Critical care research and pre-emptive informed consent: a practical approach used in Chris Hani Baragwanath ICU

Consent in covid: A researcher's dilemma

An informed consent is a vital component of health care and forms an important component of any research study. Informed consent is the process where a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. A proper consent is imperative to ensure safety of the patients. However, obtaining a consent in the hospital settings has become a matter of concern in the times of this coronavirus-19 (COVID-19) pandemic. This brief review describes the additional complexities added to the consent for research and the various modifications needed in view of this pandemic. The current consent proformas need to be modified and individualised to the patient ensuring patient safety during research in the ongoing pandemic. We need to become more familiar with the technology and electronic tools as the acceptable alternative tools of communication in the current scenario. There is a need to incorporate a separate covid consent with due consideration to deferred consent, pre-emptive consent or waiver of a consent.

Effectiveness of participant recruitment strategies for critical care trials: A systematic review and narrative synthesis

BACKGROUND

Critical care trials are limited by problems with participant recruitment, and little is known about the most effective ways to enhance trial participation. Despite clinical research improving in the past decades within intensive care, participant recruitment remains a challenge. Not all eligible patients are identified, and opportunities for enrolment into clinical trials are often missed. Interventions to facilitate recruitment need to be identified to improve trial conduct in the critical care environment. Therefore, we aimed to establish the effectiveness of recruitment strategies in critical care trials in order to inform future research practice.

METHODS

Databases including MEDLINE, Embase, CINAHL and PsycINFO were searched for English language papers from inception to February 2020. The objectives were to: (1) establish the effectiveness of recruitment strategies and (2) recommend how effective recruitment strategies can inform research practice. Two reviewers independently assessed papers for inclusion and critically appraised the quality of the studies. Discrepancies were discussed within the research team. Relevant data were extracted and thematically coded into five overarching themes using a narrative synthesis approach. The review was prospectively registered on PROSPERO (CRD42019160519).

RESULTS

The search resulted in 2509 initially identified articles, with 15 that met the inclusion criteria. Articles reported a combination of quantitative, mixed methods and qualitative studies and a range of low-, moderate- and high-quality studies. Although, in-keeping with narrative synthesis approaches, none were excluded based on methodological quality. Five themes were identified relating to: patient eligibility identification, who provides information and seeks consent, resource limitations, research culture or environment and the consent model used. The relative success of recruitment strategies was dependent upon the experience and availability of the staff involved in the approach, trial design, the application of the strategy to the specific intensive care environment, the acceptability of the recruitment and consent models used, and the efficiency of the recruitment procedures. Opportunities for consent were missed in a proportion of eligible patients in most studies, suggesting that clinicians may avoid recruiting more complex patients or in more complex situations and that further development of strategies is needed.

CONCLUSION

More effective recruitment strategies are required to enhance recruitment and the representativeness of the patient sample obtained in critical care trials, in order to expand the evidence base for treatments in this field. Greater focus is needed on assessing the performance of different recruitment strategies within different types of studies and critical care research environments. Future research should explore key stakeholders' experiences of, and attitudes towards, recruitment and establish the most important and feasible modifiable barriers to recruitment.

Enrollment Challenges in Critical Care Nursing Research

BACKGROUND

Enrollment challenges for critical care research are common. Contributing factors include short enrollment windows, the crisis nature of critical illness, lack of research staff, unavailable legal proxy, family dynamics, and language barriers.

OBJECTIVE

To describe enrollment statistics for an ongoing critical care nursing trial, barriers to recruitment, and strategies to enhance enrollment.

METHODS

Two years' worth of recruitment and enrollment data from an oral care intervention trial in critically ill adults receiving mechanical ventilation at 1 hospital were analyzed. Recruitment logs include number of patients screened, eligible, enrolled, and declined and patients' sex, race, and ethnicity.

RESULTS

Target enrollment (15.5 patients per month) was based on experience and historical data. Strategies implemented to promote enrollment included providing study personnel at least 18 hours per day for 7 days per week, regular rounds, communication with direct care staff, and Spanish consent processes. In 2 years, 6963 patients were screened; 1551 (22%) were eligible. Consent was sought from 366 (24% of eligible patients). Enrollment averaged 13.3 patients per month (86% of projected target). The main factor impeding enrollment was unavailability of a legal proxy to provide consent (88%). The refusal rates of white (11%), black (13%), and Hispanic (16%) patients did not differ significantly. However, those classified as Asian or as more than 1 race declined significantly more often (35%) than did white or black patients (P = .02).

CONCLUSIONS

Unavailability of a legal proxy within a short enrollment window was the major challenge to enrollment. Various factors influenced consent decisions. Clinical study design requires more conservative estimates.

