Introduction
Methods
Study design/participants
Behavioural specification: Action, Actor, Context, Time (AACTT)
Data collection
Data analysis
Interviews with pre-hospital trial researchers
Interviews with P-PRO clinical investigators
Patient and public involvement
Results
Sample characteristics
Pre-hospital trial researchers
P-PRO clinical investigators
Findings
Interviews with pre-hospital trial researchers: overarching challenges and opportunities across the field
...there’s so few of them [paramedics] that have actually been through the [research] process before…there isn’t that collective understanding that you rely on to a large degree within major specialties in the hospital, so that’s back to culture of not having that background in research as well. Pre-hospital trial researcher 1.
…paramedics were very keen to be involved in research because actually it was something that they could own, they could develop from their own professional perspective and also from their cohort… Pre-hospital trial researcher 2.
…the research procedures, themselves, may delay delivery of specific aspects of care, or may complicate the care to such an extent that those things that are being done are not done properly. It is a small team, potentially working in a difficult environment with very little bandwidth. Pre-hospital trial researcher 7.
... it’s a pressured environment and if we want to get trials off the ground, deliver trials and recruiting in an efficient way, we need to keep the [administrative] demands to a minimum. We’re meant to make it easy for our staff to recruit patients. Pre-hospital trial researcher 6.
…we spent a fair amount of time in various motorway service stations up and down the country chatting to Jehovah’s Witness hospital liaison people about how not to enrol a Jehovah’s Witness without their consent. Pre-hospital trial researcher 2.
…there were occasions when patients were deemed so critically ill that they take them to the nearest hospital. If those nearest hospitals weren’t part of your study, getting as we would be doing professional legal or personal legal representative consent became difficult or impossible, and so we lost a number of patients to follow up because we had no way of obtaining consent. Pre-hospital trial researcher 4…because I guarantee the first patient you recruit will go [sic] another trauma centre and then you’ll have randomised the patient but have no means to capture the follow up data. Pre-hospital trial researcher 3
A lot of interventional treatments in a variety of different conditions are time-sensitive, say heart attacks, there’s a lot of evidence out there that treatments are time-sensitive. The earlier you get them, the better the benefit…so there’s definite benefit in moving treatment forward. That’s the big advantage of pre-hospital trials, is that they are working in that environment before they arrive in hospital… Pre-hospital trial researcher 5.
… some of the big pre-hospital trials, all of the credit went to the hospitals that took patients afterwards, even though all the work was done in pre-hospital care, and that’s still an ongoing problem… Pre-hospital trial researcher 1.
… if you’re considering any trial involving air ambulances, you have to be so, so cognisant of in all of your negotiations that they are not NHS organisations, they are … independent charities whose sole job is to raise money to allow the pre-hospital teams to provide an enhanced level of care … Pre-hospital trial researcher 2.
Then the other very significant thing was because it took us a long time to get that first cluster open if you like, during that time people started to lose equipoise and started to read more into the military data on administering [intervention]. The important thing to remember as well is that a lot of the clinicians that staff pre-hospital services are in the military. So not only have they seen it first-hand they also… they’ve bought into it. Pre-hospital trial researcher 3.
Interviews with P-PRO clinical investigators: specific challenges and opportunities for a pre-hospital trial of REBOA
Whilst I’ve said ultimately we don’t know whether our patient would have survived without us I think we’re going to have a group of patients who are literally therefore dying in front of us and maybe if we were in an RCT we wouldn’t have put a balloon in or we wouldn’t have inflated a balloon. Once you’ve gone down this road you could end up feeling that you’ve denied a patient some care that could have saved them. Consultant, participant 4.
There’s passionate people who are very pro and people who aren’t, but I suppose the thing is that the vast majority of clinicians who are involved in this also understand the importance to the population of these patients to answer this question. Consultant, participant 8.
It’s very fluid, it’s very dynamic, there’ll be certain situations where you start down a trajectory or a path of treatment and actually when you’ve reassessed, not that it’s incorrect, but actually that path slightly changes and they might respond well to something that then stops you on that path or just slows you down that path… Paramedic, participant 3.
…But the things that we do to try and bring any scene under control are the same that we do whether it’s a P-PRO or not, which are all about communication, primacy of care, dissemination of plan, role allocation, you know? Scene safety… it all comes down to… the unique skill set of pre-hospital care is just communication, you know? There’s no technical skill. And the ability to have been in enough scenes that you’ve got bandwidth to deploy that communication, and actually that’s not unique to REBOA or the P-PRO scenes. Consultant, participant 7.
… I think three or four [staff members] is a really nice number because there’s quite a lot going on, and I suppose some of it may be equally the HEMS team delivering the procedure … what’s the number to facilitate the randomisation of the patient group, is it two or is it three, because at some point to randomise you’re going to have to… facilitate the randomisation. Paramedic, participant 5.
…But yeah, it needs to be left to the investigators, but for people on the day to day, I think the pressure of recruiting a number shouldn’t have any influence on the decision-making process and there’s a problem if it does. I’m not sure entirely how helpful they [recruitment targets] are. Consultant, participant 7.
…It’s difficult to take away that human side when you… and certainly some of these patients have a high conscious level initially and they just… the conscious level just gets worse and worse and you’ve kind of made that emotional contact. Paramedic, participant 5.
…we go on a helicopter and we sometimes get to people in ten, 15, 20 minutes and they’re almost dead, it’s harder to look at that person and say… if it tells me not to put a balloon in I’m happy with the next 40 minutes, or even if I’m unbelievably quick and it’s 20 minutes, am I really happy with that without intervening? That doesn’t necessarily mean we shouldn’t do an RCT, but I think we might find that the alternative is quite invasive in those patients, i.e. maybe a thoracotomy or something like that. But the time does have an effect because when we get there quicker and they’re that sick, that’s a very different patient to an hour down the line and they’re that sick. Consultant, participant 6.