E S Excellence
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 Core group with research infrastructure Established collaborations >8 years
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 optimising 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
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.) Statistics and logistical support Centre 1 Centre Centre 2 3
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
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