E S Excellence Emergency Medicine Recognised as a specialty in - - PowerPoint PPT Presentation

Excellence

E

S

Emergency Medicine

• Recognised as a specialty in 1993
• Prevention, diagnosis and management of acute and urgent

aspects of illness and injury

• Encompasses the full spectrum of episodic undifferentiated

physical and behavioural disorders

• Rapid growth; by 2011 in Australia and New Zealand:
• 1377 Fellows (currently increasing by ≥100 per year)
• ~8 MILLION Emergency Dept. presentations per annum
• Academic development has lagged behind
• Initial focus on undergraduate and postgraduate training
• Systems of care and simple clinical studies
• WA has the only University Department of EM in Australasia

NIH Emergency Research Roundtable Ann Emerg Med 2010

• “Crisis in emergency care in the United States, including a need to

enhance the research base for emergency care” NIH Task Force on Research in Emergency Medicine

• Focus for EM research
• Timing, sequence, and time sensitivity of disease processes and

treatment effects.

• Evidence gaps – clinical priorities
• Infection, sepsis, septic shock
• Respiratory / allergy emergencies
• Resuscitation; hypotension and ischemia-reperfusion
• Acute chest pain and acute abdominal pain
• Geriatrics.

US EM research networks

• EMERGEncy ID Net
• Syndromic surveillance/research of emerging infections in the US
• 12 geographically diverse urban Eds.
• Emergency Medicine Network (EMNet)
• Began as the Multicenter Airway Research Collaboration (MARC)

with a focus on respiratory/allergy emergencies

• Expanded to include health policy & public health objectives
• 204 medical centers http://www.emnet-usa.org
• Neurological Emergency Treatment Trials (NETT)
• Interventional trials on acute neurologic disorders
• Organized around a clinical coordinating centre with 10 to 20 clinical

“hubs” http://nett.umich.edu/nett/welcome

US EM research networks

• Pediatric Emergency Care Applied Research Network (PECARN)
• Focus is observational and randomized trials for acute illnesses and

injuries in children, and it comprises 4 research “nodes” with 22 participating sites. http://www.pecarn.org

• Resuscitation Outcomes Consortium (ROC)
• Focus on out-of-hospital research in management of

cardiopulmonary arrest and severe traumatic injury

• 10 regional centres across North America.

http://roc.uwctc.org/tiki/tikiindex.php

• US Critical Illness and Injuries Trial Group (USCIITG)
• Focus is to establish priorities for critical illness injury research.

http://public.wudosis.wustl.edu/USCIITG/default.aspx

Opportunities

• Emergency Medicine
• High growth, increasingly important part of health care
• Hospital entry point for acute illness and injury
• Covers the time frame when many interventions have greatest

potential to change disease course

• UWA has a unique (leading) position in Australasian EM
• We have a group of EDs in WA, interstate and NZ with proven

ability to work together and recruit patients into multicentre clinical studies

Achievements so far

• Some “firsts” for EM in Australasia
• Integration of bedside and laboratory research in the ED
• A Clinical Nurse Manager Emergency Research with a team of

Clinical Research Nurses on the floor, extended hours

• Inclusion of an EM group in a research institute (WAIMR)
• Competitive grants
• With collaborators in a variety of disciplines
• With interstate collaborators
• Clinical trials
• Ranging from simple <-> complex/mechanistic
• Multi-centre, interstate and overseas collaborations

Liverpool Hospital

New Zealand

Established collaborations >8 years Core group with research infrastructure

Where might C(s)CREM fit in?

• Focus on linking confirmatory and hypothesis-generating

mechanistic laboratory work with clinical trials in the ED, is novel and internationally competitive.

• ASP  ASP-FFP
• RAVE I  RAVE II
• EDA I  EDA II
• CISS/BLISS 
• POLAR and the NRP 
• Australian collaboration to link in with international networks
• Translation of research into EM clinical practice in Australia
• Career development of Australian EM academics

Proposal

CRE Objectives

• General
• Improve outcomes for acutely ill and injured patients by
• ptimising early management in the ED phase of care
• Specific
• Conduct high quality, collaborative, multi-centre clinical trials

with patient-focussed outcomes that are relevant to the acute (ED) phase of patient care (the undifferentiated patient)

• Provide a framework for professional development of EM

academics, with a focus on high quality clinical trials

• Integrate within our trials, wherever possible, mechanistic

(explanatory and/or hypothesis generating) laboratory investigations

Centre 1 Centre 3 Centre 2

Statistics and logistical support

Structure

• Collaborative patient recruitment across all sites
• Each centre leads one or more themes across group
• Research nurse coordinator(s) at each centre, funded by CRE,

managing local cluster of EDs

• Centre 1 responsible for statistical and logistics support (incl. data

management, audit, trial pack procurement, shipping etc.)

Incentive = mutual benefit

• EM clinical research is particularly difficult because of the

diversity of presentations / diseases

• Collaborative recruitment across all sites = numbers that

would be impossible even for a large centre on its own

• Each participating centre has opportunity to lead the group in

area(s) where its staff have specific expertise

• Critical mass of researchers - multiple areas of expertise

across several sites and funding from a variety of sources

ability to maintain multiple studies and thus a productive research “engine” in each ED

Problems

• Track records are competitive within the field of EM, but

modest in general NHMRC terms

• Need to get more runs on the board as a group
• So much time spent on writing grant proposals
• VIC and QLD are poised to make huge leaps forward due to

massive investments in EM research and we will loose our competitive edge in the next 2-3 years

Strategy

• Over the last 2 years;
• Agreed priority areas
• Sepsis / Respiratory
• Brain injury (trauma and stroke)
• Anaphylaxis
• PhD students (2 senior EM specialists)
• Pursuing collaborations with other specialties
• Developed a range of projects that are ready to go / underway
• Maintain and develop key partnerships with “sister hospitals”
• See similar acute trauma/medical caseload as RPH
• Have clinical academics and support staff on site
• Have proven themselves to be reliable research partners

(Liverpool Hospital NSW, Royal Brisbane Hospital QLD)

What we need now

• Discretional funding in the order of ~$250,000 over 2 years to

widen the scope of our “ready-to-go” projects

• Already funded and underway within CCREM
• Expand to include 2 interstate centres
• Stipend for 1-2 full time lab PhD students, to work alongside our

two current clinical PhD students.

• This will quickly establish a track record for the group and

UWA leadership, with data and publications starting within 12 months.

Bluntly

• SMAHS spends just under $1M p.a. on CCREM (3 hospitals)
• Senior clinical (consultant) staff (5), with ~2.5 FTE allocated to

research

• Research support staff (5 FTE Research Nurses and 1 FTE RA)
• WAIMR/RPHMRF provides considerable laboratory

infrastructure

• NHMRC, other competitive grants, and HDWA infrastructure

grants fund the CCREM laboratory

• UWA… (not so much yet)
• ?missing an opportunity

Proposed organisational structure