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Building a Program of Research: 15 Tips

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Transcript of "Building a Program of Research: 15 Tips"

  1. 1. Building a Program of Research: 15 Tips From Doctoral Student to Academic Faculty
  2. 2. 1. Pick a topic you are passionate about from your own clinical experience Using ECG information to improve patient care Improving nursing practice related to ECG monitoring
  3. 3. Annals of Internal Medicine 1986 UCSF 2. Determine unsolved problems by searching the literature
  4. 4. Supraventricular Tachycardia (SVT) Narrow normal QRS complex Ventricular Tachycardia (VT) Wide bizarre QRS complex Drug that blocks @ AV node SVT with aberrant conduction
  5. 5. Left “Rabbit Ear” Pattern = VT Lead V1 Right “Rabbit Ear”Pattern = SVT Lead V1 3. Search the literature on all research directly related to the topic Wellens HJ, et al. Value of the ECG in the differential diagnosis of a tachycardia with a wide QRS complex. Am J Med 1978.
  6. 6. Monitoring Lead V1 Requires Five Electrodes LALA RLRL LLLL RARA CC
  7. 7. “Of the conventional ECG leads, the one that contains the most information…is V1, which should therefore make the best lead for routine monitoring. But V1 is inconvenient, since 5 electrodes must remain constantly attached. A satisfactory compromise, conceived in theory and confirmed in practice, employs a modified V1.”
  8. 8. Dr. Marriott’s modified V1 (MCL1) UCSF
  9. 9. Can wide QRS tachycardia be accurately diagnosed with V1 criteria when monitoring in MCL1? UCSF MCL1 Left “Rabbit Ear” Pattern = VT
  10. 10. Henry J. L. Marriott, MD In developing MCL1, I confirmed that it matched V1 in an out- patient clinic population. I did not compare these leads during arrhythmias, but I would expect them to be comparable during wide complex tachycardias. 4. Contact key scientists for advice about your research ideas Hein Wellens, MD We did not evaluate MCL1 in our study. UCSF
  11. 11. 5. Pick renown mentors for your doctoral committees Henry J. L. Marriott, MD Kathy Dracup, DNSc Mel Scheinman, MD
  12. 12. 6. Publish on your topic (Quals papers) so your name is associated with the topic
  13. 13. ENVIRONMENT External/Social Internal/Cellular NURSING THERAPEUTICS Health Continuum / Transitions POTENTIAL Health Problem ACTUAL Health Problem INDIVIDUAL • Genetics • Lifestyle (coronary risk factors) • Psychodynamic factors (anxiety) • Functional status • Work • Family • Culture • Religion •Ischemia •Acid-base • Autonomic nervous system •Electrolytes •Drugs Electrical Activity of the HeartElectrical Activity of the Heart Normal ECG Abnormal ECG Arrhythmias, ST segment changes of ischemia, QT interval prolongation • Diagnose ECG • Assess patient • Notify MD • Document • Administer Rx • Evaluate efficacy • Determine goals of ECG monitoring (arrhythmia, ischemia, QT interval) • Monitor ECG (select appropriate lead; place electrodes accurately; evaluate monitor alarms) Drew BJ Heart & Lung 1989;18:8-15.
  14. 14. 7. Conduct studies as a doctoral student; publish & present at national scientific conferences How prevalent is inaccurate lead placement?
  15. 15. V1 II V1 II
  16. 16. National random survey of AACN members working in critical care & telemetry units Average age, 35 yrs Average yrs critical care experience, 8.5 yrs Drew, Ide, & Sparacino Heart & Lung 1991;20:597 N = 302
  17. 17. 0 50 100 150 200 250 300 Correct Incorrect Drew BJ, et al. Heart & Lung 1999;20:597-609. Accuracy of lead placement in a random survey of hospital nurses in the USA # RNs 23% 77% UCSF
  18. 18. 8. Publish clinical articles as well as research articles in order to influence practice
  19. 19. 9. Publish ALL your dissertation findings UCSF
  20. 20. WCT’s n=133 SVT n=35 VT n=98 Drew & Scheinman, PACE 1995;18:2194
  21. 21. VT recorded during invasive cardiac electrophysiology study (EPS)
  22. 22. Key dissertation findings re: wide QRS tachycardia  12-Lead ECG was best If it weren’t so cumbersome, it would be great to monitor all 12 leads  V1 was the best single lead; MCL1 should not be substituted for V1 40% of VTs have different QRS morphology in MCL1 vs V1  Routinely-monitored Lead II was poor Correctly identifies only 34% of WCTs UCSF
  23. 23. RA V5 V1 LA LLRL V4 V3 V2 V6 Disadvantage of 12-Lead ECG for hospital monitoring UCSF
  24. 24. 10. Design each subsequent study to build logically upon your prior studies Apply for “friendly” funding for initial studies (e.g., Sigma Theta Tau, companies that make related products, start-up funds from your own school)
  25. 25. 11. Collect data for > dissertation
  26. 26. 12. Once you’ve published 4-5 preliminary research articles, think of the next logical research question and apply for MAJOR funding (e.g., NIH).
