Emergency Medicine Research Associates
Background
Unrecognized abdominal and pelvic injuries can result in catastrophic disability and death. Sporadic reports of “occult” injuries have generated concern, and physicians, fearing that they may miss such an injury, have adopted the practice of obtaining computed tomography on virtually all patients with significant blunt trauma. This practice exposes large numbers patients to dangerous radiation at considerable expense, while detecting injuries in a small minority of cases. Existing data suggest that a limited number of criteria can reliably identify blunt injury victims who have “no risk” of abdominal or pelvic injuries, and hence no need for computed tomography (CT), without misidentifying any injured patient. It is estimated that nationwide implementation of such criteria could result in an annual reduction in radiographic charges of $75 million, and a significant decrease in radiation exposure and radiation induced malignancies.
Objective
This study seeks to determine whether “low risk” criteria can reliably identify patients who have sustained significant abdominal or pelvic injuries and safely decrease CT imaging of blunt trauma patients.
Our Role
All blunt trauma victims undergoing computed tomography (CT) of the abdomen/pelvis in the emergency department (ED) will undergo routine clinical evaluations prior to radiographic imaging. Our volunteers will observe and record vitals for each trauma patient. We are also responsible for assuring that ED physicians record the presence or absence of specific clinical findings as well as the presence or absence of abdominal or pelvic injuries.
Background
Sepsis is defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection” (Sepsis-3 Consensus). It is the leading cause of death in U.S. hospitals and has been identified as a condition requiring early and aggressive intervention. As the condition progresses, it may lead to the state of septic shock in which there is a profound and complex derangement of the inflammatory response and cellular metabolism with vasodilation and circulatory collapse. This condition carries a much higher mortality rate. A landmark study led by Dr. Rivers in 2001 showed that Early Goal Directed Therapy (EGDT), which included the use of intravenous fluids and vasopressors to maintain minimum values of specific vital signs related to perfusion (CVP, SvO2, and MAP) led to a significant decrease in mortality. Large amounts of early intravenous (IV) fluid administration (along with early recognition and administration of antibiotics) has continued to be a mainstay in sepsis treatment. Recent trials (ProCESS, ARISE, and ProMISe) have demonstrated that that targeting of similar physiologic endpoints (CVP, SvO2, and MAP) using fluid resuscitation did not lead to a decrease in mortality. It was interesting to note that overall mortality in all arms was lower than in the 2001 study, presumably due to advances in the overall standard of care (including early recognition and aggressive treatment) of sepsis. Additionally, the FEAST trial, limited to pediatric patients, found that children in septic shock who received early IV fluids had a higher 48-hour mortality. Also, the small CLASSIC trial showed that a more conservative fluid approach led to decreased incidence of kidney injury, though mortality remained similar. This has brought into question the benefits of the widespread practice of aggressive fluid in order to maintain the previously studied hemodynamic endpoints.
Specific Aims
This study aims to determine the impact of a restrictive fluids strategy (vasopressors first followed by rescue fluids) as compared to a liberal fluid strategy (fluids first followed by rescue vasopressors) on 90-day in-hospital mortality in 2,320 patients with sepsis-induced hypotension.
Our Role
Patient screening; assist study team with enrollment and study start up procedures.
Background
According to the World Health Organization, palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. Palliative care can include hospice care, but is distinct from hospice in that it may be delivered throughout the time course of serious, life-limiting illness alongside life-prolonging, disease-model treatment. Emergency department (ED)-initiated palliative care has been shown to improve patient-centered outcomes in older adults with serious, life-limiting illnesses. However, the optimal modality for providing such interventions is unknown.
Objective
The aims of this study are to compare nurse-led telephonic case management to facilitated, outpatient specialty palliative care for older adults with serious, life-limiting illness on: (1) quality of life in patients; (2) healthcare utilisation (eg, ED revisits, hospital admissions, hospice use); (3) loneliness and symptom burden; and (4) caregiver strain, caregiver quality of life, and bereavement.
Our Role
EMRA’s will screen the ED trackboard to identify patients with potential CHF, COPD, or cancer and notify the study team if the patient meets full screening tool criteria.
