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Emergency Room Survey

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Emergency Room Survey Survey Planning, Administration and Cost SIDUC: AN INTEGRATED SYSTEM OF DRUG USE SURVEYS SIDUC STANDARDIZATION EMERGENCY ROOMS Population of ... – PowerPoint PPT presentation

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Title: Emergency Room Survey


1
Emergency Room Survey
  • Survey Planning, Administration and Cost

2
SIDUC AN INTEGRATED SYSTEM OF DRUG USE SURVEYS
Key Informants
FORENSIC MEDICINE
Detention Centers
HOUSEHOLD SURVEYS
JUVENILE OFFENDERS
EMERGENCY ROOMS
STUDENT SURVEYS
TREATMENT CENTERS
3
SIDUC STANDARDIZATION
4
EMERGENCY ROOMS
  • Population of reference
  • Patients of Emergency Rooms.
  • Analyzed population
  • a) all patients b) typical weeks. Judgmental
    sample.
  • Method of data collection
  • Interview laboratory analysis.

5
FORENSIC MEDICINE
  • Population of reference
  • Death by accident, homicide, suicide.
  • Analyzed Population
  • a) all , b) Typical weeks.
  • Method of data collection
  • Autopsy and laboratory analysis.

6
Steps to be Taken
  • A funding source or multiple sources must be
    found (or no survey)
  • Decisions must then be made about who will direct
    the research undertaking
  • What types of expert and staff support will be
    needed, and
  • What is a realistic timetable
  • for the overall endeavor
  • for the major components

7
Session Outline
  • Core Survey Activities
  • Personnel
  • Budget
  • Schedule

8
Core Activities
  • Establishment of Advisory Committee
  • Develop Proposal
  • Seek Permission to conduct
  • Finalize Methodology
  • Training
  • Survey Implementation
  • Data Collection, Handling, Analysis, Report
    Writing

9
Advisory Committee
  • Stakeholders identification/representation
  • Ministry of Health
  • Public Hospital Authority
  • ER Director
  • Police
  • Ministry of Transport
  • Rep from private hospital
  • COB Research Unit
  • N.Bgt Can avoid problems at the end
  • Can help to sell the survey

10
Communications Regarding Survey
  • Ministerial Responsibility (CMO)
  • Institutional Responsibility
  • Public Hospital Authority (PMH, RMH)
  • Institutional Review Boards/Ethics Comm.
  • How to contact the chosen hospitals
  • Administrator
  • ER Manager

11
Contact With Selected Institutions
  • Step 1
  • An introductory letter to the Administrator,
    informing him/her of the study and its purposes.
    It will also
  • Ask to inform the ER Manager of decision
  • Step 2
  • Contact the ER manager via telephone to confirm
    that everything is in order just prior. At this
    point

12
Project Personnel
  • Lead Investigator(s)
  • Core Staff
  • Site managers
  • Data Managers
  • Data Collection Staff
  • Doctors
  • Nurses
  • Medical Records Clerks
  • Consultant(s)

13
Personnel Selection Process Options
  • Advisory Committee to provide oversight of the
    enterprise and the selection of the lead
    investigators
  • AD can help to engage people or organizations
    needed to fund, conduct, or make use of the
    research
  • DIS too many cooks in the kitchen and may
    introduce political considerations into the
    process
  • REC committee should deal with the broad policy
    and financial issues and leave the scientific
    decisions to the scientists
  • Recruitment of one or more individuals to run the
    project
  • Individual researchers may take the initiative to
    conduct such a survey

14
Lead Investigator
  • Ideally will be a part of the activity from
    beginning to end
  • Will provide the planning and integration needed
    to be sure that the end product matches the needs
    and objectives
  • Should be trained social scientists with some
    experience in survey research techniques

15
Core Staff(Site Managers)
  • These key individuals will remain with the study
    for its duration
  • Participate in various activities and make sure
    that they are carried out according to plan.
  • Most likely will supervise various components of
    the study, under the general direction of the
    lead investigator(s)
  • Should be well educated and preferably have some
    experience with research activities.

