Seven-step framework to enhance practitioner explanations and parental understandings of research without prior consent in paediatric emergency and critical care trials

Background

Alternatives to prospective informed consent enable the conduct of paediatric emergency and critical care trials. Research without prior consent (RWPC) involves practitioners approaching parents after an intervention has been given and seeking consent for their child to continue in the trial. As part of an embedded study in the ‘Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children’ (EcLiPSE) trial, we explored how practitioners described the trial and RWPC during recruitment discussions, and how well this information was understood by parents. We aimed to develop a framework to assist trial conversations in future paediatric emergency and critical care trials using RWPC.

Methods

Qualitative methods embedded within the EcLiPSE trial processes, including audiorecorded practitioner–parent trial discussions and telephone interviews with parents. We analysed data using thematic analysis, drawing on the Realpe et al (2016) model for recruitment to trials.

Results

We analysed 76 recorded trial discussions and conducted 30 parent telephone interviews. For 19 parents, we had recorded trial discussion and interview data, which were matched for analysis. Parental understanding of the EcLiPSE trial was enhanced when practitioners: provided a comprehensive description of trial aims; explained the reasons for RWPC; discussed uncertainty about which intervention was best; provided a balanced description of trial intervention; provided a clear explanation about randomisation and provided an opportunity for questions. We present a seven-step framework to assist recruitment practice in trials involving RWPC.

Conclusion

This study provides a framework to enhance recruitment practice and parental understanding in paediatric emergency and critical care trials involving RWPC. Further testing of this framework is required.

Oral nitroglycerin solution for oesophageal food impaction: a prospective single-arm pilot study

BACKGROUND

Thirteen episodes of oesophageal food impaction (EFI) per 100 000 people present to a medical setting each year. Several pharmacological interventions meant to relieve such impactions have been explored; none have proven superior.

OBJECTIVES

Perform a single-arm feasibility study of oral nitroglycerin solution for EFI.

METHODS

Twenty adult patients presenting to a single urban tertiary medical centre thought to have EFI were given up to three doses of 0.4 mg nitroglycerin solution orally and evaluated for resolution of symptoms, new symptoms and vital signs. Patients with intractable vomiting, haemodynamic instability, airway compromise, oesophageal perforation, coronary ischaemia or presentation delayed greater than 12 hours were excluded.

RESULTS

17 of 20 enrolled subjects received the intervention. The average duration of symptoms prior to intervention was 285 min (SD=187). Four subjects did not tolerate the intervention (inability to swallow or headache). Two of 17 (11.8%) subjects obtained temporally proximal symptom resolution: 11 min after the second dose, and 7 min after the third dose. Seven also received glucagon during their visit, with 0% temporally proximal symptom resolution. Fifteen underwent endoscopy, with food bolus identified in 12. One subject had brief and mild hypotension with spontaneous resolution. Two subjects developed a headache after nitroglycerin administration. The median length of stay for those who found relief without endoscopy was 195 min (range 129-261) vs 374 min (range 122-525) among those with endoscopy.

CONCLUSION

The observed rate of relief after oral nitroglycerin solution for EFI is disappointing but comparable to previous glucagon, benzodiazepines and effervescent beverage studies, and that of placebo. Oral nitroglycerin solution appears to be well tolerated among those able to swallow, although in our sample several subjects were unable to tolerate swallowing entirely.

Opt-out screening for HIV, hepatitis B and hepatitis C: observational study of screening acceptance, yield and treatment outcomes

BACKGROUND

We initiated an emergency department (ED) opt-out screening programme for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) at our hospital in Dublin, Ireland. The objective of this study was to determine screening acceptance, yield and the impact on follow-up care.

METHODS

From July 2015 through June 2018, ED patients who underwent phlebotomy and could consent to testing were tested for HIV, HBV and HCV using an opt-out approach. We examined acceptance of screening, linkage to care, treatment and viral suppression using screening programme data and electronic health records. The duration of follow-up ranged from 1 to 36 months.

