Acute Care Research Research Articles

A comparison of recreational therapy and child life practice: Similarities, differences, and opportunities

Transdisciplinary care and collaboration among team members is necessary and essential to maximize patient outcomes. Collaboration is the most effective when professionals understand the unique role of each discipline. This is potentially more difficult when disciplines overlap in some services provided, or when an individual on the team is dually certified. In pediatric care settings, this is often the case for recreational therapy (RT) and child life (CL). The purpose of this study is to highlight the benefits of transdisciplinary care, as well as summarize similarities and differences between the two fields based on profession-based documents. Findings indicate 28 unique areas of RT practice, 18 grey areas (items found in both RT and CL profession-based documents with shades of differences), eight items found in one profession that are highly likely to occur in both professions, and 31 areas of similarity. Items of similarity do not raise concern, as the items appear to be common among many healthcare professions, such as developing a therapeutic relationship and conducting an assessment. Differences stem from underlying principles of each profession. RT is primarily a treatment/therapy-based profession (eg, functional skill development), whereas the foundation of CL is a helping-based profession (eg, coping within the hospitalized environment). RT must effectively deliver a message of its unique contribution to the healthcare landscape with special emphasis on functional skills development, client and family education and counseling, and community integration and transition training related to maximizing healthy engagement in play, leisure, recreation, and community activities post hospitalization for continued recovery, development, and prevention. Methods of disseminating findings and strengthening RT evidence-based research in pediatric acute care are provided, along with suggested opportunities for collaborative research.

A systematic approach for studying the signs and symptoms of fever in adult patients: the fever assessment tool (FAST)

BackgroundAlthough body temperature is one of four key vital signs routinely monitored and treated in clinical practice, relatively little is known about the symptoms associated with febrile states. The purpose of this study was to assess the validity, reliability and feasibility of the Fever Assessment Tool (FAST) in an acute care research setting.MethodsQualitative: To assess content validity and finalize the FAST instrument, 12 adults from an inpatient medical-surgical unit at the National Institutes of Health (NIH) Clinical Center participated in cognitive interviews within approximately 12 h of a febrile state (tympanic temperature ≥ 38° Celsius). Quantitative: To test reliability, validity and feasibility, 56 new adult inpatients completed the 21-item FAST.ResultsThe cognitive interviews clarified and validated the content of the final 21-item FAST. Fifty-six patients completed the FAST from two to 133 times during routine vital sign assessment, yielding 1,699 temperature time points. Thirty-four percent of the patients (N = 19) experienced fever at one or more time points, with a total of 125 febrile time points. Kuder-Richardson 20 (KR-20) reliability of the FAST was 0.70. Four nonspecific symptom categories, Tired or Run-Down (12), Sleepy (13), Weak or Lacking Energy (11), and Thirsty (9) were among the most frequently reported symptoms in all participants. Using Generalized Estimating Equations (GEE), the odds of reporting eight symptoms, Warm (4), Sweating (5), Thirsty (9), General Body Aches (10), Weak or Lacking Energy (11), Tired or Run Down (12) and Difficulty Breathing (17), were increased when patients had a fever (Fever Now), compared to the two other subgroups—patients who had a fever, but not at that particular time point, (Fever Not Now) and patients who never had a fever (Fever Never). Many, but not all, of the comparisons were significant in both groups.ConclusionResults suggest the FAST is reliable, valid and easy to administer. In addition to symptoms usually associated with fever (e.g. feeling warm), symptoms such as Difficulty Breathing (17) were identified with fever. Further study in a larger, more diverse patient population is warranted.Trial RegistrationClinical Trials Number: NCT01287143 (January 2011)

A smartphone-based exercise adherence intervention for people with metabolic syndrome: a feasibility pilot study