16
Data Collection Staff
  • Decide whether the data will be collected by
    individuals from outside the hospitals or not
  • ER Staff If the patients will trust the MDs or
    Nurse to protect their confidentiality
  • Outside Staff If the staffing situation presents
    a challenge, then staff members must be hired,
    trained, supervised and usually compensated
  • trained health social workers, trained field
    interviewers from a survey research organization,
    university students, etc

17
Consultants
  • Overall Planning
  • To direct technical assistance at various stages,
    depending of course on the areas of expertise of
    the lead investigators
  • If the lead investigators are new to this area of
    research, consider a short-term consultation with
    an experienced expert in the initial planning
    stage, again at the analysis planning stage, and
    perhaps at the interpretation stage
  • If brought in from abroad, seek the assistance
    and support of one of the international
    organizations that deal with the control of drug
    abuse (UNODC, OAS)
  • Sample Planning
  • Consultation with a sampling statistician also is
    likely to be very helpful, again at an early
    point in the planning effort
  • Statistical Analysis
  • If neither a general consultant from the
    substance abuse field nor statistician is able to
    help on data analyses, seek an expert on
    statistical analyses.
  • The job is usually not to actually conduct the
    analyses but to advise on the choice of analyses
    and appropriate computer programs for conducting
    them.

18
Budget Planning
  1. Personnel Costs
  2. Non-Personnel Costs

19
Factors that May Impact Personnel Budget
  • Labor costs in the country
  • Whether it is necessary to use data collection
    staff from outside the hospitals
  • The method of data entry
  • The need for technical assistance
  • The size of the sample needed and the size of the
    country across which that sample will be spread
  • influence both staff and travel costs
  • Amount of the personnel assigned to plan and
    conduct the ER survey who are already on the
    payroll of a participating agency.

20
Sample Budget Outline
PERSONNEL COSTS Lead investigators Field staff (if applicable) for __ weeks Supervisors/Site Manager Facilitators/MDs, Nurse, Med Rec. Core support staff Secretarial/Clerical Subcontractor Costs For data entry (if applicable) For any other services being purchased Consultants Fringe benefits NON-SALARY COSTS Office Rental (if applicable) Furniture (if applicable) Equipment (as needed) Phones, Fax, Copy machine, Computers Supplies Telephone service Advertising/Recruiting Costs Printing Questionnaires Manuals Brochures, instruction sheets, etc. Final report Shipping and postage Questionnaires to hospitals Questionnaires back from hospitals Other Travel Costs For investigators For field staff (if applicable) Overhead charges (if any)
21
Estimated Budget for Bahamas Emergency Room Drug
Survey
22
Estimated Budget for Bahamas Emergency Room Drug
Survey (Contd)
23
Survey Scheduling
24
Scheduling Tips
  • Considerable time and expense can be saved by
    undertaking several streams of activity
    simultaneously
  • Anticipating which efforts need to be completed
    before the next steps can proceed
  • Schedule should not be too abbreviated as there
    may be some unexpected developments
  • Effort should be made to make realistic estimates
    of the time necessary to complete each line of
    activity
  • Field staff should not be promised work until the
    investigators actually expect to proceed with the
    data collection (increased costs)

25
Survey Scheduling
  • Hospital Recruitment
  • Data Collection
  • Analysis and reporting
  • Dissemination and utilization activities

26
Scheduling Hospital Recruitment
  • If participation is decided by central edict
    (Ministry of Health), the process may be fairly
    rapid.
  • If involved in the planning, this assures their
    willingness to cooperate
  • If the individual hospitals or hospital
    authorities have the authority to decline
    cooperation, the process of securing cooperation
    can be a substantial and time-consuming one.
  • Investigator(s) may have to write to each
    hospital administrator inviting participation
  • Conduct a follow-up call (or possibly a series of
    calls) to urge the hospitals participation and
    answer questions
  • Communicate with higher authorities, if their
    approval is also required.

27
Scheduling Data Collection
  • Once the main data collection is proceeding, the
    responsible investigators should be monitoring
    carefully the quality of the data being
    collected, to be sure that those collecting it in
    the field are following instructions, and to
    identify problems early that might be rectified.
  • Plans can also be underway for how the data is to
    be collected and forwarded and how the returned
    data are to be coded and/or edited
  • Also, the investigators can begin planning the
    analyses that they would like to conduct at the
    completion of data collection and data cleaning.

