A platform for paediatric acute care research

Although well established in North America, paediatric emergency medicine (PEM) in Australia and New Zealand is a more recent subspecialty. It has grown from two independent colleges: the Royal Australasian College of Physicians (RACP) and the Australasian College for Emergency Medicine (ACEM). As recently as the 1990s, training in PEM was fashioned by individuals with an interest, selecting acute paediatric care, emergency and paediatric intensive care electives while training under one of the above two colleges, with a few individuals undertaking Fellowships in North America. In the early 2000s, subspecialty specific training was formalised under a Joint Training Committee of the two colleges. Trainees in the final 3 years of advanced training are required to complete a specific training programme comprising 18 months of PEM, 6 months of paediatric intensive care and 12 months of either general paediatrics or adult emergency medicine, for trainees of the ACEM and RACP, respectively. Since then, the workforce of PEM specialists has grown at all major centres as well as at many non-tertiary centres, either within stand-alone paediatric EDs or within mixed EDs with sizable paediatric presentations. While the primary role for all EDs is service provision, PEM physicians were aware that much acute practice in EDs, both in high volume and rare but life-threatening conditions, was not adequately evidence based. Research capacity and output has thus grown with the development of PEM as a subspecialty. As the front door of the hospital, EDs are the point where the acute care issues for all paediatric subspecialties need to be initiated and, where there is a lack of evidence, researched. The ED therefore provides a unique opportunity for research collaboration across specialties. Multicentre research has been conducted in paediatric subspecialty fields for decades. There are multiple advantages of multicentre research over single-centre projects:1 the availability of larger participant numbers to complete projects in a shorter period of time; the ability to address questions where outcomes are infrequent but serious or differences are small; findings are potentially more useful and generalisable; and multicenter research decreases duplication of effort and pools resources and expertise across sites. More recently a number of subspecialties have developed research networks.2-5 Network research has a number of advantages including the development of a longer term strategy by building on previous research findings and methodologies and the development of research capacity and research infrastructure. These elements should assist networks in becoming more competitive for grant funding. Additional benefits are study-associated standardisation of disease management and thus improving care across network sites. Paediatric emergency research within networks has been conducted in North America for more than a decade, beginning with Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) of the American Academy of Paediatrics (AAP). In 2001, the Pediatric Emergency Care Applied Research Network (PECARN) was formed based on a multimillion dollar grant from the US federal government with the aim of improving PEM research. The three North American networks have been highly successful in adding high-level evidence with worldwide impact, sourcing large grants and bringing multicentre projects to publication in prestigious journals, such as the New England Journal of Medicine,6, 7 Journal of the American Medical Association8 and The Lancet.9 In 2004, aided by a seed grant from the Murdoch Children's Research Institute in Melbourne, the Paediatric Research in Emergency Departments International Collaborative (PREDICT) was formed as a PEM research network for Australia and New Zealand. The network, which includes all tertiary paediatric hospitals and several mixed EDs with a large paediatric census, has grown from an initial 10 sites to 15 sites. The network structure is flat, with site representatives delegated to a research steering committee, which in turn elects a five-person executive committee to manage administrative affairs, communication, strategic direction and governance. Decisions on study initiation are based on majority voting by the research steering committee. Initial projects included an assessment of the network's epidemiology and scoping studies to assess clinical practice guidelines and variation in practice across the network in key PEM presentations of gastroenteritis, asthma, bronchiolitis, seizures, croup, analgesic practice and procedural sedation.10-17 Subsequent large-scale retrospective studies18, 19 provided the basis for planned interventional studies. The network's first major competitive grant, from the National Health and Medical Research Council (NHMRC), funded a randomised trial comparing intravenous with nasogastric hydration in infants hospitalised with bronchiolitis.20 This study, the results of which have been published in Lancet Respiratory Medicine,20 randomised 759 patients at seven PREDICT sites in Australia and New Zealand, and demonstrated that nasogastric and intravenous rehydration had similar lengths of stay and low adverse events profiles. Currently, the major studies being undertaken are the first randomised controlled trial worldwide of second-line status epilepticus management in children, conducted at 13 PREDICT centres and funded by the New Zealand Health and Research Council, and a large prospective validation study of clinical decision rules for head injured children developed outside Australia and New Zealand, conducted at 10 centres and funded by the NHMRC.21 Most recently, the network was awarded a 5 year Centres for Research Excellence (CRE) grant from the NHMRC. This grant will allow PREDICT to significantly improve its research capacity across the network through the training of clinician researchers in PEM, establishment of a multisite PhD programme and enable mentoring by overseas experts. The lack of PEM researchers with higher degrees is an impediment to more investigator-led research in PEM. Alongside with the development of research capacity, the grant will also allow us to conduct a number of large