Caroline Watkins

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Caroline Watkins Professor of Stroke & Older People’s Care Director of Research and Innovation, College of Health and Wellbeing University of Central Lancashire Preston, UK & Australian Catholic University, Sydney [email protected] Participation in Health Research: Edge walking?

Transcript of Caroline Watkins

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Caroline WatkinsProfessor of Stroke & Older People’s Care

Director of Research and Innovation, College of Health and WellbeingUniversity of Central Lancashire

Preston, UK &

Australian Catholic University, Sydney

[email protected]

Participation in Health Research: Edge walking?

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Research priorities those of clinicians?

“Practitioners will continue to ignore research publications until they are seen as helpful and relevant”

Sobell (1996)

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Key Message

Today’s research is tomorrow’s care……

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Trainees Coordinating Centre Trainees Coordinating Centre

National Institute for Health Research

Established 2006:A vehicle for implementing Government’s strategy for applied health research

£1bn annual spend

Vision:Improving health and wealth of nation through research

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Trainees Coordinating Centre Trainees Coordinating Centre

NIHR Remit• People and patient based applied health research• Research capacity to improve health/healthcare• Patients, samples or data from patients, people who are

not patients, populations, health technology assessment and health services research

• The potential to have an impact on the needs of patients and the public within 5 years of completion

• Prepared to support research into medical education

• No basic research involving animals and/or animal tissue

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Trainees Coordinating Centre

Research Training Opportunities from

NIHRDavid Richards, PenCLAHRC, University of Exeter Medical School

(additional material from Peter Thompson, NIHR TCC)

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Really? Me?

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Trainees Coordinating Centre Trainees Coordinating Centre

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Trainees Coordinating Centre Trainees Coordinating Centre

NIHR Fellowships Programme

• Salary • Full tuition fees (for PhD)• Research costs• Full training and development• Awards 3 years full time (part-time options of 75% or

60%) or up to 5 years for SRF• Can be based at HEI or NHS Trust• Annual competition for all levels• Next launch – October 2016

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Trainees Coordinating Centre Trainees Coordinating Centre

Post Doctoral Research Fellowship (NIHR PDF)Early post doctoral Fellowship(≤ 3 years WTE Post Doctorate)3 years FT (4 or 5 years PT)

Applicant:PhD/MD or have submittedOutput from researchEvidence of commitment toresearch career

Doctoral training award 3 years FT (4 or 5 years PT)

Applicant:Some previous research experienceSome outputs from researchEvidence of commitment to

researchcareer

Doctoral Research Fellowship (NIHR DRF)

NIHR Fellowships

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Trainees Coordinating Centre Trainees Coordinating Centre

Senior Research Fellowship (NIHR SRF)

Most senior NIHR Fellowship5 years ( Chair)

Applicant:Significant postdoctoral experienceOutstanding publication recordIndependenceLeadership potential Record of research capacitydevelopment

Later postdoctoral award (≤ 7 yrs WTE Post Doctorate)3 years FT (4 or 5 years PT)

Applicant:PhD/MD and postdoctoral experienceSignificant output from researchEvidence of increasing independenceExperience of developing research skills of others

Career Development Fellowship (NIHR CDF)

NIHR Fellowships

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Trainees Coordinating Centre Trainees Coordinating Centre

NIHR Fellowships

Postdoctoral award (≤ 5 yrs WTE Post Doctorate)18 months to 2 years FT or PT

Applicant:PhD/MD and maybe postdoctoral experience

• Individuals from any scientific discipline wanting to contribute to improving health or healthcare e.g. basic scientists moving to applied health research

• Individuals who have had their research careers interrupted e.g. career break, who can identify clear training needs

• Proposed research must be within the NIHR remit

Transitional Research Fellowship (NIHR TRF) new from 2013

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Trainees Coordinating Centre Trainees Coordinating Centre

HEE/NIHR Integrated Clinical Academic Programme

Health Education England Review recommended expansion to all registered non medical/dental registered healthcare professionals committed to developing a career which combines research and continued clinical practice.