RESULTS

Over the 36-month study period, there were 140 550 ED patient visits, of whom 88 854 (63.2%, 95% CI 63.0% to 63.5%) underwent phlebotomy and 54 817 (61.7%, 95% CI 61.4% to 62.0%) accepted screening for HIV, HBV and HCV, representing 41 535 individual patients. 2202 of these patients had a positive test result. Of these, 267 (12.1%, 95% CI 10.8% to 13.6%) were newly diagnosed with an infection and 1762 (80.0%, 95% CI 78.3% to 81.7%) had known diagnoses. There were 38 new HIV, 47 new HBV and 182 new HCV diagnoses. 81.5% (95% CI 74.9% to 87.0%) of known patients who were not linked were relinked to care after screening. Of the new diagnoses, 86.2% (95% CI 80.4 to 90.8%) were linked to care.

CONCLUSION

Although high proportions of patients had known diagnoses, our programme was able to identify many new infected patients and link them to care, as well as relink patients with known diagnoses who had been lost to follow-up.

Phenomenological study exploring ethics in prehospital research from the paramedic's perspective: experiences from the Paramedic-2 trial in a UK ambulance service

OBJECTIVES

We set out to investigate paramedics' views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA).

METHODS

An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview.

RESULTS

Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic's willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care.

CONCLUSION

A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.

Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis

BACKGROUND

Serious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and lack of clinical practice guidelines for this population. The primary objective was to investigate practice patterns in performance of LPs in the ED management of febrile infants aged ≤30 days with bronchiolitis.

METHODS

A cross-sectional survey of two national paediatric emergency research networks (PediatricEmergency Research Canada (PERC) and the PediatricEmergency Research UK/Ireland (PERUKI)) was conducted January to November 2017 using a modified Dillman technique. The survey was preceded by a clinical vignette describing a well appearing, 21-day-old infant with low-grade fever, respiratory findings typical of bronchiolitis and no perinatal serious bacterial infection (SBI) risk features.

RESULTS

The response rate from PERC was 169/250 (68%) and 172/201 (86%) from PERUKI. Nine physicians in training were excluded, leaving 332 eligible participants. Although most physicians believe that neonates with bronchiolitis rarely have meningitis (PERC 141/161 (87.6%); PERUKI 154/171 (90%)) and feel comfortable diagnosing bronchiolitis in this group (PERC 136/161 (84.5%); PERUKI 143/171 (83.6%)), there was significant variation in the proportion who would be likely/very likely to perform an LP (PERC 100/161 (62.1%); PERUKI 15/171 (8.8%)) (p<0.0001). Practice in Canada, <10 years in practice and lack of comfort with diagnosing bronchiolitis represent multivariable predictors of LP; OR 23.7 (95% CI 11.7 to 47.9), 2.3 (95% CI 1.2 to 4.2) and 2.5 (95% CI 1.1 to 5.0), respectively. Rapid knowledge of respiratory syncytial virus positivity would decrease LP probability from 35.4% to 20.2%.

CONCLUSION

Estimated probability of performing LPs and other interventions in otherwise healthy febrile neonates with bronchiolitis is highly variable between emergency physicians in Canada and the UK/Ireland. Network, <10 years in ED practice and comfort level with diagnosing bronchiolitis in newborns constitute independent predictors of the likelihood of LP performance.

Why sample size estimates?

Sample size estimates are critical to the planning and interpretation of clinical studies, whether they are descriptive or analytical. Too small a sample size will result in imprecise estimates in a descriptive study and failure to achieve 'statistical significance' in an analytic or comparative study. Here we discuss what both researchers and readers should understand about the reasons for sample size estimates, how they are done and how achieving or not achieving the desired sample size can affect the interpretation of the outcomes.

Understanding the management of patients with head injury taking warfarin: who should we scan and when? Lessons from the AHEAD study

Anticoagulated patients represent an important and increasing proportion of the patients with head trauma attending the ED, but there is no international consensus for their appropriate investigation and management. International guidelines vary and are largely based on a small number of studies, which provide poor-quality evidence for the management of patients taking warfarin. This article provides an overview of the clinical research evidence for CT scanning head-injured patients taking warfarin and a discussion of interpretation of risk and acceptable risk. We aim to provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying 'one-size-fits-all' guidelines to individual patients. There is good evidence for a more selective scanning approach to patients with head injuries taking warfarin than is currently recommended by most guidelines. Specifically, patients without any head injury-related symptoms and GCS score 15 have a reduced risk of adverse outcome and may not need to be scanned. We argue that there is evidence to support an individualised approach to decision to CT scan in mild head injuries on warfarin and that clinicians should feel able to discuss risks with patients and sometimes decide not to scan.

