Taking Action

Research in Emergency Medicine Needs a new Breath of Life

Posted by
Tiago Beck
on
Jan 14, 2019
Today’s research is tomorrow’s standard of care.

While this statement can apply to any research developing a more efficient, effective, ethical and workable process towards a positive change in healthcare, there is a concerning inequality of distribution towards research and research funds between the various areas of medicine.

The goal of improving health while preventing and treating disease and illness in patients is universal in medicine, extending through cardiology, nephrology, pulmonology, and even emergency medicine (EM). The latter is one of the most critical components of the healthcare system that sees more than 136 million patients annually in the united states alone (CDC, 2015) yet this component receives far too little attention when it comes to research. It is the only medical care resource that is both an immediate and universal service and the assistance and care it provides goes beyond just life- and limb- saving. EM can further act as a safety net for health care and societal systems. Identifying the trends among these patients, in particular, injury and illnesses, infections, drug abuse, and violence may help to identify impending societal problems (Aghababian et al., 1997). The lack of research is therefore paradoxical to the potential for information gained by a high number of patients, a universal front door, and the fundamental uncertainties that are associated with emergency medicine (Jafar, Graham & Horner, 2018).

The challenges

So where does this discrepancy and preference for other areas for research come from? Understandably a number of challenges arise in the broad and often uncertain nature of emergency medicine, yet Good and Driscoll (2002) focus on more specific factors. They believe conducting clinical research in EM is often impeded by inadequate training, inadequate funding and insufficient time. Kraus et al., (2012) extended this list by identifying the complex ethical considerations that arise in high pressure and emotional settings.  The last hurdle to be faced by research in EM concerns the evidence-to-practice gap, a process estimated to take 17 years. This slow translation into medical care is due to “a lack of familiarity with the literature, ingrained habits and practice styles, institutional and financial barriers to change, failure to translate findings into guidelines, and poor understanding of effective strategies to implement treatments in real‐world situations” (Bernstein, Stoney & Rothman, 2015).

Training is said to be at the forefront of the problems. A lack of knowledge and experience about the research issues, failure to come up with a good research question or protocol, an overzealous attitude towards overly ambitious projects are problems that pervade the process of EM research. The paucity of proper education and mentoring often stop the research in its early phases. (Good & Driscoll, 2002; Smith et al,. 2017; Aghababian et al., 1997).

Time and time again, an unsupportive academic environment and scarcity of specialized expert supervision have resulted in young researchers unfamiliar with the process having difficulty finding funding and advice for new ideas and projects. The further insufficiency of courses and learning materials for research, in particular for EM research issues, only exacerbates the challenges faced. (Good & Driscoll, 2002)

Not just the academic environment challenges the research, also the intrinsic highly pressured, immediate, emotional and often overburdened environment of emergency medicine will disrupt a controlled collection of data. Interruptions, staff rotations, and the temptation to go for a “quick and dirty” study may distract, deviate, despond, or disinterest researchers, or even lead to dishonesty (in a variety of forms) (Good & Discoll, 2002).

As with all human subjects, respect for persons, beneficence, and justice should guide research in EM. This will uphold the integrity of the new knowledge even in high pressure and emotional situations where informed consent is sometimes difficult to express (Kraus et al., 2012).

The solutions

So what can we do? How can we overcome the challenges faced, improve and attract more research, and reduce the evidence-to-practice gap? How can we improve the safety and integrity of both the researchers and participants? And how can we motivate more funding?

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The first step requires developing a strong research question, seeking experienced supervision, and coming up with a robust thought-out study protocol, that answers questions regarding ethical approval, the funding applications, and ultimate utilization of the research (Good & Doscoll, 2002). Furthermore, new legal directives for consent for research in incapacitated patients has lead to the development of a provision of a “legal representative” to consent on behalf of the patient. This system replaces the previous reliance on the vagaries of opinion of local research ethics committees. This reduces a number of unclear areas regarding the use of patients information (Coats & Shakur, 2005).

A new breath

The next stage is data collection. We must begin by looking at the nature of emergency medicine and the systems currently in place. Is there one solution that can improve the decision making, diagnosis, and treatment in emergency situations while simultaneously allowing “bedside clinical research”? The most valuable resource for both emergency physicians and researchers, in this case, is information and more respectively its management.

The way in which the information is captured, stored, shared, analyzed, displayed and standardized can improve physicians’ problem solving and decision making processes by presenting pertinent data whenever and wherever it is required. At the same time, clinical research applications, such as Teamscope, allow high quality and large quantities of data to be collected at bedside and analyzed with a few clicks. This enables medical research to be contemporaneous (“real-time”). The documentation of clinical care occurs closer in time and location to the actual event, improving reliability (Cordell, 1994). It allows 24H use with no downtime, and the ability to share the information between numerous healthcare professionals or researchers for different shifts.

