excellence - uwa · nih emergency research roundtable ann emerg med 2010 •“crisis in emergency...
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Excellence
E
S
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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
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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.
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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
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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
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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
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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
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Liverpool Hospital
New Zealand
Established collaborations
>8 years
Core group with research infrastructure
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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
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Proposal
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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
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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.)
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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
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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
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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)
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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.
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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
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Proposed organisational structure