multicentre studies. Within these studies, PEM researchers are working with neurologists, neuropsychologists, intensivists, trauma surgeons, anaesthetists and oncologists to improve the evidence base for a wide range of paediatric conditions. One of the critical issues in multicentre research is the need to establish secure and cost effective data capture and entry systems. The PECARN network in the USA has a funded contracted data management centre that manages all network studies. The recent NHMRC CRE funding of PREDICT will allow us to establish an effective multisite data management system in conjunction with the newly established Australian Paediatric Trials Network (http://www.PTNA.com). Local research training, within PEM, will need to go beyond higher degree students as most current research is conducted at network sites by clinicians, trainees, students, research coordinators and research assistants who do not have higher degrees. One of the efforts of a team within PREDICT has been to provide part-time clinical researchers with practical research education through a publication series1, 22 and an acute care research course with a focus on clinical researchers in emergency, intensive care and anaesthesia. The recent NHMRC CRE funding of PREDICT will further provide network-wide research training with a particular focus on research governance and good clinical research practice. Research by college trainees creates a unique set of issues. Although PEM is a fertile ground for research topics for trainees, many such projects are based on small numbers, are retrospective and are of low impact. Furthermore, although the individual colleges have set requirements for research, there is no readily available research training provided and individual sites may have limited capacity for research training and supervision (ACEM also provides the option of undertaking a research course instead of a research project). The establishment of PREDICT has provided a platform for research topics and research education of trainees by binding them into existing and established research education and supervision within the network. Trainee projects have included baseline practice surveys23 and prospective pilots for larger studies.21 Recently, we have combined the efforts of a group of trainees at multiple sites to conduct data collection at their respective hospitals and then share access to the resulting large dataset to answer specific questions on the same topic, such as the need for intensive care admission in bronchiolitis. Network size and number and type of participating sites are crucial elements for all multicentre projects. There remains a trade-off between a larger number of sites to contribute participants, research capacity of sites and the efficiency of the network. In addition, while larger sites may be able to provide greater numbers of participants, involvement of smaller sites, particularly non-tertiary sites, increases the generalisability of findings and may improve inter-hospital links and knowledge translation. Internationally, PREDICT and PERC (Canada) have expanded, whereas PECARN has reduced their overall number of sites. One of the ways that PREDICT would wish to involve increasing numbers of smaller non-tertiary EDs is in health delivery and knowledge translation research. This is seen as particularly relevant, as the majority of children who present to EDs within Australia and New Zealand do so at non-tertiary hospitals. Both in Canada and in the USA, knowledge translation has been identified as a key issue in emergency medicine.24, 25 Although our knowledge increases, the gap between what we know and what we practice may actually widen. Knowledge translation is aiming to close this gap. PERC has recently been funded by the Canadian Institutes for Health Research to undertake a sustained research programme into knowledge translation in PEM.24 The conceptual foundation for the proposal was to bring together clinical research and knowledge translation in a multiyear programme. The framework for the project is an iterative figure-eight model that provides logical steps for research and interlinks clinical and knowledge translation research. The assessment of how research findings should be best translated into clinical departments will be through cluster randomised studies. Similarly, the long-term research strategy of the PREDICT CRE programme includes a cluster randomised trial to implement the findings of our bronchiolitis work.20 Ultimately, we would like to include more non-tertiary EDs, nursing and allied health research in our research efforts and develop PREDICT as a platform for non-emergency researchers and industry sponsored research. Based on the experience with H1N1-related research,26 PREDICT may also play a role in global disease surveillance efforts. Although the North American networks have been most helpful with informal advice and support for the foundation of PREDICT, more recently the regional PEM networks from the USA (PECARN and PEM CRC), Canada (PERC), Europe (Research in European Emergency Medicine) and Australia/New Zealand (PREDICT) have formed a formal association in the Pediatric Emergency Research Networks (PERN).27 This network includes 120 institutions from 19 countries and has an annual ED census of 3 million visits. This global network can answer questions with very infrequent outcomes, conduct studies that are generalisable across many settings, compare management across countries and health systems and develop international consensus. The first global PERN study, on the epidemiology of the H1N1 epidemic, was led by a PREDICT researcher and published in the British Medical Journal.26 Further PERN studies on toxicology, child traumatic stress and bronchiolitis management are in the data collection or the late concept phase. PEM has developed rapidly over the past 15 years. The development of an Australian and New Zealand emergency research network is providing an improved evidence base for emergency care in children and a platform for emergency and paediatric researchers from all specialties to conduct acute care research. FEB, EO and SD are section editors for Emergency Medicine Australasia.

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