Facilitating research projects in schools and clinical respiratory care departments

As the profession of respiratory care evolves, greater demands are being placed on educators, managers, and practitioners as they encounter a mass of new literature and the latest technology. Respiratory care schools and clinical departments are under increasing pressure to prepare students and staff with the skills needed to efficiently and effectively consider the numerous primary research investigations, systematic reviews, consensus practice guidelines, and institutional continuous-quality-improvement data. A classroom and work environment that encourages openness and discussion and rewards inquiry is of fundamental importance. Cooperative efforts from school and workplace can provide both student and practitioner with courses on scientific methodology, journal clubs, and equipment seminars. A student body and clinical staff that receive foundational and ongoing education in empirical methodology will respond by assisting in the development and implementation of practice protocols, quality assurance programs, and clinical research. A school and workplace that embrace these attitudes and practices will provide an environment that enhances learning, stimulates professional development, and ultimately provides the most current and best care for its patients.     

Developing multisite research in critical care

Conducting a clinical critical care research project simultaneously in a variety of institutions requires careful and comprehensive planning. The authors outline the steps in the planning and development of a multisite research project, stressing those areas requiring special attention and decision making.     

Murine models in critical care research

INTRODUCTION: Access to genetically engineered mice has opened many new opportunities to address questions relevant to the pathophysiology and treatment of patients in critical conditions. However, the results of studies in mice cannot disregard the unique ability of small rodents to adjust their temperature and high metabolic rate and the corresponding respiratory and circulatory requirements in response to hypoxia. POINT OF VIEW: Studies performed in mice on questions related to metabolic, circulatory, and respiratory regulation should always be considered in light of the ability of mice to rapidly drop their nonshivering thermogenesis-related metabolism. As an example, it has been recently argued that a moderate level of inhaled hydrogen sulfide may have a potential benefit in patients in coma or shock or during an anoxic or ischemic insult, as this toxic gas dramatically reduces the metabolic rate in resting mice. However, acute hypometabolism has long been described in small mammals in response to hypoxia and is not specific to hydrogen sulfide. More importantly, mice have a specific metabolic rate that is 15-20 times higher than the specific metabolic level of a resting human. This difference can be accounted for by the large amount of heat produced by mice through nonshivering thermogenesis, related to the activity of uncoupling proteins. This mechanism, which is essential for maintaining homeothermia in small mammals, is virtually absent in larger animals, including in adult humans. Accordingly, no direct metabolic effect of hydrogen sulfide is observed in large mammals. We present the view that similar reasoning should be applied when the circulatory or respiratory response to hypoxic exposure is considered. This leads us to question whether a similar strategy could occur in mice in critical conditions other than hypoxia, such as in hypovolemic, septic, or cardiogenic shock. CONCLUSION: Mouse models developed to understand the mechanisms of protection against hypoxia or ischemia or to propose new therapeutic approaches applicable in critical care patients should be understood in light of the specificity of the metabolic, respiratory, and circulatory responses of mice to a hypoxic insult, since many of these adaptations have no clear equivalent in humans.     

Unit-based research in critical care nursing

This article describes the characteristics of unit-based nursing research, highlighting the experiences of staff nurses on two critical care units. On both units, study findings facilitated changes in practice. The authors evaluate their experience and offer suggestions to critical care nurses interested in unit-based research.     

Clinician involvement in critical care research

Clinician involvement in critical care research will be essential if we are ever to achieve optimal patient outcomes. Educators and unit leadership play a pivotal role in facilitating, mentoring, and coaching clinicians both conduct research on important issues or problems in critical care and to ensure that practice routines are based on the latest research findings.     

Ethics and research in critical care

Background The past few years have witnessed several controversies regarding the ethics of conducting research involving critically ill patients, and such research is ethically challenging.Discussion Research ethics is a changing field, one that is influenced by empirical data, contemporary events, and new ideas regarding aspects of clinical trial design and protection of human subjects. We describe recent thoughts regarding several aspects of research ethics in the critical care context.Conclusion The ability of the research community to conduct research ethically and to maintain public trust would benefit from heightened awareness to the principles and requirements that govern such research.     