  27. 27. UCSF How does EASI 12-lead monitoring compare to routine CCU monitoring for detecting acute myocardial ischemia in acute coronary syndromes? ST Analysis Trial (STAT Study) (1993-96) n=490 Funded by NINR (R01 NR03436)
  28. 28. STAT Study 7:03 am EASI 12-Lead ECG 47 y/o male awaiting cardiac cath, possible PCI UCSF
  29. 29. 7:08 am EASI 12-Lead ECG STAT Study UCSF
  30. 30. 7:10 am EASI 12-Lead ECG UCSF STAT Study
  31. 31. 7:13 am EASI 12-Lead ECG UCSF STAT Study
  32. 32. 7:33 am EASI 12-Lead ECG UCSF STAT Study
  33. 33. 1. 3. 2. 5. 4. Before During Routine CCU Monitoring Leads
  34. 34. UCSF Of 463 ischemic events detected with EASI 12-lead ST monitoring:  67% had no evidence of ischemia in routine CCU monitoring leads  80% were asymptomatic (“silent”) Drew et al. Am J Crit Care 1996;5:198-206.
  35. 35. Is ST-segment monitoring valuable in patients who present to the ED with possible acute MI? ST Analysis & Monitoring of Patients & Evaluation of a Derived ECG STAMPEDE Study Funded by NINR (RO1NR03436), 1996-00, n=621 UCSF Ischemia Monitoring & Mapping in the Emergency Department In Appropriate Triage & Evaluation of Acute Ischemic Myocardium IMMEDIATE AIM Study Funded by NHLBI (RO1HL69753), 2001-2006, n=1308
  36. 36. Initial ECG in 40 y/o male presenting to the ER with increasing chest pain episodes; Troponins negative IMMEDIATE AIM Study UCSF 5:00 pm
  37. 37. 6 days following hospital discharge, patient was brought to ER after witnessed collapse on golf course UCSF IMMEDIATE AIM Study
  38. 38. Rapidly developed profound shock, could not be resuscitated, and died UCSF IMMEDIATE AIM Study
  39. 39. Synthesized Twelve-lead ST Monitoring And Real-time Tele-electrocardiography Funding: NINR (RO1 NR007881), n=800 UCSF Prospective randomized clinical trial 2003-2009
  40. 40. Determine whether individuals who call “911” for chest pain will: ST SMART Study Study Aim: UCSF 1. have shorter time to treatment when they reach the hospital 2. have better survival over 5 yrs if ED clinicians are provided with ECG ischemia monitoring information from the field
  41. 41. Santa Cruz County Dominican Watsonville San Francisco 100 miles ↑
  42. 42. ST SMART Study All EMS vehicles that respond to 911 calls in the county are equipped with portable monitor- defibrillator devices with special study software 13 AMR ambulances16 Fire Department rigs Methods:
  43. 43.  Synthesize a 12-lead ECG from 5 electrodes ST SMART Study Special Study Software is designed to:  Analyze ST segments every 30 secs & automatically transmit an ECG to the destination ED by cell phone if ischemia occurs UCSF  If the 1st transmission fails, automatic redialing occurs for a total of 3 attempts
  44. 44. 50 y/o with onset of chest pain on Sunday a.m. Case Example Attempted to drive to hospital; was found by motorist at roadside on the ground ST SMART StudyST SMART Study UCSF
  45. 45. ECG Transmitted from the Field ST SMART Study
  46. 46. 13. Become active in professional societies that put you in touch with experts in the field  International Society for Computerized Electrocardiology  American Heart Association UCSF
  47. 47. 1. Publish in journal 2. Serve as manuscript reviewer 3. Ask to be considered for editorial board 14. Contribute to key journals in your field UCSF
  48. 48. 15. Take leadership to publish clinical guidelines and scientific statements
  49. 49. Practical Use of the Latest Standards for Electrocardiography – PULSE Study Practical Use of the Latest Standards for Electrocardiography – PULSE Study Implement Practice Standards & determine whether it improves nurse behaviors & patient outcomes Funded by NHLBI May, 2008-2013
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