What is positionality and should it be expressed in quantitative studies?

Although we are increasingly reaping the benefits of qualitative studies, their approach and that of quantitative studies remain rather separate. Emergency medicine practitioners thrive off research in context as we deal with such an undifferentiated population however quantitative 'hard-science' work is conspicuous for its absence of positionality. This contrasts strongly with the way in which qualitative research, within the domain of so-called soft-science literature, uses positionality as an integral element of the research process. Without contextualising the researcher and research environment in qualitative studies, often the meaning of any research output is lost. What follows is that positionality does not undermine the truth of such research, instead it defines the boundaries within which the research was produced. ​ The absence of positionality when considered alongside the notion of bias, may challenge the quantitative idea of validity.

Understanding How Bereaved Parents Cope With Their Grief to Inform the Services Provided to Them

Our objective was to develop a rich description of how parents experience their grief in the first year after the death of their child, and how various bereavement follow-up and support services helped them during this time, with the aim of informing follow-up and support services offered to bereaved parents. Our findings situated parents' individual experiences of coping within the social and institutional contexts in which they grieved. In the first year after the death of their child, parents regulated their intense feelings of grief through loss-oriented, restoration-oriented, and/or meaning reconstruction strategies. Often, parents' relationships with others and many of the bereavement follow-up and support services helped them in this regard. This article also explores how the results may aid service providers in accompanying parents in a way that optimizes outcomes for these parents.

Reasons and evolution of non-thrombolysis in acute ischaemic stroke

Introduction

Despite increasing evidence of its efficacy in advanced age or in mild or severe strokes, intravenous thrombolysis remains underused for acute ischaemic stroke (AIS). Our aim was to obtain an updated view of reasons for non-thrombolysis and to identify its changing patterns over time.

Methods

This is a retrospective study of prospectively collected data from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) from the years 2003–2011. Patients admitted with acute stroke in the past 24 hours who had not had thrombolysis were identified; reasons for non-thrombolysis documented in the prospectively entered data were tabulated and analysed for the group as a whole. Data were analysed for the years 2003–2006 and 2007 forward because of changes in contraindications. A subgroup of patients who arrived within the treatment window ≤180 min was separately analysed for reasons for non-thrombolysis. Predictors of non-thrombolysis were investigated via multivariate regression analyses.

Results

In the 2019 non-thrombolysed patients the most frequent reasons for non-thrombolysis were admission delays (66.3%), stroke severity (mostly mild) (47.9%) and advanced age (14.1%); 55.9% had more than one exclusion criterion. Among patients arriving ≤180 min after onset, the main reasons were stroke severity and advanced age. After 2006, significantly fewer patients were excluded because of age (OR 2.65, p<0.001) or (mostly mild) stroke severity (OR 10.56, p=0.029). Retrospectively, 18.7% of all non-thrombolysed patients could have been treated because they only had relative contraindications.

Conclusion

Onset-to-admission delays remain the main exclusion criterion for thrombolysis. Among early arrivals, relative contraindications such as minor stroke severity and advanced age were frequent. Thrombolysis rate increased with the reduction of thrombolysis restrictions (eg, age and stroke severity).

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

Human factors in prehospital research: lessons from the PARAMEDIC trial

BACKGROUND

There is an urgent need to develop prehospital research capability in order to improve the care of patients presenting to emergency medical services (EMS). The Prehospital Randomised Assessment of a Mechanical compression Device In Cardiac arrest trial, a pragmatic cluster randomised trial evaluating the LUCAS-2 device, represents the largest randomised controlled trial conducted by UK ambulance services to date. The aim of this study was to identify and analyse factors that may influence paramedic attitudes to, and participation in, clinical trials.

METHODS

Personal and organisational experience from this trial was assessed by feedback from a workshop attended by collaborators from participating EMS and a survey of EMS personnel participating in the trial. A work systems model was used to explain the impact of five interwoven themes-person, organisation, tasks, tools & technology and environment-on trial conduct including gathering of high-quality data.