Multicenter clinical research in adult critical care

OBJECTIVE: To describe the development, organization, and operation of several collaborative groups conducting investigator-initiated multicenter clinical research in adult critical care. DESIGN: To review the process by which investigator-initiated critical care clinical research groups were created using examples from Europe, Australia, the United States, and Canada. Various models of group structure and function are discussed, highlighting complementary approaches to protocol development, multicenter study management, and project funding. DATA SOURCES: Published peer review research and unpublished terms of reference documents on the structure and function of these groups. DATA SYNTHESIS: The overall goal of clinical critical care research groups engaged in multicenter studies is to improve patient outcomes through conducting large, rigorous investigations. Research programs we reviewed included the following: a) multicenter epidemiologic studies and surveys; b) technology evaluations of mechanical ventilation; c) investigations focused on three priority fields (acute lung injury, infection, and acute brain injury); d) a series of randomized trials of treatments for one syndrome (acute respiratory distress syndrome); and e) diverse methodologies addressing several clinical problems. The structure and function of these research groups differ according to their historical development, research culture, and enabling resources. Specific protocols emerge from clinical questions generated by investigators or from collectively prioritized research agendas. Project funding includes government support, peer-review grants, intensive care foundations, industry, local hospital funds, and hybrid models. Infrastructure for study management varies widely. CONCLUSIONS: Several national and international groups have engaged in investigator-initiated multicenter critical care research. The development, organization, and operational methods of these groups illustrate several collaborative models for clinical investigations in the intensive care unit. Common characteristics of these groups are a cohesive spirit, a sense of mission to achieve shared research goals, and acknowledgment that such an organization is much more than the sum of its parts.     

Clinician-implemented research utilization in critical care.

The application of research findings to practice is critical for improving patients' outcomes and for ensuring that nursing practice is both cost-efficient and effective. Unfortunately, research findings that clearly should be used are not always implemented, a fact termed the "research-practice gap." In 2000, as a result of the interest of staff nurses in establishing evidence-based practice, nurses from 7 adult critical care units at the University of California Davis Health System, Sacramento, Calif, began discussions on how to implement such a practice. A critical care research utilization committee was formed with representation from each of the adult critical care units, the emergency department, and the postanesthesia care unit. This committee was responsible for reviewing and revising each critical care policy and procedure on the basis of the best available evidence. The impetus for this project was a concern that current policies and procedures were, in part, based on tradition rather than on science and did not always reflect rapid changes in critical care, including use of new equipment, new treatments, and new findings. This project produced a number of beneficial outcomes. Policies and procedures were revised on the basis of scientific evidence, new research questions were generated on the basis of gaps in the literature, and the number of clinical nurses involved in using research to improve practice increased.     

Ethical considerations in pediatric critical care research

Pediatric critical care nurses are exposed to research in the critical care environment on a routine basis and should be knowledgeable about the ethical considerations inherent in this process. The following discussion includes information that centers on the ethical issues of conducting research with children. First, children as a vulnerable population is explored, followed by selected ethical principles that pertain to research, the role of the technological imperative in research, the process of informed consent, and finally, nursing considerations.     

Monitoring and oversight in critical care research

Institutionally based research ethics review is a form of peer review that has – for better or worse – become the norm throughout the world. The vast majority of research ethics review takes the form of protocol review alone, conducted in advance of the research. Although oversight and monitoring in clinical research have long been recognized as essential features of sound research ethics, they are seldom exercised in ways that fulfill their motivating goals: to ensure that research is conducted as planned; that research participants comprehend the information presented to them in the consent process; and that the potential benefits and risks of study participation remain acceptable. Annual review of continuing research, monitoring informed consent, monitoring adherence to approved protocols and monitoring integrity of research data comprise the main types of monitoring and oversight activity. We believe that our institutionally based systems of research ethics review and responsibility require greater engagement and participation from researchers and research administrators. The appropriate role of critical care researchers and research administrators is to provide leadership to move toward a greater recognition of the importance of monitoring and oversight for ethical and high quality clinical research.     

Worldwide research productivity in critical care medicine

Introduction

The number of publications and the impact factor of journals are accepted estimates of the quantity and quality of research productivity. The objective of the present study was to assess the worldwide scientific contribution in the field of critical care medicine.

Method

All research studies published between 1995 and 2003 in medical journals that were listed in the 2003 Science Citation Index (SCI^®) of Journal Citation Reports under the subheading 'critical care' and also indexed in the PubMed database were reviewed in order to identify their geographical origin.

Results

Of 22,976 critical care publications in 14 medical journals, 17,630 originated from Western Europe and the USA (76.7%). A significant increase in the number of publications originated from Western European countries during the last 5 years of the study period was noticed. Scientific publications in critical care medicine increased significantly (25%) from 1995 to 2003, which was accompanied by an increase in the impact factor of the corresponding journals (47.4%). Canada and Japan had the better performance, based on the impact factor of journals.

Conclusion

Significant scientific progress in critical care research took place during the period of study (1995–2003). Leaders of research productivity (in terms of absolute numbers) were Western Europe and the USA. Publications originating from Western European countries increased significantly in quantity and quality over the study period. Articles originating from Canada, Japan, and the USA had the highest mean impact factor.. Canada was the leader in productivity when adjustments for gross domestic product and population were made.