Background
In the U.S., approximately 750,000 people suffer from sepsis each year, a prevalent condition that leads to a mortality rate of 18-38%. Two common complications associated with sepsis are acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), which further increase patients' mortality when occurring simultaneously. While sepsis can cause a wide range of clinical problems, it lacks specific treatment methods targeted to reduce complications such as ARDS and AKI.
Objective
The purpose of this study is to determine whether intravenous administration of Acetaminophen for 120 hours can effectively mitigate the effects of CFH and reduce the chance of developing organ dysfunction. The trial will attempt to measure the effectiveness of this relatively available and inexpensive treatment.
Our Role
Our volunteers screen for septic patients in the Emergency Department. Potential patients identified by EMRAs will have their fluid administration status, medication list, oxygenation devices, and supplemental oxygen volume checked by the volunteer, sometimes through direct communication with nurses and residents. We then assist with the enrollment process for qualifying patients.
Background
Suicide is currently the second leading cause of death for US youth ages 15-24, but evidence is limited regarding optimal interventions in the ED for reducing their risk of future suicide attempts. Current evidence supports some tested interventions for reducing later suicide attempts and encouraging further mental health treatment, but it is not yet known whether it is sufficient to provide only an evidence-based intervention in the ED, or whether additional therapeutic follow-up contacts are needed to improve youth outcomes.
Treatments
The study addresses this knowledge gap by comparing two evidence-based interventions for reducing suicide attempts and improving outcomes for youth presenting to EDs with suicidal episodes: (a) Safety-Acute(A), a crisis therapy session in the ED focused on enhancing safety (previously called Family Intervention for Suicide Prevention, FISP); and (b) SAFETY-A + Coping Long-term with Active Suicide Program (CLASP), comprised of brief therapeutic follow-up contacts after discharge from the ED/hospital.
Objective
The first aim is to evaluate whether SAFETY-A combined with CLASP aftercare is superior to SAFETY-A alone (with usual site referral and aftercare) for reducing the risk of suicide attempts and increasing initiation of follow-up mental health treatment. Second, the team will examine differences in how well the two study intervention approaches work for different groups of youth, especially those who are racial or ethnic minorities, from rural communities, or socioeconomically disadvantaged. Third, the team aims to increase the value and relevance of the study by engaging patients, parents, family members, providers, and system stakeholders involved in health and mental health care in project leadership and activities throughout the study.
Our Role
We screen the ED trackboard to identify adolescents presenting to the ED with suicidal ideation or behavior all days of the week at all times. If the patient meets inclusion criteria, we coordinate with both ED residents and the psychiatry department to help enroll the candidate.
Background
More than 380,000 patients suffer an out of hospital cardiac arrest (OHCA) each year in the US. Significantly improved outcomes in cardiac arrest are associated with early and aggressive resuscitation and treatment for these patients. Currently, early cardiac resuscitation is limited by the ability of physicians to protect the brain from global cerebral ischemia during resuscitation. Two recent trials have shown that early therapeutic cooling in comatose OHCA patients that present with shockable heart rhythms increases good neurological outcomes. These results have not been shown for patients with asystole or pulseless electrical activity (PEA). Duration of cooling and its effect on outcomes have also not been assessed.
Objective
There are two primary objectives relating to characterization of the duration-response curve for hypothermia in OHCA patients. The first is to determine the shortest duration of cooling that will provide maximal treatment effect. The second is to determine if cooling is more effective than non-cooling. There are three secondary objectives. The first is to characterize the safety of the various durations of cooling used. The second is to characterize the neuropsychological outcomes resulting from cooling and non-cooling in OHCA patients. The third is to characterize the effect of cooling on patient-reported quality of life.
Our Role
EMRAs will identify potential post-cardiac arrest comatose patients. EMRAs will subsequently head down to the ED where EMRAs will be in charge of gathering the paperwork and information needed to verify a patient is eligible. In the ED, EMRAs will also remind staff to initiate cooling and confirm that the care team has spoken with the family. Once EMRA confirms this and eligibility is confirmed, a Shepherd (resident working as a co-investigator for the trial) will be activated to obtain informed consent.
