularly those involving very sick patients. A waiver of the duty to obtain consent would seem the most attractive but it is extremely difficult to obtain and may require a public consultation exercise (including widespread advertising and discussion at public meetings) before it is granted. If a study like the 3PO study is to be considered again, I would try to get the ethics committee to approve a Zelen's methodology. Andy Lockey suggested that the 3PO Study might kill me; he migh..

Steven Crane 9/1/01

SpR in A&E Medicine

    J Accid Emerg Med 2000;17(3):199-200.

. Doctors assistants-do we need them? H Law, J Sloan.

    J Accid Emerg Med 1999;16(2):114-16

. A survey of needlestick injuries in paramedics and technicians in The West Yorkshire Metropolitan Ambulance Service. P Gaffney, T Carrigan, G Johnson. Prehospital         Immediate Care 2000;4:30-33.

. Toxicological screening in trauma. TD Carrigan, H Field, RN Illingworth, P Gaffney, DW Hamer. J Accid Emerg Med 2000;17:33-37.

. Doctors assistants-do we need them? H Law, J Sloan.

J Accid Emerg Med 1999;16(2):114-16

. NHS Direct in West Yorkshire. P Gaffney.

Yorkshire Medicine 1999; 11(4):82-3.

. Echoes of things to come. Ultrasound in UK emergency medicine practice. J Brenchley, JP Sloan, PK Thompson

J Accid Emerg Med 2000;17(3):170-75

. Paediatric pre-hospital trauma care.

P Gaffney, G Johnson.

Trauma 1999;1(4):279-284.

. Survey of the use of rapid sequence induction in the Accident and Emergency department.

A Walker, J Brenchley

J Accid Emerg Med 2000;17(2):95-7

. Too much to read and not enough time. A suggested reading list for Specialist Registrars. H Law, F Andrews, Yorkshire Accident and Emergency trainees. J Accid Emerg Med (In press).

. Paediatric pre-hospital care: postal survey of paramedic training managers.

P Gaffney, G Johnson. Arch Dis Child (In press)

. The effect of introduction of NHS Direct on telephone enquiries to an A&E department.

J Jones MJ Playforth

J Accid Emerg Med (In press)

. Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital.

AS Lockey RD Hardern Resuscitation (In press)

Scientific meeting of The Faculty of Accident and Emergency Medicine 2000

. Views and needs of specialist registrars on research in A&E medicine

A Walker, TB Hassan, A Gray

. 'Herbal highs'-natural and safe or nasty and scary.

C Doughty, A Walker

. Can a CD-ROM teaching programme improve the confidence of A&E SHO's in assessing deliberate self-harm patients? A Walker, J Brenchley

. Eliminating barriers to rapid thrombolysis in A&E. Are the targets appropriate and achievable? AA Khan, A Taylor, C Kirke et al

. The facts of death. P Gilligan, D Hegarty, C Muldoon et al

. A survey of needle stick injuries in paramedics and technicians in West Yorkshire Metropolitan Ambulance Service. P Gaffney, G Johnson

.

999 EMS research forum, Harrogate, July 2000

. Are paramedics prepared for paediatric emergencies?

P Gaffney, G Johnson.

. 999 cases attending A&E departments - a comparison of those who did and those who did not first call NHS Direct. P Gaffney, S Crane, G Johnson, M Playforth.

. Does risk stratification apply to British A&e patients presenting with acute syncope? S Crane

. An analysis of 999 referrals made by NHS Direct. P Gaffney, S Crane, G Johnson, M Playforth.

. The trauma special study module website.

P Gaffney, G Johnson.

. Paediatric pre-hospital care: postal survey of paramedic training managers.

P Gaffney, G Johnson.

York Medical Society 2000

. Are paramedics prepared for paediatric emergencies? P Gaffney, G Johnson.

Scientific meeting of The Faculty of Accident and Emergency Medicine 1999

. Use of anti-D immunoglobulin in the management of threatened miscarriage in the A&E department. L Weinberg

. Toxicological screening in trauma. TD Carrigan, H Field, RN Illingworth, P Gaffney, DW Hamer.

. Is pain being adequately assessed and managed in paediatric Accident and Emergency patients?

F Andrews, P Gaffney,

A Whitehead