Clinical Research in the Emergency Department: Strengths and Flaws
Advisor: Mr. Kenneth Fleming
Internship Location: Maimonides Medical Center
Onsite Mentor: Antonios Likourzeos, MA MPH
From biomedicine to agriculture to economics, research drives the advancement of our world. In specific, clinical research has asserted itself as crucial to improving global health. Strengthening our ability to conduct clinical research at the hospital level would greatly benefit the healthcare world. As a volunteer at Maimonides Hospital, I am inspecting the strengths and flaws of how clinical research is conducted in a hospital setting. Over the past month, I have helped with various ongoing research studies. During these studies, I analyze how certain interactions in scenarios (older patients, language barrier, etc) affect patient participation in research. I have noticed a key part of obtaining a willing patient is a clear explanation of the research. Frequently, patients become confused when questioned about research because the research team does not include doctors or nurses. An explanation that leads to no confusion is ideal, and what I am trying to find through my senior project. Additionally, my senior project will supply a fundamental understanding of how to best conduct research for my future career and how best to help hospitals increase their efficiency in conducting and recording clinical research.
Project Blog
Week 0: Welcome to my Senior Project
Hi! My name is Charlie Pitts, and I’m super excited to blog my senior project. The world of health has always been extremely interesting to me. I love to exercise, eat healthy, and learn a wide variety of topics (especially health). Throughout high school, I wrote a research paper on dietary diseases in the Pacific Islands, worked on the Belleayre Mountain Ski Patrol, and took many online courses about health. I’ve learned a tremendous amount about health through these experiences and have been able to help many patients in the Belleayre Ski Patrol. Through my experience, I’ve noticed how important research is in advancing the subject of health which led me to my senior project.
I will be blogging about my project on clinical research in a hospital. My main focus is to share what researching in a world-class care hospital means and if there are ways to improve clinical research efficiency.
First, I will define some terms that will be used throughout this project. Bench-to-bedside refers to using research results directly from patient interactions to benefit other patients. Throughout my internship, I will accompany research staff to engage with numerous patients and gather research results directly from patients' bedsides. Another term to define is what it means to improve clinical research efficiency. Improving clinical research efficiency implies more patient participation in research, increasing research results.
Interning at the Maimonides Research Department will assist in answering my question of “How can we improve clinical research efficiency.” To acquire an answer, I will conduct staff interviews, read a multitude of online articles, and constantly engage with patients.
I can’t wait to blog my senior project experience and share what I learn. Hopefully, I’ll be able to advance the world in some way through the senior project.
Week 1: Blog Week 1: Approaching and Minimizing Bias
Throughout week 1, I have focused on Bias in Clinical Research. Bias is “any tendency which prevents unprejudiced consideration of a question” (Pannucci & Wilkins, 2011). Some examples of bias include under or over-representing one side of the study, not reporting conflicts of interest, and inaccurately expressing the analysis.
In my study of clinical research participation, I need to minimize bias to produce the most accurate and well-informed results. Throughout this week’s blog, I will explain how I expect to counter bias in my study. Of course, bias is impossible to eliminate, but I will do my best to minimize it.
Confirmation bias is looking for data that supports your hypothesis and declining information that disagrees with you. This bias is relatively easy to minimize. I will include all discovered results (including all the outliers).
Selection bias is when the sample group studied doesn’t match the target group that the research will help. For example, if I only studied the people who agreed to participate in my study, then I would miss out on the people who disagreed to participate. To minimize this, I will track the amount of people who decline to participate.
Recall bias is when researchers don’t perfectly recall the past. This leads to inaccuracy when writing down results, analysis, or just notes. I will immediately write down what I observe after each interview or discussion with a patient.
Finally, observer bias is when a researcher’s opinions or expectations change the study results. This bias stems from a researcher’s prior beliefs. To minimize observer bias, I will use a neutral and open mindset throughout my study.
In conclusion, bias is important to minimize when creating an accurate study. That is why I took measures to examine multiple types of bias.
Week 2: Blog Week 2: Patient + Staff Participation in Research
Throughout week 2, I discovered how diverse studies can be and analyzed the effects. The variousness of studies has a profound impact on patient participation in studies. I seek to understand the variousness of studies to make my study more accurate.
One of the research studies I am currently working on with Maimonides examines emergency department doctors. Our methodology is to watch over emergency department doctors and record what they are working on for two hours. They perform a wide variety of tasks, some for short periods, others for long periods. As a researcher, I follow them around and record their tasks.