BackgroundDespite well-established benefits of exercise in the management of metabolic syndrome, evidence to support exercise adherence after program completion is lacking. We used a smartphone-based exercise adherence intervention (Virtual Trainer; Ex-VT) for adults with metabolic syndrome in Hong Kong, China. The objectives were to measure the feasibility, potential effectiveness, and implementation of Ex-VT in sustaining prescribed exercise practice for risk reduction in metabolic syndrome. MethodsIn this multisite, randomised controlled trial, participants with metabolic syndrome were randomly allocated to either intervention (Ex-VT) or exercise reference (control) groups using block randomisation with a block size of ten. Both groups attended four once-weekly group exercise sessions. The Ex-VT group received goal-directed, person-centered exercise adherence coaching via a smartphone virtual trainer application. Data was collected at baseline and at 12 weeks. Primary outcome was adherence to exercise prescription, as measured using pedometers and International Physical Activity Questionnaire. Changes in metabolic syndrome risk indicators (waist circumference, blood pressure, and blood lipid and glucose concentrations) were also measured after a 12 h fast. Data analysis was based on intention to treat. The trial is registered with Chinese University of Hong Kong Centre for Clinical Research and Biostatistics, number CUHK_TMP00056. Ethics approval was obtained from the Joint Chinese University of Hong Kong–New Territories East Clinical Research Ethics Committee and written consent were obtained from participants. FindingsTwenty subjects were recruited to the study (recruitment rate: 71·4%), and randomly assigned, 1:1, to Ex-VT or control groups. They were aged 30–69 (mean 56·85 [SD 7·08]), 65% women, and 55% worked full-time. Two subjects (one per group) dropped out (retention rate: 90% for both groups). At 12 weeks, participants in the Ex-VT group demonstrated better adherence with exercise prescription (72%) than those in the control group (48%; p=0·036). Reductions from baseline in systolic blood pressure (p=0·02), diastolic blood pressure (p=0·045), and waist circumference (p=0·048) were seen in the Ex-VT group, despite no between-group difference. We found no significant changes in blood lipid and glucose concentrations. No adverse events were reported. InterpretationHigh retention rates suggest that Ex-VT is an acceptable intervention for this population. Preliminary findings on adherence and metabolic syndrome risk indicators suggest that a large randomised controlled trial to explore the effects of Ex-VT would be safe, feasible, and warranted. FundingDepartmental Research Fund, Cardiac and Acute Care Research Theme Group, The Nethersole School of Nursing, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China (CV1502).

Abstract TMP72: Geographic, Demographic and Socioeconomic Analysis of StrokeNet Research Network Population Coverage

Introduction: StrokeNet is an NIH research network to advance research for acute treatment, prevention, and recovery/rehabilitation following stroke. Hypothesis/Objective: We characterized the adult population with geographic access to a StrokeNet acute care research site and its representativeness of the overall US population. Methods: Data on research sites was obtained from the StrokeNet National Coordinating Center and geocoded. Ground and air-ambulance data identify transport times of 60, 90 and 120 minutes, corresponding to transport distances of 20, 40 and 65 miles, respectively. Geographic Information System (GIS) software overlaid these radii on thematic maps of StrokeNet adult acute care hospitals, their referral clinics, and participating VAMC hospitals. The analysis used complete 2010 US census data and 2013 data for economic variables, coded to the block group level. Descriptive data presented with comparison to national averages. Results: 281 sites were identified as of August 1, 2015. 38%, 50%, and 60% of the total US population were within 20, 40 and 65 miles of an identified site. Geographic coverage and analysis for gender, race, age, and income are presented below. High rates of access were identified for Hispanic/Latino, Black, and Asian populations and households with high median incomes. Limited rural access was identified. Data on rehabilitation and pediatric access to be presented. Conclusions: Current StrokeNet sites provide geographic access to acute care research opportunities for a substantial portion of the US population. The encompassed population reflects the demographic and socioeconomic makeup of the nation as a whole.

Status and Future Perspectives of Utilizing Big Data in Neurosurgical and Stroke Research.

