Project Snapshot – SENTINEL

Sepsis Epidemiology in Australian and New Zealand Children 

Design:

Multi-centre, prospective observational study to investigate the prevalence, management, and outcomes of children with sepsis.

Setting and Target:
  • 11 PREDICT sites in Australia and New Zealand (same sites as enrolling for PROMPT Bolus).
  • Inclusion criteria: Age <18 years, requiring hospital admission for treatment with IV/IM/IO antibiotics and circulatory support (IV fluid bolus or inotrope) OR admission diagnosis of sepsis OR admission to ICU for treatment of severe infection.
  • Exclusion criteria: Patients transferred from another hospital in >24hours since initial presentation, patients transferred from another hospital ward to ED, patients presenting with trauma who receive antibiotics for prophylaxis or circulatory support for blood loss.
Ethics and consent:

Ethics approval for verbal consent for 90-day follow-up (text, email, or phone); enrol patient when meeting inclusion criteria. Consent by enrolling clinician or within 24 hours by research team.

Current status:

Enrolling at 8/11 PREDICT sites, 1001 patient enrolled to date. Variability in hospital’s ability to screen for missed enrolments (easier if electronic medical record). Site visits commenced (as for PROMPT Bolus), with excellent data entry at all sites visited so far. Data queries primarily for missing data at this stage. Site reports / quality reports to begin in the next month.

Project Snapshot – PRoMPT BOLUS

Pragmatic Paediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS)
A pragmatic, international randomised controlled trial comparing 0.9% saline to balanced fluids for sepsis resuscitation and initial maintenance.

Aim:

To evaluate the effectiveness and safety of balanced fluids for sepsis resuscitation and initial maintenance compared to 0.9% saline.

Setting and Target:

11 PREDICT sites in Australia and New Zealand; 2200 patients; MRFF funded. 23 PECARN (US) sites; 4500 patients; NIH funded. 12 PERC (Can) sites; 2600 patients; CIHR funded.

Primary outcome:
  • Major Adverse Kidney Events (MAKE 30) at hospital discharge or within 30 days of enrolment (death, requirement for renal replacement therapy, persistent renal dysfunction).
  • Inclusion criteria: Children aged 6 months – 18 years, requiring hospital admission for sepsis and >1 fluid bolus.
  • Exclusion criteria: 40ml/kg fluid, clinician judgement not safe (suspected brain herniation, known hyperkalaemia / hypercalcaemia / hepatic or renal failure, known metabolic or mitochondrial disease, known pregnancy, known fluid allergy.
Ethics and consent:

Ethics approval for delayed consent (waiver of consent to randomise). Consent by the research team once patient stabilised.

Participating sites:

Australian and New Zealand sites: Kidz First Hospital Middlemore, Waikato Hospital, Starship Hospital, Royal Darwin Hospital, Gold Coast University Hospital, Queensland Children’s Hospital, Westmead Children’s Hospital, Sydney Children’s Hospital, Perth Children’s Hospital, Monash Health, Women and Children’s Hospital, The Royal Children’s Hospital. Townsville Hospital seeking funding.

Current status:
  • Recruiting at 8/11 PREDICT sites, 101 patients enrolled to date. We are behind on enrolment, largely due to delays in getting sites up and running. Very few missed enrolments.
  • US recruiting at 21 sites, with 1300 patients recruited so far. Canada are recruiting at 1 site, with 2 enrolments so far.
  • Compliance with study fluids overall is good, more patients in 0.9% saline arm have been non-compliant. Some of these patients have been taken off the study fluid due to safety concerns by their treating team (hyperchloraemia etc).
  • Site visits for data checking have commenced, with GCUH, WCH, MMC, and PCH all doing a great job of data entry.
  • We have started sending out data queries, though the majority of these are missing data at this stage. We are working on monthly reports which will start being sent out soon.

Involving Consumers in your Research – Article 2: Involving consumer advisors in development of the PEACHY projects.

Over the next few months we will contribute a series of articles outlining how we have involved consumers in the Million Minds research program, what we have learned and how we might improve things in the future.

Background

When the “Kids are not Ok” program of research was funded by the Medical Research Futures Fund, we felt that it would be critical to get consumer advisors involved in the development, design and ongoing roll-out of the research.  In this article we will describe how we involved the Kids are Not OK Consumer Advisor group in the development of:

PEAChY O

Pharmacological Emergency Management of Agitation in Children and Young People – A randomised controlled trial of oral medication.