     

Facilitating best practice in aged care: exploring influential factors through critical incident technique

Aim.  The focus of this study is on the perspective of facilitators of evidence-based aged care in long-term care (LTC) homes about the factors that influence the outcome of their efforts to encourage nursing staff use of best practice knowledge.
Design.  Critical incident technique was used to examine facilitators' experiences.
Methods.  Thirty-four participants submitted critical incident stories about their facilitation experiences through face-to-face interviews, telephone interviews, and/or a web-based written questionnaire. The resultant 123 stories were analysed using an inductive qualitative approach.
Results.  Factors at individual and contextual levels impacted the success of facilitators' work. The approaches and traits of facilitators as well as the emotionality and intellectual capacity of nursing staff were the individual factors of influence. On a contextual level, the inherent leadership, culture, and workload demands within LTC homes, as well as externally imposed standards were influential.
Conclusions.  Primary factors influencing the facilitation of best aged care in LTC homes appear to be largely relational in nature and intimately connected to the emotionality of those who work within these settings. Enhancing the interactional patterns amongst staff and leaders as well as promoting a positive emotional climate may be particularly effective in promoting better aged care nursing practice.     

Challenges in conducting end-of-life research in critical care

Critical care units present some unique challenges to the researcher, especially when the research topic of interest is related to end-of-life care. The purpose of this article is to address some of the methodological and practical issues related to conducting end-of-life research in the critical care setting. Recruitment barriers include gaining access to a clinical site, gaining access to patients, and prognostic uncertainty. Additional barriers include challenges related to informed consent, data collection, the research team, and ethical considerations. Strategies are described that can be used to guide researchers to conduct end-of-life research successfully in critical care.     

Factors affecting consent in pediatric critical care research

Purpose  

Consent for research is a difficult and unpredictable process in pediatric critical care populations. The objectives of this study were to describe consent rates in pediatric critical care research and their association with patient, legal guardian, consent process, and study design-related factors.     

重症医学文献计量学分析

目的采用文献计量学的方法展现国内外重症医学文献现状、原始研究与二次研究情况及研究热点,为相关研究提供参考。 方法计算机检索PubMed、Web of Science、万方数据知识服务平台、中文科技期刊数据库、中国知网期刊全文数据库和中国生物医学文献数据库,查找国内外关于重症医学研究的文献,检索时间均限定为1970年1月1日至2017年9月1日,运用Excel 2013提取文献的基本信息,社会网络分析软件Ucient 6.0分析国家间的合作关系,HistCite 12.03进行文献时间序列分析。 结果共纳入国内外文献353 882篇,有1963篇Meta分析发表,国内外均显示文献呈逐年上涨趋势,而国内文献的上升趋势主要集中在2005至2017年。文献中的原始研究与二次研究都主要集中在欧美国家,发表数量以美国为首,但研究机构以多伦多大学为首。国内Meta分析已跻身全球第4位,但原始研究数量较少,且机构分散。国外研究集中在机械通气和脓毒症等方面,国内胰腺炎研究较多。 结论在过去的近50年间,重症医学领域研究呈现逐年递增趋势,仍是当前医学研究中的热点,欧美国家处于主导地位。国内重症医学研究水平与国外差距较大,主要体现在文献的数量、原始研究的开展以及与其他国家的合作度均较低。     

The research agenda for trauma critical care

In this research agenda on the acute and critical care management of trauma patients, we concentrate on the major factors leading to death, namely haemorrhage and traumatic brain injury (TBI). In haemostasis biology, the results of randomised controlled trials have led to the therapeutic focus moving away from the augmentation of coagulation factors (such as recombinant factor VIIa) and towards fibrinogen supplementation and administration of antifibrinolytics such as tranexamic acid. Novel diagnostic techniques need to be evaluated to determine whether an individualised precision approach is superior to current empirical practice. The timing and efficacy of platelet transfusions remain in question, while new blood products need to be developed and evaluated, including whole blood variants, lyophilised products and novel red cell storage modalities. The current cornerstones of TBI management are intracranial pressure control, maintenance of cerebral perfusion pressure and avoidance of secondary insults (such as hypotension, hypoxaemia, hyperglycaemia and pyrexia). Therapeutic hypothermia and decompressive craniectomy are controversial therapies. Further research into these strategies should focus on identifying which subgroups of patients may benefit from these interventions. Prediction of the long-term outcome early after TBI remains challenging. Early magnetic resonance imaging has recently been evaluated for predicting the long-term outcome in mild and severe TBI. Novel biomarkers may also help in outcome prediction and may predict chronic neurological symptoms. For trauma in general, rehabilitation is complex and multidimensional, and the optimal timing for commencement of rehabilitation needs investigation. We propose priority areas for clinical trials in the next 10 years.