The management, analysis, and integration of Big Data have received increasing attention in healthcare research as well as in medical bioinformatics. The J-ASPECT study is the first nationwide survey in Japan on the real-world setting of stroke care using data obtained from the diagnosis procedure combination-based payment system. The J-ASPECT study demonstrated a significant association between comprehensive stroke care (CSC) capacity and the hospital volume of stroke interventions in Japan; further, it showed that CSC capabilities were associated with reduced in-hospital mortality rates. Our study aims to create new evidence and insight from ‘real world’ neurosurgical practice and stroke care in Japan using Big Data. The final aim of this study is to develop effective methods to bridge the evidence-practice gap in acute stroke healthcare. In this study, the authors describe the status and future perspectives of the development of a new method of stroke registry as a powerful tool for acute stroke care research.

Emergency Preservation and Resuscitation Trial: A Philosophical Justification for Non-Voluntary Enrollment.

In a current clinical trial for Emergency Preservation and Resuscitation (EPR), Dr. Samuel Tisherman of the University of Maryland aims to induce therapeutic hypothermia in order to 'buy time' for operating on victims of severe exsanguination. While recent publicity has framed this controversial procedure as 'killing a patient to save his life', the US Army and Acute Care Research appear to support the study on the grounds that such patients already face low chances of survival. Given that enrollment in the trial must be non-voluntary, the study has received an exemption from federal standards for obtaining informed consent. How exactly, if at all, is non-voluntary enrollment morally justifiable? In this essay, I appeal to the notable work of Hans Jonas in an effort to defend the EPR trial's use of non-voluntary enrollment. It is often thought and, as I show, it may appear that Jonas has called for the end of experimental medical practice. Still, I derive from Jonas a principle of double-effect upon which physicians may be seen as morally permitted to pursue innovations in emergency medicine but only as a byproduct of pursuing therapeutic success. With this position, I argue that the EPR trial can be granted a stronger philosophical justification than simply waiving the requirement of obtaining informed consent. The double-effect justification would obtain, perhaps regardless of the success of such innovative procedures as therapeutic hypothermia.

Correction to article New Zealand Emergency Medicine Network: A collaboration for acute care research in New Zealand

Correction to article New Zealand Emergency Medicine Network: A collaboration for acute care research in New Zealand

PAC conference: Babl on acute care research updates

PAC conference: Babl on acute care research updates

Older Adults Research in Acute Care – Breaking the Barriers

Population-based growth has familiarized health care providers with the special needs of older patients. We know the elderly, those 65 years or older, represent 13.7% of the U.S. population, with a projected rise to 19% by 2030 (Administration on Aging, 2013). Yet, the Cumulative Index to Nursing and Allied Health indicates that only 3%-6% of clinical trials are specific to the older adult aged population (Orwig, Williams, & Martin, 2011). Older adult patients in acute care hospitals (ACH) are known to have multiple comorbidities that include respiratory ailments, cardiac diseases, falls, cognitive impairments, and depression (Formiga et al., 2012; CDC, 2014). Studies have demonstrated that comorbid conditions increase with age (Formiga et al., 2012; Barnett et al., 2012).

New Zealand Emergency Medicine Network: a collaboration for acute care research in New Zealand.

The specialty of emergency medicine in Australasia is coming of age. As part of this maturation there is a need for high-quality evidence to inform practice. This article describes the development of the New Zealand Emergency Medicine Network, a collaboration of committed emergency care researchers who share the vision that New Zealand/Aotearoa will have a world-leading, patient-centred emergency care research network, which will improve emergency care for all, so that people coming to any ED in the country will have access to the same world-class emergency care.

Non-response to therapy in acute and rehabilitative psychosomatic inpatient care - a systematic review

The study reviews the state-of-the art on failure research in acute and rehabilitative psychosomatic inpatient care. The main focus of interest lies in describing the frequency and possible predictors of unsuccessful therapeutic treatments. We systematically searched the databases MEDLINE, PsycARTICLES, PsycINFO und PSYNDEX and selected studies from the past 20 years focusing on treatment failure in the inpatient psychosomatic treatment of adult patients. A total of 31 studies were included, 15 of which allowed the extraction of predictors of non-response or deterioration. 20 %to 30%of patients leave psychotherapeutic treatment without any significant change; 5 %to 10%deteriorate during their stay.A high level of symptom distress at intake, a chronic course of the disease as well as somatoform or personality disorders are associated with non-response and deterioration. Early response to treatment and a dysfunctional therapeutic alliance are possible further predictors, whereas sociodemographic and sociomedical variables are unlikely to have a predictive validity. Hypotheses about possible predictors can be derived from the results of this review. However, the interpretation of the results is limited by the heterogeneity of the methodology and of the samples of the studies included. Nevertheless the results can be used as a basis for further hypothesis-driven research.