PEAChY M

Pharmacological Emergency management of Agitation in Children and Young people –  A randomised controlled trial of IntraMuscular medication

Where and when did we start….
When the study protocols were being drafted, we decided we needed to consult with consumers about how participants would be recruited in the ED and how consent would be obtained. The reality was that we wanted to obtain a waiver of consent to recruit children into the study but needed to sound this out with parents to determine if this was reasonable.

What did we do….
Meeting 1 (online via zoom)

  • Warm up – introductions were made, our parent consumers talked about their lived experience of attending the ED with their children who had mental health issues.
  • Elyssia explained the rationale for embarking on this trial and summarised the trial overview (including non-medication ‘de-escalation’ attempts and trial drugs), what the studies were about and what they aimed to do.
  • Questions about the study in general were invited and discussed in the group.
  • Elyssia presented our intent to obtain a waiver of consent for this trial and listed the rationale, benefits and potential risks.
  • All consumer advisors were invited to comment on how they felt about recruitment under a waiver of consent.  All expressed their understanding and were comfortable with the waiver – given the stressful circumstances in the ED.
  • Parents were also in favour of being notified that participants were enrolled in a trial and that their (de-identified) data would be collected.They wanted to receive information about:
    – Background information on acute severe behavioural disturbance and treatment methods, trial purpose, intended outcomes and the trial drug/s their child received.
  • Detailed minutes of the meeting were taken.
  • Essential points of the discussion were incorporated into the study protocol in a specific section about consumer involvement.
  • It was agreed that we would also get input into the participant information to be developed.

Follow up email consultation

  • Consumers were consulted via email re drafting of the participant information form.
  • Consumers had the opportunity to review and provide feedback on the participant information form prior to this being submitted for ethical review.

Since then…..

  • We successfully obtained a waiver of consent from the lead HREC for the study and this has been accepted at most interstate sites.

What we learned about working with consumers to design our protocol and materials….

  • It takes time – ideally start early!
  • Careful facilitation of the meetings is important taking care to involve everyone and allow time for discussion and different points of view to be raised.
  • Consumers often contribute ideas that clinicians may have missed!
  • Consumers are generally very accepting of ideas such as a waiver of consent that are viewed as posing significant ethical risks. To ensure this acceptance, a clear explanation and justification of why this is the best approach and how it will improve the experience for the young person and their family members when they participate in the trial is required.
  • Careful write up in the protocol of how consumers have been involved in development of the study has been valuable for obtaining ethics approval.

Project Snapshot – Observational study of COVID-19 Infections: Clinical Characteristics and Outcomes at PREDICT Sites

Aim:

Describe clinical features and outcomes of patients < 18 years who tested positive with COVID-19 and presented to hospitals across Australia in the PREDICT network.

Design:

A multicentre retrospective study involving data extraction from medical records on children who test positive for COVID-19 and are seen in emergency or admitted to hospital.

Recruitment:

Sites – 23 hospitals across 8 Australian states and territories

Current Status:

• Our first audit of cases was from 1/2/20 to 30/9/2020 and involved our original 14 hospitals across 5 states.
• This data has since been published in MJA  and we are now completing our second audit of cases with the inclusion of 9 new sites expanding our coverage, which will include cases up to 31/12/2021.

Much has happened in this study since it began. New strains keep evolving and COVID case numbers have blown out in many locations. To keep the workload manageable, our focus is on the children who go to ED or are admitted.

This is the only study to date that looks at COVID in children on a national multicentre level and describes their care requirements and short-term outcomes in the first two years of the pandemic. We aim to complete the next audit and publish again soon, stay tuned!

Thanks to all our site research teams who have come along for the ride!
Cate Wilson, Laila Ibrahim and Franz Babl

New PREDICT publications

Congratulations to the following PREDICT authors:

Haskell L, Tavender EJ, O’Brien S, Wilson CL, Borland ML, Cotterell E, Babl FE, Zannino D, Sheridan N, Oakley E, Dalziel SR. Can targeted interventions change the factors influencing variation in management of infants with bronchiolitis? A survey of Australian and New Zealand clinicians: A paediatric research in emergency departments international collaborative (PREDICT) study. J Paediatr Child Health. 2022 Feb;58(2):302-311. doi: 10.1111/jpc.15710. Epub 2021 Sep 9. PMID: 34498782.

Project Snapshot – Sustaining improvements in the management of infants with bronchiolitis – a PREDICT study

The PREDICT ‘Knowledge Translation in Australasian Paediatric Acute Care’ (PREDICT KT study) (HREC/16/RC), a multicentred, cluster, randomised control trial of infants with Bronchiolitis, demonstrated that use of targeted, theory-informed interventions (clinical leads, stakeholder meeting, train-the-trainer workshop, targeted educational package, audit/feedback) significantly improved compliance with five key non-evidence-based practice recommendations for bronchiolitis (chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline) in acute care settings by 14.1% (adjusted risk difference, 95% CI, 6.5%-21.7%; P < .001).

