A refresh for Emergency Medicine

Authors: Laura Cottey, Jason Smith, Caroline Whiting on behalf of the JLA EM PSP Steering Group

In 2017, the research priorities for emergency medicine (EM) in the UK were announced following a priority setting partnership (PSP) with the Royal College of Emergency Medicine (RCEM) and James Lind Alliance (JLA).(1)

Emergency medicine has faced significant change since 2017 with the COVID-19 pandemic and mounting pressure on urgent care and emergency services. Research in emergency medicine has not only continued throughout these challenging times but has also built momentum with initiatives such as the launch of the Trainee Emergency Research Network (TERN) and the National Institute for Health Research (NIHR) Emergency Care Incubator.(2) Furthermore, the NIHR and other large research funders have awarded over £8 million to projects directly addressing the EM research priorities, and in December 2019 the NIHR launched a themed call across all of their funding streams addressing “injuries, accidents and urgent and emergency care”.(3)

As we look to the future of research in emergency medicine, with several of the original priorities being addressed, the time was ripe for a refresh in order to define our research priorities for the coming few years. Here we share the process and a summary of what has been learnt.

Getting started

In an ever-changing healthcare landscape, it was clear that the refresh process needed to be quicker than the original priority setting partnership. A steering group was put together comprising emergency clinicians, allied healthcare professionals, patients, carers and representatives from the JLA. A timeline was agreed, which set an ambitious plan for the refresh to be completed within seven months from February 2022 to October 2022.

Question time

The first step was to put out a call for new research questions to be submitted. This was disseminated through a variety of means and the survey was open for three months. It saw submissions from a range of stakeholders, although once again we found it challenging to engage patients and carers in this phase of the process. In total, 77 questions were submitted. These were reviewed and combined, giving a list of 58 questions which were allocated into eight themes: major trauma, trauma in the older patient, head injury, medical conditions such as a heart attack, back pain, staff workforce and resources, artificial intelligence and then singular themes. It was interesting to see new questions relating to topics such as artificial intelligence and the use of new technology; of concern (but perhaps not surprising), themes around staff burnout and wellbeing were still prevalent.

Do we know the answer already?

The next step involved a large team effort to understand if any of these submitted questions had already been answered. With the help of emergency medicine trainees and medical students, each of the 58 questions was reviewed in turn and the evidence assessed through a literature review process. We used the BestBET format for this,(4) which proved very helpful. At the end of that process, if the question had no clear answer, then it went through to the next round.

At this stage, the original top 30 questions from 2017 were reviewed. If any of those questions hadn’t been answered over the preceding five years or been re-submitted in an original or similar form, they were included in the next round and ranked as per the new questions.

Prioritising

The initial submission list of questions was refined and all questions underwent review by the steering group to produce lay summaries of the questions and a glossary of terms. Further combining of questions took place, if applicable, and any questions identified as being out of scope were removed. 49 questions were included in the interim survey for ranking in order of importance.

The results of this interim prioritisation survey were analysed to produce the ranking of questions and separately analysed for patients and clinicians. The Steering Group reviewed the top 10 questions for patients/carers and healthcare professionals and shortlisted any additional questions to take forwards to the final prioritisation workshop, where a shortlist of the top 26 questions was discussed.

Reaching the top 10

A final prioritisation workshop was led by facilitators from the JLA and was held on 23 September 2022; this involved stakeholders who discussed and ranked the 26 questions on the shortlist to produce a top 10. The workshop consisted of a series of small group discussions, with participants split into three groups, and whole group consensus sessions. Participants were asked to rank the 26 questions prior to attendance, the top and bottom ranking were then shared in small groups coupled with details of the ranking from the interim prioritisation survey categorised by respondent role. Questions in middle ranking were discussed and the group facilitator of each group compiled a top, middle and bottom list of the 26 questions. The first round of ranking, using the same participants in small groups, aimed to rank questions placed in the three groups from 1 to 26. The three group facilitators then combined the 1 to 26 ranking from all groups and presented these back for further discussion. A second round of ranking in small groups, of different composition, resumed. A final session with all participants present displayed the aggregate ranking from the second round and allowed for further discussion to reach a consensus on the Top 10.

What have we learnt?

This research priority refresh is the first of its kind to update the priorities from an earlier PSP. We have re-defined the priorities for emergency medicine in the UK, which will hopefully guide the research agenda for the coming years. With a large team of willing volunteers and a proactive steering group a short turnaround time can be achieved, whilst using robust and established methodology,

One of the key learning points from this process and for wider reflection in emergency medicine is how to achieve meaningful and purposeful engagement with patients and carers to shape research direction. Research priorities should be driven by all stakeholders’ needs and ranking from the interim survey demonstrated a variation in prioritisation between healthcare professionals and patients/carers. The challenge with emergency medicine covering a wide range of symptoms and conditions is that the usual process for involving patient stakeholder groups is often not suitable or achievable, so it is difficult to secure the diversity of views required. For future refresh processes, additional methods to increase the patient and carer input may need to be considered and lessons may be learnt from other medical specialities in due course to create wider engagement of all stakeholders.

To find out more about the Emergency Medicine priorities visit the Research Priorities page on the Royal College of Emergency Medicine's website. 

References

1. Smith J, Keating L, Flowerdew L, O’Brien R, McIntyre S, Morley R, et al. An Emergency Medicine Research Priority Setting Partnership to establish the top 10 research priorities in emergency medicine. Emerg Med J. 2017 Jul;34(7):454–6.
2. Trainee Emergency Research Network [Internet]. TERN. Available from: https://ternresearch.co.uk
3. Funded Research: Emergency Medicine [Internet]. James Lind Alliance Priority Setting Partnership. Available from: https://www.jla.nihr.ac.uk/funded-research/emergency-medicine/24425
4. Mackway-Jones K. bestbets.org: Odds on favourite for evidence in emergency medicine reaches the world wide web. Emerg Med J. 2000 Jul 1;17(4):235-a-236.