Studying Community Consultation in Exception From Informed Consent Trials*

Studying Community Consultation in Exception From Informed Consent Trials*

Ethics in Acute Care Research: A Global Perspective and Research Agenda

The 2013 Academic Emergency Medicine consensus conference focused on global health and emergency care research. One conference breakout session discussed research ethics and developed a research agenda concerning global acute care research ethics. This article represents the proceedings from that session, particularly focusing on ethical issues related to protecting human subjects while conducting acute care research. Protecting human research subjects from unnecessary risk is an important component of conducting ethical research, regardless of the research site. There are widely accepted ethical principles related to human subjects research; however, the interpretation of these principles requires specific local knowledge and expertise to ensure that research is conducted ethically within the societal and cultural norms. There is an obligation to conduct research ethically while recognizing the roles and responsibilities of all participants. This article discusses the complexities of determining and applying socially and culturally appropriate ethical principles during the conduct of global acute care research. Using case studies, it focuses both on the procedural components of ethical research conducted outside of "Western" culture and on basic ethical principles that are applicable to all human subjects research. This article also proposes specific research topics to stimulate future thought and the study of ethics in these complex circumstances.

Emergency Care Research Funding in the Global Health Context: Trends, Priorities, and Future Directions

Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research.

Beyond ideal speech situations: Adapting to communication asymmetries in health care

Inclusive, unconstrained and honest communication is widely advocated as beneficial and ethical. We critically explore this assumption by reflecting upon our research in acute care, informal care and public health. Using Habermas' ideals of dialogue to conceptualise ideal speech, we concur with observations that health care is often characterised by intractable exclusions and constraints. Rather than advocating implementing the ideals of dialogue, however, we examine how people adapt to these difficult and intransigent contexts. Non-ideal contexts, we find, sometimes call for non-ideal responses. Deception and furthering personal interests, and thus departing from the ideals of dialogue, can be adaptive responses.

Multidisciplinary acute care research organization (MACRO)

Clinical research will increasingly play a core role in the evolution and growth of acute care surgery program development across the country. What constitutes an efficient and effective clinical research infrastructure in the current fiscal and academic environment remains obscure. We sought to characterize the effects of implementation of a multidisciplinary acute care research organization (MACRO) at a busy tertiary referral university setting. In 2008, to minimize redundancy and cost as well as to maximize existing resources promoting acute care research, MACRO was created, unifying clinical research infrastructure among the Departments of Critical Care Medicine, Emergency Medicine, and Surgery. During the periods 2008 to 2012, we performed a retrospective analysis and determined volume of clinical studies, patient enrollment for both observational and interventional trials, and staff growth since MACRO's origination and characterized changes over time. From 2008 to 2011, the volume of patients enrolled in clinical studies, which MACRO facilitates has significantly increased more than 300%. The percentage of interventional/observational trials has remained stable during the same period (50-60%). Staff has increased from 6 coordinators to 10, with an additional 15 research associates allowing 24/7 service. With this significant growth, MACRO has become financially self-sufficient, and additional outside departments now seek MACRO's services. Appropriate organization of acute care clinical research infrastructure minimizes redundancy and can promote sustainable, efficient growth in the current academic environment. Further studies are required to determine if similar models can be successful at other acute care surgery programs.

Focusing a Gender Lens on Emergency Medicine Research: 2012 Update

The influence of sex and gender on patient care is just being recognized in emergency medicine (EM). Providers are realizing the need to improve outcomes for both men and women by incorporating sex- and gender-specific science into clinical practice, while EM researchers are now beginning to study novel sex- and gender-specific perspectives in the areas of acute care research. This article serves as an update on the sex differences in a variety of acute clinical care topics within the field of EM and showcases opportunities for improving patient care outcomes and expanding research to advance the science of gender-specific emergency care.