Consequently, the loss of dependency on paper-based mediums, (plagued by slow retrieval, potential illegibility, and difficulty in sharing) (Synder et al., 2011) can decrease the healthcare costs while maintaining or improving quality and care processes. There is a reduction of error and a minimization of duplication of effort (Wong & Abendroth,1996).

The benefits of such research and the accompanying quality of care has even lead to health insurance companies and payers requiring that the value of purchased care be demonstrated through measurable improvement in patient outcomes (Cordell, Overhage, & Waeckerle, 1998). This idea of value-based healthcare can, and should be further expanded to emergency medicine.

A necessary change

The emergency health care workers (physicians, nurses, paramedics, EMTs) must act rapidly and accurately to diagnose a condition and reverse a disease process. They must be able to treat these patients 24 hours a day, both when the patient chooses or when the condition mandates yet the treatment often begins before an exact diagnosis is known. The treatment decisions are based on limited information yet must be accurate and efficient to ultimately optimize the patient outcomes and cost-effectiveness. (Aghababian et al., 1997; Cordell, Overhange & Waeckerle, 1998).

A sustained and developed commitment to emergency medicine research is needed if we want to see tangible improvements in the process of emergency decision making.

Octo Barnett wrote: “the practice of medicine is dominated by how we process information, how we record information, how we retrieve information, and how we communicate information.” Our goal now is to find the most effective methods to integrate technology to do just this. To strive for a continuous development of quality, safety, and efficiency for the best health care outcomes. Today’s research is tomorrow’s standard of care.

Cover image: U.S. Navy photo by Seaman Apprentice Veronica Mammina (CC BY 4.0)


References

  1. Aghababian, R., Barsan, W., Bickell, W., Biros, M., Brown, C., Cairns, C., . . . Zalenski, R. (1996). Research directions in emergency medicine. American Journal of Emergency Medicine, 14(7), 681-683. doi:10.1016/S0735-6757(96)90089-3
  2. Bernstein, S., Stoney, C., & Rothman, R. (2015). Dissemination and implementation research in emergency medicine. Academic Emergency Medicine, 22(2), 229-236. doi:10.1111/acem.12588
  3. Centers for Disease Control and Prevention. (2015). National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. Retrieved from https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf
  4. Coats, T. J., & Shakur, H. (2005). Consent in emergency research: new regulations. Emergency medicine journal, 22(10), 683-685.
  5. Cordell, W. H. (1994). Information technologies for emergency medicine. Academic Emergency Medicine, 1(2), 194-197.
  6. Cordell, W., Overhage, J., & Waeckerle, J. (1998). Strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs. the information management work group. Annals of Emergency Medicine, 31(2), 172-8.
  7. Good, A., & Driscoll, P. (2002). Clinical research in emergency medicine: Putting it together. Emergency Medicine Journal, 19(3), 242-242. doi:10.1136/emj.19.3.242
  8. Jafar, A., Graham, B., Horner, D., (2018). The role of research in emergency medicine training [Blog]. Retrieved from https://blogs.bmj.com/emj/2018/01/31/the-role-of-research-in-emergency-medicine-training
  9. Kraus, C., Guth, T., Richardson, D., Kane, B., & Marco, C. (2012). Ethical considerations in education research in emergency medicine. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 19(12), 1328-32. doi:10.1111/acem.12019
  10. Smith, J., Keating, L., Flowerdew, L., O'Brien, R., McIntyre, S., Morley, R., & Carley, S. (2017). An emergency medicine research priority setting partnership to establish the top 10 research priorities in emergency medicine. Emergency Medicine Journal, 34(7), 454-454. doi:10.1136/emermed-2017-206702
  11. Snyder, C., Wu, A., Miller, R., Jensen, R., Bantug, E., & Wolff, A. (2011). The role of informatics in promoting patient-centered care. The Cancer Journal, 17(4), 211-218. doi:10.1097/PPO.0b013e318225ff89
  12. Wong, E. T., & Abendroth, T. W. (1996). Reaping the benefits of medical information systems. Academic medicine: journal of the Association of American Medical Colleges, 71(4), 353-357


Tiago Beck

As long as I can remember medicine, and in particular neurology has been my fascination. I am currently a pre-med student at the Erasmus University in Rotterdam. I have been exploring countries and medical fields my whole life and it has ultimately lead me to the Netherlands where next to uni, I work as an assistant researcher at the Erasmus Medical Center and write blogs here and there. And this is just the beginning...


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