Here’s the top 10 (and more) research priorities in EM. James Lind & St.Emlyn’s

James Lind Alliance St.Emlyn'sWe’ve blogged before about the James Lind Alliance1,2 project that’s been running with the Royal College of Emergency Medicine. In brief this is an exercise that engages the profession, researchers and patients to come to a consensus on which topics are the most important for future research. The alliance has done some amazing work with other organisations and around specific diseases that have led to successful research funding. In brief, this matters and it can drive the UK research agenda.

The process started some 18 months ago, but last week the final meeting took place in Manchester where clinicians, patients and researchers came together to rank the final 30 topics to be taken forward.

I was honored to be joined by Jason Smith who ran the project, Sandra Regan from the JLA, Sam McIntyre from RCEM and Liza Keating from Reading for the podcast. A special mention for Liza who has done really remarkable things to make ED research happen in Reading, if you ever want inspiration to get research up and running in your department give Liza a call. Click on the link below if you want to know a little more about the process.

So what are the priorities?

OK. Let’s get to the top 10. This is how the questions were put to the group on the day. There was additional information about how the questions were ranked by a wider panel of clinicians and patients using an online system.

Rank Question
1 QUESTION: What is the best way to reduce the harms of emergency department crowding and exit block? We need a better measure of crowding that drives sensible improvements for the seriously ill and injured, adolescents and the frail elderly.
2 QUESTION: Is a traditional ED the best place to care for frail elderly patients? Would a dedicated service for these patients be better (involving either a geriatric ED, or geriatric liaison services within the ED), or given that this population is expanding should our current services be tailored towards this group?
3 QUESTION: How do we optimise care for mental health patients; including appropriate space to see patients, staff training, early recognition of symptoms, prioritisation compared to physical illness, and patient experience?
4 QUESTION: With regards to how ED staff development is managed, what initiatives can improve staff engagement, resilience, retention, satisfaction, individuality and responsibility?
5 QUESTION: How can we achieve excellence in delivering end of life care in the ED; from the recognition that a patient is dying, through symptomatic palliative treatment, potentially using a dedicated member of staff to work with palliative patients and their relatives, and handling associated bereavement issues?

Note: additional element to question from being combined- In End of Life Care Decision Making, which factors should influence ceilings of care, palliation and extended resuscitation?

6 QUESTION: The effects of implementing new techniques in assessing patients with chest pain (which include new ways of using high sensitivity troponin tests, and decision rules such as the MACS rule and the HEART score) in practice. Would patients like a say in what is an acceptable risk, and should these tools be used alongside shared decision making to provide safe and appropriate care, minimise unnecessary risk and inconvenience for patients?
7 QUESTION: What is the ideal staffing for current UK EM practice, including doctors, nurses, healthcare assistants, porters, radiographers, clerical and reception staff.
8 QUESTION: Do early undifferentiated (broad spectrum) antibiotics in suspected severe sepsis have a greater benefit and cause less harm to patients than delayed focussed antibiotics in the ED?
9 QUESTION: In adults who are fully alert (GCS 15) following trauma does cervical spine immobilisation (when compared to no cervical spine immobilisation) reduce the incidence of neurological deficit, and what is the incidence of complications?
10 QUESTION: Which trauma patients should be transferred to a Major Trauma Centre rather than going to another hospital first?

 

You can download the full list of top 30 research priorities here – FINAL Ranking V1 james line alliance EM

So what do you think?

I reckon that everyone who reads this list will be both excited and a bit disappointed. Excited because there is something you like and maybe a little perplexed about why some of the topics are on there. Don’t worry if that’s the case as it’s inevitable when we challenge ourselves to get consensus on a topic as broad as emergency medicine

As you can expect there was a lot of debate and disagreement through the day and inevitably it’s highly unlikely that the final ordering of topics will be the personal choice of anyone on the day. That’s OK though, this process is about consensus and despite some rather challenging views from some quarters who maybe came with a personal agenda I’m confident that the process annulled this and that final rankings do truly reflect the entire group’s priorities.

As an example I am really torn about overcrowding being at the top of our research priorities. On the one hand it’s clearly so important and the most harmful thing happening in EM at the moment, on the other I’m not a massive fan of systems research and prefer those that have more directly identifiable patient related outcomes. Part of coming together as a consensus group is about accepting these quandries and submitting to the opinion of the group.

Some thanks before we finish.

I can’t finish this blog without thanking all of those who took part in the process. Richard Morley was a superb chair who, with Prof. Jason Smith led a steering group who put in a tremendous amount of work over the last 18 months principally in their own time and often with quite tight deadlines. I’d also thank everyone who submitted questions to the website and who helped rank those we put together before the final meeting. Finally, it’s worth mentioning the professionalism, wisdom, patience and really remarkable people skills of the JLA team. Getting a bunch of EM clinicians to concentrate for more than 4 hours and to come to a consensus was impressive and at times a masterclass in getting things done (esp. Catherine White who chaired the day).

What next?

It does not end here. These priorities are an invitation to researchers and funding bodies to understand, create, bid and deliver research in these areas. It is inevitable that some of the questions will change form over time, but those researchers who stay true to the themes here are more likely to get funding. Indeed, it was noticeable that senior members of the NIHR and other research funding bodies were present as observers on the day.

Clearly, although this process has finished, the next stage, the work to deliver the answers to these research priorities to the benefit of our patients has only just begun.

vb

S

@EMManchester

Before you go please don’t forget to…

References

1.
James Lind Alliance. NIHR. http://www.jla.nihr.ac.uk./. Published 2016. Accessed January 22, 2017.
2.
James Lind Alliance Update. St.Emlyn’s. http://stemlynsblog.org/james-lind-alliance-update-st-emlyns/. Published 2016. Accessed January 22, 2017.

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