A burn center paradigm to fulfill deferred consent public disclosure and community consultation requirements for emergency care research

IntroductionTo fulfill Food and Drug Administration and Department of Health and Human Services emergency care research informed consent requirements, our burn center planned and executed a deferred consent strategy gaining Institutional Review Board (IRB) approval to proceed with the clinical study. These federal regulations dictate public disclosure and community consultation unique to acute care research. ObjectiveOur regional burn center developed and implemented a deferred consent public notification and community consultation paradigm appropriate for a burn study. MethodsPublished accounts of deferred consent strategies focus on acute care resuscitation practices. We adapted those strategies to design and conduct a comprehensive public notification/community consultation plan to satisfy deferred consent requirements for burn center research. ResultsTo implement a robust media campaign we engaged the hospital's public relations department, distributed media materials, recruited hospital staff for speaking engagements, enlisted community volunteers, and developed initiatives to inform “hard-to-reach” populations. The hospital's IRB determined we fulfilled our obligation to notify the defined community. ConclusionOur communication strategy should provide a paradigm other burn centers may appropriate and adapt when planning and executing a deferred consent initiative.

Abstract P147: Telestroke Software Offers Improved and Novel Methods of Studying Physician Decision Making

Introduction: Data quality in stroke registries is typically dependent upon some form of chart review and manual data abstraction. The retrospective nature of this process is inherently prone to incomplete and inaccurate data collection with limited insight into the process of physician decision making. Hypothesis: New software packages accompanying telestroke systems will dramatically improve the quality of data by automating the abstraction process and providing real-time access to electronic databases. Methods: Telestroke systems provide web-based programs that record various levels of data. InTouch Technologies, Inc. currently provides StrokeRESPOND v3.0, a web-based program that facilitates telestroke consultation by organizing elements of the physician-patient encounter, including history, vitals, physical exam, laboratory results, and radiographs, and by generating a consultation note. Many data elements captured in the user interface mirror traditional metrics of acute stroke care research and can be de-identified and then directly transferred into an electronic database. The “forced choice” (aka hard-stop) design of data entry and elimination of secondhand abstraction can minimize data corruption and loss. Further, because each point of data entry and manipulation is time-stamped, powerful metadata_“data about data”_can be explored. By analyzing the sequence and patterns of clinical information entry and utilization, the actual thought process of the physician user can be investigated and provide new insights into stroke treatment. Optimization of acute stroke management, a complicated protocol, can be driven by identification of physician decision making patterns associated with multiple outcomes, including higher rates of treatment and faster treatment times. Conclusions: Specialized software programs will improve registry data collection, completeness and accuracy. The generation of metadata offers exciting, new avenues of research. Prospective stroke research using this methodology will require the collaboration of multiple academic institutions and industry partners.

Forging a critical alliance: Addressing the research needs of the United States critical illness and injury community*

Discuss the research needs of the critical illness and injury communities in the United States. Workshop session held during the 5 National Institutes of Health Symposium on the Functional Genomics of Critical Illness and Injury (November 15, 2007). The current clinical research infrastructure misses opportunities for synergy and does not address many important needs. In addition, it remains challenging to rapidly and properly implement system-wide changes based upon reproducible evidence from clinical research. Author presentations, panel discussion, attendee feedback. The critical illness and injury research communities seek better communication and interaction, both of which will improve the breadth and quality of acute care research. Success in meeting these needs should come from cooperative and strategic actions that favor collaboration, standardization of protocols, and strong leadership. An alliance framed on common goals will foster collaboration among experts to better promote clinical trials within the critically ill or injured patient population. The U.S. Critical Illness and Injury Trials Group was funded to create a clinical research framework that can reduce the barriers to investigation using an investigator-initiated, evidence-driven, inclusive approach that has proven successful elsewhere. This alliance will provide an annual venue for systematic review and strategic planning that will include framing the research agenda, raising awareness for the value of acute care research, gathering and promoting best practices, and bolstering the critical care workforce.