RESULTS

The challenge of training a geographically diverse EMS workforce required development of multiple educational solutions. In order to operationalise the trial protocol, internal organisational relationships were perceived as essential. Staff perceptions of the normalisation of participation and ownership of the trial influenced protocol compliance rates. Undertaking research was considered less burdensome when additional tasks were minimised and more difficult when equipment was unavailable. The prehospital environment presents practical challenges for undertaking clinical trials, but our experience suggests these are not insurmountable and should not preclude conducting high-quality research in this setting.

CONCLUSIONS

Application of a human factors model to the implementation of a clinical trial protocol has improved understanding of the work system, which can inform the future conduct of clinical trials and foster a research culture within UK ambulance services.

TRIAL REGISTRATION NUMBER

ISRCTN08233942.

Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland

OBJECTIVE

Paediatric Emergency Research in the UK and Ireland (PERUKI) is a collaborative clinical studies group established in August 2012. It consists of a network of 43 centres from England, Ireland, Northern Ireland, Scotland and Wales, and aims to improve the emergency care of children through the performance of robust collaborative multicentre research within emergency departments. A study was conducted regarding the research priorities of PERUKI, to establish the research agenda for paediatric emergency medicine in the UK and Ireland.

METHODS

A two-stage modified Delphi survey was conducted of PERUKI members via an online survey platform. Stage 1 allowed each member to submit up to 12 individual questions that they identified as priorities for future research. In stage 2, the shortlisted questions were each rated on a seven-point Likert scale of relative importance.

PARTICIPANTS

Members of PERUKI, including clinical specialists, academics, trainees and research nurses.

RESULTS

Stage 1 surveys were submitted by 46/91 PERUKI members (51%). A total of 249 research questions were generated and, following the removal of duplicate questions and shortlisting, 60 questions were carried forward for stage 2 ranking. Stage 2 survey responses were submitted by 58/95 members (61%). For the 60 research questions that were rated, the mean score of 'relative degree of importance' was 4.70 (range 3.36-5.62, SD 0.55). After ranking, the top 10 research priorities included questions on biomarkers for serious bacterial illness, major trauma, intravenous bronchodilators for asthma and decision rules for fever with petechiae, head injury and atraumatic limp.

CONCLUSIONS

Research priorities of PERUKI members have been identified. By sharing these results with clinicians, academics and funding bodies, future research efforts can be focused to the areas of greatest need.

ABG needle study: a randomised control study comparing 23G versus 25G needle success and pain scores

OBJECTIVE

To determine whether a narrower gauge needle used in ABG sampling is associated with lower pain scores and complication rates without increasing the level of difficulty of the procedure.

METHODS

We performed a prospective single-blinded randomised control study of patients from a tertiary-level emergency department in Sydney who required an ABG analysis over the period of June 2010-July 2012. Patients were randomised to either a 23G or 25G needle and the primary outcome that included pain experienced by these patient were recorded as pain scores on a 10 cm hatched visual analogue scale. The difficulty scores and complications were also noted from the operator.

RESULTS

Data for 119 consenting eligible patients were included in the analysis. 63 patients were allocated to the 23G needle group and 56 to the 25G needle group. The mean pain score was 3.5 (SD=2.7) for the 23G group and 3.4 (SD=2.7) for the 25G group with a mean difference between the pain scores of 0.1 (95% CI -0.9 to 1.1, p=0.83). The 23G and 25G mean difficulty score was 3.4 (SD=2.6) and 4.3 (SD=2.4), respectively, with a mean difference of 0.9 (95% CI -0.03 to 1.7, p=0.06). 21.6% of patient in the 23G needle group experienced some complication with regard to the sampling in the form of haematoma, tenderness or paraesthesia in comparison to 5.4% of patients in the 25G needle group (p=0.03).

CONCLUSIONS

There was no significant difference in pain scores experienced by patients undertaking ABG sampling with either a 23G or 25G needle.

TRIAL REGISTRATION NUMBER

ACTRN12609000957291.