28
Scheduling Analysis and Reporting
  • Often not accorded the attention that they
    deserve because not enough time and resources
    were set aside for them at the outset of the
    study.
  • Be sure to leave a significant interval for the
    analysis, interpretation, and writing of results.
  • At this late stage, normally only the lead
    investigator(s) and an analyst or two are still
    needed on the study staff, perhaps in addition to
    a secretary.

29
Scheduling Dissemination and Utilization
Activities
  • Once the report is completed, arrangements should
    be made to get it into the hands of people likely
    to be influenced by its results.
  • The lead investigators may wish to meet with
    certain groups, or make presentations to
    particular audiences to whom the work has
    relevance.
  • Policy and programmatic level

30
Flow Chart of Activities for the Conduct of a
School Survey
 INSTRUMENT DEVELOPMENT AND REFINEMENT Develop questionnaire ? Pretest questionnaire ? Pilot test questionnaire field procedures ? Make final revisions to questionnaire field procedures PERSONNEL Select lead investigators ? Hire core staff    FIELD PREPARATIONS Develop field procedures ? Hire and train field staff (if applicable) ? Develop instruction manual for survey leaders  SAMPLE HOSPITAL RECRUITMENT Design sampling plan ? Secure data for selecting hospital sample ? Draw sample of hospitals ? Recruit the sampled hospitals ? Schedule the data collection in each hospital
31
Flow Chart of Activities for the Conduct of a
E.R. Survey
CONDUCTING THE MAIN SURVEY Conduct full data collection ? Code/clean/edit questionnaires ? Enter data ? Build computer file ? Conduct data analyses ? Write reports ? Disseminate/utilize results
32
Ethical Considerations
  • Data must remain completely confidential or
    completely anonymous
  • no identifying information on a patients
    questionnaire
  • If specific identifying information for the
    individual is contained on the questionnaires
    de-identify at the earliest possible stage
  • Store the personally identifying information
    separately from the answers to the rest of the
    questionnaire with some type of link system
  • Avoid publicly identifying individual hospitals
    if possible
  • Permission to participate at all levels
  • Commitment to use results

33
Emergency Room Survey
  • QUESTIONNAIRE DEVELOPMENT

34
Factors That Impact Final Content
  • Amount of time the medical staff can afford to
    make available in an AE setting
  • Quality, completeness
  • Treatment Vs Prevention
  • SIDUC Rules
  • Possibility of including other topics due to cost
    sharing with other agencies
  • Ability of respondents to complete the
    questionnaire
  • Complexity should not exceed respondents
    capabilities

35
Levels of Priority
Highly Recommended Necessary to achieve objectives. Questions likely to be important to almost any epidemiology study of substance use
Recommended Those that should be given very serious consideration Risk and Protective Factors Other sources Injury Surv. Questions from Stakeholders
Optional May not measure concepts of vital interest in every study
36
Sequence and Priority of Elements In The
Questionnaire
  • Introduction
  • Background and demographic characteristics
  • Age, Gender, Employment, Occupation
  • Use of alcohol
  • Use of illicit substances
  • Use of controlled substances

37
List of Drugs
Alcohol Cocaine HCl. Coca Paste
Marijuana Tranquilizers Methamphetamines
Solvents and Inhalants Sedatives Flunitrazepam (Rohypnol, etc)
Hallucinogens Amphetamines Crack Cocaine
Heroine Anticholinergics Ecstasy
Opium/Morphine Anti-depressants Other
38
Defining Drugs For The Respondent
  • Names and descriptions must be reviewed to see if
    they are appropriate in the cultural setting in
    which they will be asked.
  • The main point is that the names used accurately
    communicate to respondents which substance(s)
    should be included in what they report, and which
    substances should not, and under what
    circumstances.
  • To determine a list of appropriate slang or
    street names for various drugs, the investigators
    may want to speak with treatment professionals
    and known drug users in the age group under
    study.
  • If a longer question stem is required to get the
    definition clarified for your respondents, then
    that may be justified. (See SIDUC Manual)
  • For legally prescribed drugs, it is important
    that the respondents understand what occasions of
    use they should and should not report in
    answering the questions.

