Excellence

E

S

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

Established collaborations

>8 years

Core group with research infrastructure

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

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.)

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