The process leading to help seeking following childhood trauma

In this article we explore the process leading to help seeking following childhood trauma among women who were currently in treatment. We interviewed 13 participants from six treatment groups for clients exposed to human-inflicted traumas. Transcripts were analyzed using a hermeneutical-phenomenological approach. Help seeking was initiated after a prolonged period of time (13 to 58 years after first trauma exposure), during which participants relied heavily on a strategy of managing on their own. Self-management contributed to delays in help seeking, but was also an important resource. High levels of distress were reported prior to help seeking, often without help seeking being considered as an option. The participants sought help when encountering situational demands exceeding available resources, resulting in experiences of exhaustion and loss of control. We present a model of the help-seeking process, underlining the importance of respecting and exploring the individual process of seeking help when offering trauma-specific treatment.

Social network analysis of Iranian researchers on emergency medicine: a sociogram analysis

BACKGROUND

The purpose of this study was to report interaction patterns among Iranian authors of emergency medicine using social network analysis methodology, focusing on coauthorship network.

METHODS

The bibliographic data of Iranian authors on the 'emergency medicine' field during the years 2001-2011 were retrieved from the Science Citation Index Expanded database. Co-occurrence matrices were made by BibExcel and were imported to Ucinet and NetDraw to delineate coauthorship network. To detect structural patterns among authors, we considered some measures of social network analysis, such as density, centralisation indices, component analysis and cut-points. Lastly, subject experts separately analysed the content of papers.

RESULTS

Of 116 papers published, the network was composed of 10 components, with the largest component having 25 authors. Using social network analysis measures, we identified science bottlenecks in knowledge sharing, hub authors and accelerators of information flow. Topic analysis showed 'Wounds and Injuries' as the most recent theme in all components because of existence of national registry for trauma, high burden of road traffic injuries and research priority of injuries in Iran.

CONCLUSIONS

because of Iranian low productivity in the emergency medicine field, social network analysis seems to be a proper option for bibliometrics to identify central authors and detect knowledge structure in this field.

Evolved design makes ThoraQuik safe and user friendly in the management of pneumothorax and pleural effusion

Background

We have previously described the utility of ThoraQuik, a device designed to be fit for purpose for aspirations of pneumothorax and pleural effusions. We evaluated the safety, efficacy and operator handling of the evolved prototype, ThoraQuik II, which has a lesser profile and a spring loaded Veres needle for added safety.

Methods

A prospective, observational clinical trial with ethics and MHRA approval was conducted in a single centre. Patients with diagnosed pneumothorax (including tension pneumothorax) and pleural effusion were consented and recruited. The ease of device introduction, penetration and ease of use were evaluated. Clinical and radiological improvements were the clinical endpoints and operator feedback was analysed.

Results

20 procedures were performed on patients (mean age: 63.4 years (range: 30–90 years) with 75% male subjects) recruited between September 2008 and August 2009. Nine patients had pneumothorax (tension pneumothorax n=4) and 11 had pleural effusions. 19 patients completed the study with symptomatic and radiological resolution. One patient was withdrawn due to poor pain threshold disproportionate to the procedure. No complications were encountered. 68% had complete clinical and radiological resolution and 32% had partial resolution (these patients needed a definitive drain and hence were not aspirated to completion). The operator feedback in the study rated the device as very good or excellent in 90% patients.

Conclusions

Our study found the use of ThoraQuik II to be safe and easy in draining pneumothorax and pleural effusions. The changes to ThoraQuik II made it more user friendly.

Induction of a shorter compression phase is correlated with a deeper chest compression during metronome-guided cardiopulmonary resuscitation: a manikin study

OBJECTIVES

Recent studies have shown that there may be an interaction between duty cycle and other factors related to the quality of chest compression. Duty cycle represents the fraction of compression phase. We aimed to investigate the effect of shorter compression phase on average chest compression depth during metronome-guided cardiopulmonary resuscitation.

METHODS

Senior medical students performed 12 sets of chest compressions following the guiding sounds, with three down-stroke patterns (normal, fast and very fast) and four rates (80, 100, 120 and 140 compressions/min) in random sequence. Repeated-measures analysis of variance was used to compare the average chest compression depth and duty cycle among the trials.

RESULTS

The average chest compression depth increased and the duty cycle decreased in a linear fashion as the down-stroke pattern shifted from normal to very fast (p<0.001 for both). Linear increase of average chest compression depth following the increase of the rate of chest compression was observed only with normal down-stroke pattern (p=0.004).

CONCLUSIONS

Induction of a shorter compression phase is correlated with a deeper chest compression during metronome-guided cardiopulmonary resuscitation.