39
Definition of Drugs
Formal Name Street Name
Cocaine Coke, crack, white lady, blow, etc.
Marijuana Weed, herb, grass, refer, pot, ganja, etc.
40
Example of A Stem Change
Concern General question Vs specific questions that will ensure that all questions are answered by all respondents Concern General question Vs specific questions that will ensure that all questions are answered by all respondents
Original (OAS) Change
Have you taken any drugs within the 6 hours preceding your injury Have you taken any of the following within the 6 hours preceding your injury Alcohol Marajuana etc
41
Layout In The Event of Lab Confirmation
  • Blind Vs Not Blind
  • If Not, questions and Lab results on same form
  • No means to connect necessary
  • IF blind, questions and lab results are separated
  • Unique identifiers are needed to re-unite
  • NB identifiers can be added after AE but before
    transfer to lab

42
Other Useful Suggestions
  • Skip patterns are more difficult for respondents
    to follow correctly than a simple, uninterrupted
    series of questions therefore, it is advised
    that they be minimized.
  • Pre-test by getting a limited number of like
    respondents to complete the questionnaire.
  • Determine average time to complete.
  • individually interview them about whether the
    instructions were clear and whether there were
    any questions or answers that they had difficulty
    understanding or using.
  • Determine if they understood each class of drug

43
Other Useful Suggestions Contd
  • Pilot testing to
  • see how the actual administration procedures in
    the ER will go,
  • see how long it takes the patients to answer the
    questions and
  • identify remaining problems in the content and
    clarity of the questionnaire.

44
Emergency Room Survey
  • Data Collection Procedure

45
Decisions Prior to Collection
  • WHAT What data will be collected
  • WHO Who will be responsible for data
    collection
  • WHEN When to collect data to ensure a normal
    sample
  • WHERE What hospitals are to be included
  • HOW How to conduct all aspects of survey
    administration

46
What data will be collected
  • Questionnaires
  • SIDUC
  • Bahamas
  • Lab confirmation data
  • Site reports on
  • refusals
  • ineligibles

47
Who will be responsible for data collection
  • Conducting the interview of each section of the
    questionnaire
  • How to select survey leaders
  • AE Data Flow
  • Lab sample flow
  • routinely collected information
  • Ensuring that a continuous supply of
    questionnaires are available
  • Ensuring a continuous supply of lab sampling
    equipment are available (?)
  • Ensuring that completed forms and lab samples are
    routed properly

48
Selection of Survey Leader
  • ER Staff
  • Pros
  • already in the ER
  • know the ER and are familiar with ER routines
  • Patients may feel more comfortable with MD or
    Nurse
  • least expensive
  • Cons
  • Competing interests
  • ER Services Vs survey completion
  • Research Assistant
  • Pros
  • More consistency across hospitals
  • Cons
  • More expensive
  • doubts regarding the ability to convince patients
    to participate
  • E.g., Social Workers in Haiti

49
When to collect data
  • SIDUC - Sample
  • Vs
  • Institutionalized routinely collected as part
    of diagnosis

50
Timing of Data Collection
  • It is important to choose a period which should
    not be preceded by any holiday, ensuring that the
    patients refer to a normal week or month when
    answering the questionnaire
  • If more than one hospital is included, it is a
    must to administer the data collection at the
    same time in all hospitals
  • In the event of inter-country comparisons
    (SIDUC), the time of data collection must be as
    similar as possible since the use of alcohol and
    other drugs vary at certain identifiable periods.
  • e.g. December (Christmas) ?
  • January (Recuperation) ?
  • Holidays ?
  • Lent ?