The aim of this study is to assess sustainability of improvements in reducing inappropriate therapies in infants with Bronchiolitis, at the 26 sites which participated in the PREDICT KT Study, one (2018) and two year (2019) post implementation of intervention. A retrospective medical audit and qualitative semi-structured interviews will be conducted at each site over two years following initial implementation of the KT Study interventions. Our results will help determine the sustainability of this intervention over time, determine any improvements in control group hospitals, examine the learning and decay effects of the intervention, determine fidelity and adaptation of the intervention and explore factors which may have contributed to sustained improvements in either intervention or control group sites.

Link to further project details

News:
  • Ethics approval has been received for Australian sites and provisional ethics approval has been received for New Zealand sites.
  • Sites will only be recruited if they participated in the PREDICT KT Study. Currently, 16 of the 20 Australian sites have agreed to participate.
  • Governance approvals are underway for the 16 Australian sites, with hopes to commence recruitment at these within the first half of 2022.
  • A protocol manuscript has been drafted and will be submitted for publication soon.

 

Project Snapshot – KIDS THRIVE

Trans-nasal Humidified Rapid-Insufflation Ventilatory Exchange in Children Requiring Emergent Intubation

AIM:

The aim of this study is to assess the effect of THRIVE as a method for prolonging apnoeic oxygenation during the emergency intubation of children to reduce the proportion adverse events (specifically, oxygen desaturation) and increase the proportion of first attempt success for endotracheal intubation.

RECRUITMENT STATS AS @ 24/2/22:

Study commenced 09/05/2018

  • Sample size: 960
  • Current Overall Enrolment Total: 820

Sites currently recruiting as @ 24/2/22

  • Queensland Children’s Hospital – ED & PICU
  • Children’s Hospital at Westmead – PICU
  • Gold Coast University Hospital – ED & PICU
  • Monash Children’s Hospital – ED & PICU
  • Perth Children’s Hospital – PICU
  • Royal Children’s Hospital, Melbourne – PICU & NICU
  • Townsville Hospital – ED & PICU
  • Women’s and Children’s Hospital PICU
  • University Children’s Hospital Zurich – PICU

Planned to start recruitment in 2022

  • BC Children’s Hospital Vancouver – PICU
NEWS:

2,191 children have been screen for inclusion into the KIDS THRIVE study and to date 820 have been randomised and consented. Of the enrolled children approximately 11% have been intubated in the ED, 80% in the PICU and 9% in the NICU. This study has been approved for consent to continue (delayed consent) due to the emergent nature of intubations. The Kids THRIVE Trial Steering Committee (TSC) have had complex ongoing discussions regarding the COVID-19 pandemic and the disease in children; and recommended the study not be paused and that sites be allowed to develop their own local plan on how to manage the recruitment of patients. In 2020 a systematic, prioritized, risk-based approach to monitoring the KIDS THRIVE project was undertaken and centralised in depth source documentation verification and monitoring of the trial is well underway. Our most exciting news is that The Kinderspital Children’s Hospital in Zurich recruited their first patient on valentine’s day this year and we welcome them to the study team. We anticipate finishing recruitment at the end of the year.

The KIDS THRIVE study gratefully received initial seed funding from the Emergency Medicine Foundation, and additional funding from the Thrasher Research Fund and the National Health and Medical Research Council.

Involving Consumers in your Research – Article 1: Recruitment

Involving Consumers in your Research

Over the next few months Cate Wilson, Simon Craig, Marietta John-White and other project leads will contribute a series of articles outlining how we have involved consumers in the Million Minds research program, what we have learned and how we might improve things in the future.

Article 1: Recruiting a consumer advisor group for the Kids are not OK

Background….

When the “Kids are not Ok” program of research was funded by the Medical Research Futures Fund, we felt that it would be critical to get consumer advisors involved in the development, design and ongoing roll-out of the research for the 5 key project areas:

(1) Delphi Study – An email survey of staff, patients, carers and relevant community services eg. police, school counsellors. to prioritise research questions and agree on core outcome measures for future studies.

(2) Retrospective Study – A review of medical records

(3) Prospective Observational Study – Enrolment in the ED and follow-up for 12 months

(4) Safety Planning for Suicidality – We planned to conduct a trial of a safety planning program supported by an app and telephone support for patients who present to the Emergency Department at risk of suicidal crisis.