This relates to my study because informed consent is required to study the doctors. The doctors are required to sign a document, describing what we will do and that their employment could be at risk. Their employment is only at risk if we see them doing something inappropriate while watching them for two hours (which is unlikely). Still, seeing that sentence where they need to sign stops many doctors from agreeing to the study. On the other hand, some doctors might find being followed for two hours irritating which results in them declining to participate. Both of these causes lead to less staff participation in research.
Another research study I’m assisting Maimonides with relates to acute respiratory infections. Acute respiratory infections obstruct the airway and prevent normal breathing. Keeping in mind the seriousness of the infections, obtaining consent to do research is very difficult. There must be informed consent which requires the patient to understand the entire study and have time to voice questions or concerns. The patient could either be in serious pain, have a procedure being conducted on them, or not comprehend the research study to their fullest ability. All of these prevent informed consent from being obtained.
These two studies have shown how a variety of factors play into less participation in studies. In future blogs, I will find the most pertinent causes that lead to patients and staff avoiding participation in research. Addressing these causes will be key to increasing the efficiency of research.
Week 3: Blog Week 3: Creating Surveys
Surveying the Maimonides Research Staff is a key component of my research study. The goal of the survey is to determine how the Maimonides Research Staff feels about patient participation in research and other related topics.
When creating the survey, I first made an answer system that is easily understood. I used the numerical values zero through five as possible answers in the survey. Zero means zero percent/none of the time, while five means one hundred percent/every time. One through four correspond to answers between zero and one hundred percent.
Next, I formulated a short set of statements to be answered by the Maimonides Research Staff. There are a wide variety of questions I could have asked, but I focused on different aspects of patient participation.
The survey uses the 0-5 scale to rate how someone feels about a statement. Some examples of statements are: “Patients say yes to participating in research” and “Research is quick and easy to conduct on the North Side.”
Over the upcoming weeks, I will distribute this survey and hope to achieve many results. This data will play a significant role in discovering how to increase research efficiency.
Ultimately, surveying will be extremely important because it allows me to collect first-hand data to incorporate into my research study. In addition to surveying, I have conducted a large amount of online research to help discover the viewpoints of other hospitals, researchers, and medical experts. These viewpoints are essential to exploring my senior project to include perspectives outside of my internship at Maimonides Hospital. In the week four blog, I plan to discuss this online research.
Week 4: Using Patience as a tool
Throughout my first few weeks, I’ve learned success in clinical research relies heavily on patience. In the Emergency Department, patience helps not only the Nurses and Doctors but also the researchers.
Patients in the Emergency Department often have some form of altered mental status. There are almost unlimited forms: some more visible than others. Some examples include trauma to the head, falling on the back, a mental disorder, or a patient who could be very old. At certain times, it is difficult to ask if the patient would be willing to participate in a research study.
The key to overcoming this challenge is patience. Approaching the patient at the right moment is vital to acquiring a positive response. Intruding while the patient is having a private conversation with an Emergency Room Nurse would not be the right time and could cause the patient to become frustrated. Therefore as the research team, we need to find the perfect moment to enter the patient’s room to ask them to participate in research.
My approach consists of a couple of different steps:
Waiting until the doctors and nurses are finished with any evaluation or procedures
Avoiding easily irritable patients
Preferably entering if a patient’s family member is present
Introducing myself in a friendly manner
Clearly explaining the research study
Emphasize any incentives to participate (if there are any)
In the end, it will always be the patient’s personal decision whether to participate in the research study. But using these steps helps keep patients interested (and not frustrated) which projects positive feelings toward the research study.
Week 5: Blog Week 5: Variety of Studies
As I continue to work with the Maimonides Research Department, I have quickly noticed a variety of research studies go on simultaneously. There are around ten researchers and five volunteers (including me) who carry out the studies. Throughout this blog, I will explain a couple of the different research studies that are currently underway which I am working on.
The first study I will touch on is called Time and Motion. Time and Motion is a fairly common research study in the medical field. This study seeks to discover how long it takes clinicians to complete a task as well as what clinicians do during their shifts. Data from Time and Motion studies can potentially help discover why Clinicians feel burnout while working. Currently, I gather data for this study through my volunteer work. There are two parts to this study: observing a physician for two hours during their shift and reporting data into a digital file.
Another study that I have recently taken part in is a lower respiratory infection study. This study seeks to compile data to advance knowledge of lower respiratory infections. Similarly to the Time and Motion study, there are multiple parts. The first part consists of finding a patient with a non-allergy-based lower respiratory infection and obtaining consent. This step ensures the patients’ understanding of the research study. Next, the data must be compiled in a digital file. This digital file must include all relevant patient notes, a respiratory interim note, and multiple other files. These files are key to reporting back findings to the outside sponsor of the research study.