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Trainees Coordinating Centre Trainees Coordinating Centre

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Trainees Coordinating Centre Trainees Coordinating Centre

HEE/NIHR Integrated Clinical Academic Programme

• Funded HEIs advertise places (institutional award)

• 100 places per annum available over next 3 years

• The University of Manchester• University of Nottingham• University of Leeds• The City University London• University of Southampton• University of Brighton• Kingston University London• University of Plymouth• University of East Anglia• Coventry University

• PhD research whilst developing clinical skills• Based at English NHS trust, other health care

organisation or HEI• Min 1 yr clinical experience and current statutory

registration• Need for both a good academic and clinical

supervisor• Salary, PhD tuition fees, research, training &

development costs (100% NHS, 80% HEI except training & development @100%)

• 3 years FT (4 or 5 years PT)• Next call March 2017

HEE/NIHR Masters in Clinical Research

HEE/NIHR Clinical Doctoral Research Fellowship

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Trainees Coordinating Centre

Good Applications1.Applicant

• (trajectory, career outputs)

2.Research Project• (scientific quality, appropriate scale and scope)

3.Training and Development• (meet the needs of the candidate and the project)

4.Environment• (research Excellence Framework rating, facilities)

5.Supervision/mentorship• (track record in relevant field, time and commitment)

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Trainees Coordinating Centre

Project

• Doable• Applied• Relevant• Five year impact rule• Quality high• PPI

– VETO ALERT! – Do not confuse PPI with focus groups and qualitative data –

that’s different (so don’t include that piece in the PPI section). PPI is actual involvement in the research process itself.

– PPI is NOT people as research participants/subjects giving data

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Trainees Coordinating Centre Trainees Coordinating Centre

HEE/NIHR Integrated Clinical Academic Programme

• Funded HEIs advertise places (institutional award)

• 100 places per annum available over next 3 years

• The University of Manchester• University of Nottingham• University of Leeds• The City University London• University of Southampton• University of Brighton• Kingston University London• University of Plymouth• University of East Anglia• Coventry University

• PhD research whilst developing clinical skills• Based at English NHS trust, other health care

organisation or HEI• Min 1 yr clinical experience and current statutory

registration• Need for both a good academic and clinical

supervisor• Salary, PhD tuition fees, research, training &

development costs (100% NHS, 80% HEI except training & development @100%)

• 3 years FT (4 or 5 years PT)• Next call March 2017

HEE/NIHR Masters in Clinical Research

HEE/NIHR Clinical Doctoral Research Fellowship

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Trainees Coordinating Centre

• Enable health and social care practitioners to develop skills to design and lead high quality clinical research

• Research relevant to patients/clients & NHS priorities

• Facilitate practitioner careers combining clinical research and research leadership with developing clinical practice

For more information:

Visit: http://www.uclan.ac.uk/study_here/postgraduate_study.php

Email: Dr Lois [email protected]

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INTERNSHIPS LINCS - 2010Lancashire Initiative for Nursing and Caring research in Stroke: Oral Flora (4 LTHTR staff) HENW – 2013-2016

Range of projects (10 staff) annually CLAHRCS - 2014

Range of projects (10 staff) & now 15 annually Senior Investigator/RCF - 2016

Range of projects – Grass Roots Care (4 LTHTR staff)

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Changes in Oral Flora in Acute Stroke:An observational study

Professor Caroline Watkins University of Central Lancashire

United Kingdom Swallow Research Group February 2016

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Stroke• UK: 150,000 people/annum

• Top 3 cause of death

• Leading cause of adult disability

• 1/5 acute hospital beds

• Increased risk of respiratory infection-first few weeks

• Risk of infection mostly more dependent patients

• 10% of stroke patients develop pneumonia

• Pneumonia associated with death (OR 3.62)

• Pneumonia potentially linked to poor oral hygiene

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Current oral care practices

• Poor oral health within supported care (Hally, 2003)

• Low priority in the hierarchy of care (Adams, 1996)

• Nursing staff dislike oral care (Boyle, 1992)

• Often delegated to care assistants (Wårdh, 1997)

• Lack of knowledge and equipment (Wårdh et al 2000)

• Lack of evidence relating to oral care interventions (Brady, 2006)

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Why is oral care important to stroke patients?Unable to attend to oral hygiene due to Physical and cognitive problems

Contributing factors following stroke• Dysphagia with increased risk of aspiration of bacteria laden saliva• Facial weakness• Food Debris in mouth• Medication• Oxygen therapy• Dehydration/Taste• Mouth Breathing• Inability to recognise need for oral care• Inability for express need for oral care• Hemiplegia• Decreased oral sensation

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Oral Flora

• Complex bionetwork

• High diversity of oral flora

• Disruption to oral cleanliness may lead to overgrowth of pathogenic bacteria

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Thick plaque formsGums are very red and swollen.