(5) Treatment for acute severe behavioural disturbance: which are the best medications? Randomised clinical trials of oral and IM medications

What came next….

We developed a flyer to assist with recruitment which outlined:

  • what the program of research aimed to do
  • what our consumer advisors would be asked to do
  • what skills or experience would be helpful
  • what the time commitment would likely be
  • where meetings would be held (all changed since COVID!)
  • what financial support would be offered ($50 per hour)
  • how to apply/express interest

How did recruitment work….

  • Initially, we asked a range of clinicians in different types of clinics/ward areas where children with a range of mental health conditions were seen, to approach potentially suitable people i.e. Parents or youth of 18 years plus.  Prior to this, we had met with the clinicians to explain what we wanted and to equip them with the flyers.  Then we kept in touch to see if they had approached anyone.
  • Response was slow but after 4 weeks we had a carer consultant refer us a potential consumer.  Two of us met with our first consumer in the hospital café and we had a casual chat to explain more about the role, answer questions and generally assess that we both understood each other.  It went well and after the meeting we offered the position formally via an email and it was accepted.
  • We had not received any other referrals from the clinicians – so we asked our first consumer about how we might recruit some others?  This was a stroke of genius as she put the word out to other people and on closed facebook groups which we otherwise would not have had access to.
  • More consumers approached us and again we did coffee (pre-COVID times!) or talked over the phone.  We recruited three more people into our consumer advisory group who provided a range of experiences and skills.
  • There were a couple of people who approached us but did not meet our requirements in terms of experience (of MH), or they later felt they could not commit.

Preparation and training….

Our organization required our consumers to complete a confidentiality agreement.  We also explained the confidentiality agreement to them and they were happy to comply.

We got the group together for face-to-face training (when this was possible) and in a 1 hour meeting we covered the following:

  • description of the funded projects
  • how Consumer Advisors would contribute
  • research ethics and good clinical practice basics
  • how to contribute effectively in meetings
  • how to review documents such as PICFs
  • developing a brief summary of your story that you are comfortable to share
  • remuneration process
  • what to do if there are problems or concerns/who to go to
  • any other questions

Some links and pdfs were also provided to support the above topics.

The consumers were remunerated for their participation in training.

Since then…..

  • We contact the group when we want their involvement in specific projects.
  • We do a yearly newsletter for the consumer group that outlines progress of the whole research program.
  • We have asked each member to complete a confidential, brief survey to evaluate how they are experiencing their involvement in the research.

What we learned about setting up a consumer advisor group….

  • It takes time – ideally start when you are thinking about the grant and get input to your aims, indicators and research priorities too!
  • Consumers are fantastic at recruiting other like-minded consumers!
  • Try and recruit at least 4 – 6 people as often 1 or 2 people can’t make it to a specific meeting.
  • Ensure you budget adequately for remuneration in your grant.

Implementation Research Workshop – 31st March 2022

This one-day, online event scheduled for 31st March 2022 will address implementation research in the PREDICT network – what is implementation research, what have we achieved and where are we heading?

Dr Emma Tavender, the PREDICT Knowledge Translation Co-ordinator, together with local and international implementation science researchers will present sessions throughout the day, concluding with small group discussions.

Topics include: introduction to implementation science, future directions in implementation research (external case studies) and planning for future PREDICT implementation research projects.

This promises to be an interesting and informative day for our PREDICT members.

Bookings are now closed for this event however if you haven’t registered and feel this workshop is of particular interest to you please email marian.chandler@mcri.edu.au.

New PREDICT publications

Congratulations to the following PREDICT authors:

Pfeiffer CK, Smith K, Bernard S, Dalziel SR, Hearps S, Geis T, Kabesch M, Babl FE; PREDICT Network. Prehospital benzodiazepine use and need for respiratory support in paediatric seizures. Emerg Med J. 2022 Jan 25:emermed-2021-211735. doi: 10.1136/emermed-2021-211735. Epub ahead of print. PMID: 35078857. 

Pfeiffer CK, Mackay MT, Long E, Stephens D, Dalziel SR, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT).  Parenteral Long-Acting Antiseizure Medications Are Used More Often to Treat Seizure Clusters Than Convulsive Status Epilepticus in the Pediatric Emergency Department. J Child Neurol. 2022 Feb 10:8830738221077751. doi: 10.1177/08830738221077751. Online ahead of print.PMID: 35142572.

Barrett MJ, Dalziel S, Lyttle M, O’Sullivan R and the Pedatric Emergency Research Networks (PERN). A bibliographic analysis of global pediatric emergency medicine research networks. Pediatric Emergency Care. Dec 2021.