Finally, a third study I assist with relates to broken hips. Many falls for elderly patients consistently lead to broken hips. When we are younger, a femur or another bone is more likely to break instead. The Maimonides Team is studying this data. This third study requires obtaining consent for patient participation in the survey (like usual) and gathering data about the broken hip.
Ultimately, I have described a small sample of the ongoing research studies at Maimonides Hospital. I did this to display the breadth of the research department and how it spans in multiple directions. Each of these studies has various levels for patient participation which complicates how we can make research more effective.
Week 6: Blog Week 6: Exploring Online Resources Part 1
In this week’s blog, I will delve into the online portion of my senior project and seek out outside opinions on how to effectively conduct clinical research.
Recently, I read an article titled “How to make research succeed in your emergency department: How to develop and train career researchers in emergency medicine.” This study was a massive study of Canadian emergency medical researchers. Its methods included emailing a survey to all Canadian emergency physician researchers, analyzing the Society for Academic Emergency Medicine, and formatting a review of all this information to present recommendations to the Canadian Association of Emergency Physicians (Perry et al., 2015). Clearly, an enormous amount of resources and time have been dedicated to this study. Therefore, their results could be key to my study.
The researchers discovered five key themes across the study: creating training opportunities, ensuring adequate protected time, salary support, infrastructure, and mentorship (Perry et al., 2015). These themes are key to ensuring success in Emergency Department Research. Here is my analysis of the five themes:
Training opportunities are important to give employees the chance to learn and practice how to research in the Emergency Department.
Emergency medical researchers need adequate protected time, so they have enough time to pursue research.
Salary support will help keep researchers satisfied with their careers and works as a support method.
Infrastructure is essential in any field because, without a built-out infrastructure, the research system will not work effectively.
Mentorship allows new emergency medical researchers to be introduced into the field with more guidance and ease.
Perry, Jeffrey J, et al. “CAEP 2014 Academic Symposium: “How to Make Research Succeed in Your Emergency Department: How to Develop and Train Career Researchers in Emergency Medicine.” Canadian Journal of Emergency Medicine, 1 May 2015, https://doi.org/10.1017/cem.2015.63
Week 7: Analyzing Time in Motion Study
For this week’s blog, I will be giving my personal view of the Time in Motion study. I have helped the Maimonides Research Team conduct over 15 two hour long studies. As I conduct more and more Time and Motion studies, I am expanding my knowledge of the strengths and flaws of the study. I hope to explain them thoroughly in this blog post.
First off, here are the steps to the study:
- Obtain Consent from the clinician
- Locate the clinician on the day of the study
- Record their tasks for two hours
- Approach the clinician to tell them the study is over
All of these steps are relatively simple. This is great because when studies become to complicated they can become difficult to follow by researchers.
Strengths:
In general, this study and its execution have been very successful. Clinicians are relatively easy to follow around throughout the Emergency Department. Clinicians are usually sitting at their desks or wandering around patients’ beds. Additionally, tasks are easy to record with the Tablet device supplied. All you have to do is click on the category of task and then the exact task. For a clinician who is looking at EKG charts, you would click the diagnostic interpretation category and then the EKG box.
Flaws:
There are very few flaws to the study that I have encountered, but one clear flaw is multitasking. If a clinician is multitasking, only one task can be recorded, not both tasks. For example, if a clinician is analyzing the charts on their computer and talking to a co-worker, only one of these tasks can be recorded. This leads to a small amount of error in the study.
In conclusion, the Time in Motion study is a well-made research study with limited flaws and encompasses what research studies should aim to be.
Week 8: Blog Week 8: Exploring Online Resources Part 2
This week's blog post will discuss the online research I am engaging in. In specific, one study stuck out to me and related closely to my research.
The study is titled “Patient perceptions of participation in emergency medicine research projects.” This study conducts a cross-sectional ED patient survey with questions about the importance of research, research involvement, and consent. With 315 surveyed patients, they achieved a solid sample size. Their results were 98.1% “believed ED research was important”, 68.4% “would welcome [research] involvement”, but only 8.4% “felt pressured to do so” ((Tonnerre et al. 2020) These results are key to revealing why low patient participation exists. Most patients think ED research is important and would welcome involvement, but very few patients feel pressured to participate. This presents a huge problem for the researchers because we need to gain skills in convincing patients to participate or have incentives for being in the research study.
While researching at the Maimonides Emergency Department, I have seen this problem in action. Sometimes I spend extra time trying to convince a potential participant. In these cases, I emphasize the importance of research and speak very kindly. I’ve realized kindness can be a key factor in swaying over the potential participant. In the Emergency Department environment, individuals can be very stressed and want to get out as soon as possible. So when I arrive and speak kindly to the patient, they calm down and are more likely to agree to research in a less agitated state. On the other hand, incentives are another effective way to get patients to agree to research. Incentives are usually a $25 or $50 Amazon gift card. Hearing money immediately alters the patients’ views and feeds their inclination to join the study. Unfortunately, many studies don’t offer incentives, so we can’t rely on incentives.