This person has gum disease

If plaque is not removed it will harden to become tartar

(calculus)

Tooth decay

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Aims

1. Identify patient characteristics and clinical factors e.g.infection, that may affect oral flora

2. Describe bacterial profile of oral flora during the first two weeks post-stroke

3. Examine changes in condition of oral cavity

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Procedure• Time Point 1: <48 hs post-admission

Patient characteristics i.e. demographic dataClinical data (documentation of infection)Oral DNA samplesOral assessment using THROAT

• Time Point 2: 48-72 hs after time point oneClinical data (documentation of infection)Oral DNA samplesOral assessment using THROAT

• Time Point 3: 7 days post-admission

Clinical data (documentation of infection)Oral DNA samplesOral assessment using THROAT

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International Stroke Research Collaboration (ISReC)

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1. Patient characteristics & Clinical factors

Time point one Time point Two Time point Three0

2

4

6

8

10

12

Respiratory Oral

UTI Cellulitus

Septacaemia

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2. Oral bacterial profile

• 103 bacterial phylotypes were isolated (98-100% sequence similarity cut-off for defining a phylotype)

• 29 of which are considered to be non-oral flora

• Of 367 samples, 211 (57.5%) Streptococcus genus

• Abnormal Streptococcus phylotypes occurred in 23 (11%) samples.

• Average number of different bacterial phylotypes/person 2.72,

2.76 and 2.32 at time points 1, 2 and 3 respectively (range 0 – 11) • No significant difference in the average number of different

phylotypes found across all three time points

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3. Condition of the oral cavity over three time points

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Thank you

Acknowledgements:

• Dr Louise Connell• Dr Liz Boaden• Wendy Loughlin• Annette Munro• Dr Hazel Dickinson• Karen Shevlin

• Dr Craig Smith• Dr Liz Lightbody• Dr Michael Leathley• Alison McLoughlin• Mary Lyons• Simarjit Singhrao • Zarine Khan• Prof StJohn Crean

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British Journal of Healthcare Assistants November 2013 Vol 07 No 11

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Stroke Care• High quality stroke care is care that is right for that

patient at that point on their care pathway

• To deliver the right care staff must have the right – Knowledge– Skills– Abilities– Time

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EVIDENCE-BASED CARE

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Knowledge?

• It ain’t what you know that gets you into trouble

• It’s what you know for sure that just ain’t so

Mark Twain

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Funding from the National Health and Medical Research Council (NHMRC) of Australia

An international collaborative project

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Sitting up is the typical nursing position for patients in the UK

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Lying flat is common in some countries

China

Switzerland

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Lying flat is standard care for acute ischaemic stroke in hospitals in Switzerland

Day Mobilisation schedule Importance

1 Bedrest/lying flat strict

2 Bedrest head 30 degrees strict

3 Bedrest head 60 degrees strict

4 Sitting on edge of bed (accompanied during care)

5 Sitting in a chair (accompanied during care)

6 Walking around in the room (with care assistant)

7 Walking around freely

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Balance of potential benefits and risks of sitting up vs lying flat

Sat up• Reduce cerebral oedema,

especially in ICH or malignant MCA infarction

• Improve cardiac function• Improve oxygenation• Increase alertness

Lying down• Improve collateral cerebral

blood flow arterial venous

• Rest the brain

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Overview

An international, multicentre, cluster

randomised, crossover, blinded outcome

assessment trial to compare the lying flat with

sitting up in acute stroke

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Trial Schema

Lying Flat Head Positioning0° for first 24 hours

Sitting Up Head Positioning≥30° for first 24 hours

Randomisation

Sitting Up Head Positioning≥30° for first 24 hours

Lying Flat Head Positioning0° for first 24 hours

STUDY SITES

Standard Nursing and

Medical Care (Local

Guidelines)Crossover Crossover

Blinded assessment of outcome at 90 days

Blinded assessment of outcome at 90 days

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Why a cluster cross-over design?

Cluster• To avoid contamination, patients will not see differences in

practice• Better compliance from both staff and patientsCross-over• Internally adjusts for background variation across hospitals• All hospitals will change practice from usual policy, thus

internally adjusting for ‘change’ • Fewer centres needed• Reduce sample size by ≥30%

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Consent• Cluster guardian

– No consent to the intervention, the intervention will be the “usual care” at that time point

– Necessary to prevent contamination of the intervention– Insufficient evidence for a specific ideal head position– Head position in both groups within the range of routine practice

• Individual patient consent – Consent for data collection (in-hospital data) – As soon as possible – Centralised 90 days follow-up assessments

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Results• >100 sites worldwide• 41 UK sites• >10,000 patients worldwide• ~4000 UK patients• 3rd European Stroke Organisation

Conference 2017, Prague, 16-18th May

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Implementing Research:Everybody’s business?

Patient

Research Nurse/Coordinator

Clinician

Manager

Researcher

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Key Message

Research is for patients and not clinicians or researchers……..

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Key to success is working together!

Research Support Team [email protected]