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Design and implementation of a large and complex trial in emergency medical services

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Robinson, Maria J., Taylor, Jodi, Brett, Stephen J., Nolan, Jerry P., Thomas, Matthew, Reeves, Barnaby C., Rogers, Chris A., Voss, Sarah, Clout, Madeleine and Benger, Jonathan R. (2019) Design and implementation of a large and complex trial in emergency medical services. Trials, 20 (1). 108. doi:10.1186/s13063-019-3203-0 ISSN 1745-6215.

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Official URL: http://dx.doi.org/10.1186/s13063-019-3203-0

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Abstract

Background

The research study titled “Cluster randomised trial of the clinical and cost effectiveness of the i-gel supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (AIRWAYS-2)” is a large-scale study being run in the English emergency medical (ambulance) services (EMS). It compares two airway management strategies (tracheal intubation and the i-gel) in out-of-hospital cardiac arrest. We describe the methods used to minimise bias and the challenges associated with the set-up, enrolment, and follow-up that were addressed.

Methods

AIRWAYS-2 enrols adults without capacity when there is no opportunity to seek prior consent and when the intervention must be delivered immediately. We therefore adopted a cluster randomised design where the unit of randomisation is the individual EMS provider (paramedic). However, because paramedics could not be blinded to the intervention, it was necessary to automatically enrol all eligible patients in the study to avoid bias. Effective implementation required engagement with four large EMS and 95 receiving hospitals. Very high levels of data capture were required to ensure study integrity, and this necessitated collaborative working across multiple organisations. We sought to manage these processes by using a large and comprehensive electronic study database, implementing efficient trial procedures and comprehensive training.

Results

Successful implementation of the study design was facilitated by the approaches used. The necessary regulatory and ethical approvals to conduct the study were secured, and benefited from strong patient and public involvement. Early and continued consultation with decision makers within the four participating EMS resulted in a coordinated approach to study set-up. All receiving hospitals gave approval and agreed to collect data. A comprehensive database and programme of training and support were implemented. More than 1500 paramedics have been recruited to the study, and patient enrolment and follow-up has proceeded as planned.

Conclusion

Care provided by EMS needs to be based on evidence. Although participants may be experiencing life-threatening emergencies, high-quality pre-hospital research is possible in well-designed and well-managed studies. The approaches described here can be used to support successful research that will lead to improved treatment and outcomes in similar patient groups.

Item Type: Journal Article
Subjects: R Medicine > RC Internal medicine
R Medicine > RF Otorhinolaryngology
Divisions: Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Clinical Trials Unit
Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences
Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH): Cardiac arrest -- Treatment -- Cost effectiveness, Trachea -- Intubation
Journal or Publication Title: Trials
Publisher: Biomed Central
ISSN: 1745-6215
Official Date: 8 February 2019
Dates:
DateEvent
8 February 2019Published
17 January 2019Accepted
Volume: 20
Number: 1
Article Number: 108
DOI: 10.1186/s13063-019-3203-0
Status: Peer Reviewed
Publication Status: Published
Access rights to Published version: Open Access (Creative Commons)
Date of first compliant deposit: 12 February 2019
Date of first compliant Open Access: 12 February 2019
RIOXX Funder/Project Grant:
Project/Grant IDRIOXX Funder NameFunder ID
12/167/102Health Technology Assessment programmehttp://dx.doi.org/10.13039/501100000664
Contributors:
ContributionNameContributor ID
Research GroupAIRWAYS-2 study team, UNSPECIFIED

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