In conclusion, it is clear patients understand the importance of research but don’t feel pressured to join. Therefore, the ability of a researcher to convince a patient to participate is vital to the study.
Tonnerre, Erik J, et al. “Patient Perceptions of Participation in Emergency Medicine Research Projects.” Emergency Medicine Australasia, vol. 32, no. 4, 10 Feb. 2020, pp. 570–572, https://doi.org/10.1111/1742-6723.13455. Accessed 26 May 2024.
Week 9: Blog Week 9: Exploring Online Resources Part 3
Hello everyone and welcome back to my blog! This week I continued my online research and found another credible source that will feed into the results of my study. This week's online source that I will consult and analyze is titled "Engaging emergency clinicians in emergency department clinical research."
This study interviewed 37 Canadian emergency medicine researchers in order to find strategies that promote clinical engagement and research activities (McRae et al., 2018). The emergency medicine researchers were interviewed over three months and put into small groups. These two factors are key to gaining accurate results; the three month period and small groups allow for the researchers to discuss strategies together over a meaningful period of time. The study ended up producing eight seperate recommendations. I believe the key takeaways out of the eight recommendations are "establishing a strong, research-supportive culture in the ED", "ensuring clear communication between the research team and ED clinical staff", and "monitoring recruitment rates and address recruitment problems" (McRae et al., 2018). A strong research-supportive culture in the ED will allow for positivity around research which is very important. Clear communication between the research team and ED clinical staff will allow research to function smoothly and prevent frustration between healthcare workers. Finally, monitoring recruitment rates and addressing recruitment problems could possibly be the most important takeaway. If we want research to succeed, then we need to continuously get people involved in the research. Recruiting more volunteers into the process greatly helps research efficiency.
McRae, A. D., Perry, J. J., Brehaut, J., Brown, E., Curran, J., Emond, M., Hohl, C., Taljaard, M., & Stiell, I. G. (2018). Engaging emergency clinicians in emergency department clinical research. CJEM, 20(3), 443–447. https://doi.org/10.1017/cem.2017.434
Week 10: Wrapping Up
Hello everyone and welcome back to my blog! This week's blog will wrap up my final days at my internship and what I accomplished there.
I continued working on the Time in Motion Study and studied two more residents on the south side of the emergency department. Both were rather normal studies as the residents consented easily to the study.
Additionally, I helped out with the urinary tract infection study. In the UTI study, I help assess patients' pain with a urinary tract infection during their time at the Emergency Department and in the weeks following their discharge. To complete this study, we called the patients by phone a week later to ask about their pain. Sometimes if there is a language barrier, we use a special app with a built-in translator to communicate with the patients.
My survey was also distributed this week. I surveyed the entire research department at Maimonides to understand their opinions on research efficiency and patient participation. My survey determined many results. These include: half of the patients are difficult to find, most patients consent to research, and half of the patients are frustrated with participating in research. These findings are relatively close to my opinions on research at Maimonides as I encounter frustration with patients about half the time too. The survey also showed that research was more difficult to conduct on the north and pediatrics side than on the south side. Patients on the north side can be very harmed which leads to them not wanting to say yes to research. And patients on the pediatrics side are young, so there parents are hesitant about research.
Post 12: Concluding blog
Hello everyone and welcome back to my senior project blog. This will be my final blog post, as I'll be wrapping up my entire senior project with this post.
Throughout, my ten-week journey at Maimonides Hospital I learned a tremendous amount. The research staff, other volunteers, patients, doctors, and nurses all helped me grow in a unique way that I'm thankful for. At the beginning of my internship, I was quite nervous to approach patients or doctors to ask about research. But slowly due to the kind research staff, self-confidence began to develop throughout the weeks. This taught me an important lesson: if you want something to be done, do it yourself. This lesson stuck with me through the remainder of my internship, and I can't wait to apply it to my life outside of Maimonides Hospital.
In addition to that lesson, I was able to answer my research question: "How does clinical research work in a world-class care hospital, sitting in the middle of New York City and are there ways to get more patients to participate?" Volunteering at Maimonides for ten weeks, I adapted to the hospital setting and learned clinical research is very fast-paced and meticulous. For the second part, I realized convincing patients to participate was all about how we approached them. Using my approach (which I detailed in an earlier blog) is extremely effective and increases patient participation by a large margin.
Thank you all for reading my blog every week and following my journey. I hope you all learned as much as I did.