Are institutional review boards effective in safeguarding patients in intensive care units?

Institutional Review Boards have been recently audited in the US, and a great deal of concerns and criticisms appeared in the medical literature and the lay press. Globally, these comments questioned the efficiency of Institutional Review Boards in fulfilling their basic mission, the protection of patients subjected to biomedical research. Vulnerable populations, such as psychiatric and incompetent patients, were particularly identified. In intensive care units, conducting research in critically ill patients unable to give informed consent themselves remains a hot issue. Several possibilities have been proposed and assessed in the recent past: pre-emptive (global) consent, proxy consent from a surrogate, deferred consent, and, more recently, waiver of consent for emergency research. Obviously, the inability to deal with this major obstacle (i.e. obtaining consent from incompetent patients) would lead to the cessation of any research in intensive care units, which is hardly acceptable and certainly unethical. Recent published studies have reported over-mortality in treatment groups, posing new questions: who should be informed of those failures, and when? What is the role of Institutional Review Boards in preventing such an issue? What type of indemnity should be proposed to the family of deceased patients during a trial?

Subject recruitment in critical care nursing research: a complex task in a complex environment

PURPOSE

This article serves to describe subject recruitment issues in a funded study in a the medical respiratory intensive care unit.

BACKGROUND

Subject recruitment can be difficult in the critical care environment. Inadequate recruitment can reduce the ability to detect treatment differences. Though causes of recruitment difficulty have been documented in medical trials, little is known concerning recruitment in critical care nursing studies.

METHODS/RESULTS

All patients admitted to a medical respiratory intensive care unit (ICU) were reviewed daily for study eligibility. Demographics and reasons for ineligibility and failure to consent were documented. Five hundred ninety-three patients were reviewed; 42 (7.1%) were enrolled; 457 (77.1%) were not eligible and not enrolled and 94 (15.8%) were eligible but not enrolled. Of those reviewed, 52% were male; 57% were black, and 41% were white. Of those eligible, but not enrolled, 40% were because of family unavailability for consent and 27% because of family unwillingness to consent. There were no significant differences in patient age or gender between those who consented and those who did not. However, those who did not consent consisted of a greater proportion of blacks than the population screened. Families' stated reasons for not consenting were primarily related to the family's stress level.

CONCLUSIONS

Conducting clinical studies in the critical care environment, enrolling subjects, and obtaining consent may be complicated by the critical nature of the patient's illness, and researchers must be aware of these issues for study success.

Do surrogate decision makers provide accurate consent for intensive care research?

CONTEXT

ICU patients are often rendered incapable of making decisions as a result of their illness. The accuracy with which patients' surrogates consent to research on their behalf is not known.

OBJECTIVE

To determine if surrogate decision makers provide accurate consent for intensive care research.

DESIGN

Cross-sectional, paired, face-to-face interviews.

SETTING

A large, managed-care, cardiac surgery service. PATIENTS AND PATICIPANTS: One hundred elective cardiac surgery patients and their self-appointed surrogates were enrolled.

INTERVENTION

Patients agreed or declined to provide informed consent to two hypothetical research trials. One trial represented minimal risk to those enrolled; the other trial represented greater-than-minimal risk. Surrogates attempted to predict the patients' responses.

MAIN OUTCOME MEASURES

The accuracy of surrogate consent was analyzed in a fashion analogous to the evaluation of a diagnostic test. Predictors of accuracy were evaluated using multiple logistic regression.

RESULTS

Overall surrogate positive predictive value for the low-risk study was 84.0% and for the high-risk study was 79.7% (p = 0.72, McNemar test). Predictors of accurate consent were not consistent across the two studies.

CONCLUSIONS

Surrogate decision makers for critical-care research resulted in false-positive consent rates of 16 to 20.3%. Further assessment and evaluation of the practice of surrogate consent for intensive care research is, therefore, recommended.

Good clinical research practice: what is it and is it possible in the intensive care unit?

With the growing quest for answers to vexing dilemmas in critically ill patients, more intensive care units are embarking on clinical research. This places increasing importance on Good Clinical Research Practice (GCRP), a set of guidelines drawn up by the Pharmaceutical Industry to assist investigators in conducting ethical, reliable scientific studies. GCRP is a combination of good basic management skills allied to ethical principles for scientific research. Based on the principles of the Declaration of Helsinki, it consists of three tenets: patient protection (ethics), credible data (science) and data control. This article describes GCRP specifically relating it to the intensive care situation, illustrating some of the concepts with practical examples. With a minimum of extra time and effort these basic principles can be integrated as routine into all research projects.