51
Where will data collection take place
  • Geographic location
  • Islands
  • Hospitals
  • Public
  • Princess Margaret (Nassau)
  • Rand Memorial (Freeport)
  • Private
  • Doctors (Nassau)

52
Activities During Administration
  • Instructions to the Survey Data Collection Staff
  • Instructions to the patients
  • Stress anonymity and confidentiality

53
Who Should Complete Survey
  • Inclusion Criteria
  • Exclusion Criteria
  • Persons lt 12 years of age
  • Gynae patients
  • Language barriers (Non-English speaking)
  • Unconscious patients (?)
  • If hospitalized and no identifiers to follow-up

54
Patients who Refuse
  • Concern is due to the possible association
    between refusal and drug use
  • It is important that the number of refusals be
    documented
  • Could compare refusals from low and high
    prevalence areas
  • It is important that refusals are treated in the
    same way in all participating hospitals and
    countries.

55
Survey AdministrationInstructions to Patients
  • Survey Instructions can be written on the front
    page of the questionnaire and should include
    information on
  • The purpose of the study (If not incorporated
    into the system)
  • The selection of patients (All selected during
    study period)
  • The study is anonymous and/or confidential
  • Steps to ensure anonymity
  • Participation is important but if not willing,
    that is their choice

56
To Ensure Anonymity
  • Following SIDUC Method
  • Questionnaires should not contain any identifiers
  • Name
  • hospital record , etc.

57
Survey AdministrationReport
  • A report should be completed (periodically) by
    the survey leader
  • Total number of refusals
  • If the study only targets a specific group, the
    number of those excluded

58
Checklist For Data Collection
  • Chose a survey leader trusted by the patients
  • Instructions to the survey leader
  • Describe how to treat patients not belonging to
    the target population
  • Describe how to treat refusals
  • Careful planning of the contacts with selected
    institutions
  • Safe transportation of material (lab component)
  • Detailed planning of the survey administration,
    including
  • stress anonymity and confidentiality
  • instructions to the survey leader
  • instructions to the patients
  • Shift report

59
Overview of Methodological Issues
  • Interpretation Of Data

60
Overview of Session
  • Representativeness the extent to which a sample
    mirrors the population of interest
  • Reliability the extent to which repeated
    measurements used under the same conditions
    produce the same result
  • Validity the extent to which answers are
    accurate representations of the underlying
    reality that they are intended to measure

61
Factors that Influence Representativeness
  • The sampling method
  • The size of the sample
  • Response rate The number of eligible non-gynae
    emergency room patients that agree to participate
    in the survey

62
The Method of Sampling Target Population
  • The target population in the Emergency Room
    survey is, by definition, persons who chose to
    come to the emergency room and excluding other
    individuals who, for whatever reason, chose not
    to attend.
  • Beware that all injured persons do not come in
    due to a number of reasons (choice,
    inaccessibility, etc.)
  • Less-severely injured persons who do not come in
    may be the result of reasons related to substance
    use
  • Large differences in emergency room attendance
    (access, availability) between countries may make
    it difficult/impossible to make meaningful
    international comparisons

63
Method of Achieving Representativeness
  • Random sampling is fundamental to obtaining a
    sample that is representative of the population
  • OR
  • Sample the entire target group

64
Sample Size and Representativeness
  • the number of sampled patients must be of
    sufficient size
  • considerations must be given to the extent of the
    analysis of drug habits in different subgroups
  • always important to sample enough patients to be
    able to analyse data separately for males and
    females
  • Response rate must be sufficiently high to enable
    representative data to be obtained

65
Categories of Response Rates
  • Institutional Cooperation
  • Public and Private Hospitals
  • Patient Cooperation For Interview
  • Proportion Participating in Lab Analysis

66
Issues Impacting Institutional Cooperation
  • An increased number of proposed surveys has made
    hospitals in some countries somewhat reluctant to
    allow patients to participate directly in such
    surveys
  • highlights the necessity of approaching
    institutions with emergency rooms formally and in
    a way that makes them feel that they are part of
    an important study

67
Issues Impacting Patient Participation
  • Participation should always be voluntary
  • Suspicions regarding True objectives has made
    patients somewhat reluctant to take time to
    participate in such drug surveys
  • highlights the necessity of approaching patients
    in a way that makes them feel that they are part
    of an important study
  • All questionnaires should be treated
    confidentially
  • The use of questionnaires without names or other
    kinds of identification
  • Guaranties of confidential treatment of
    questionnaires and data
  • Promises not to report data for individual
    patients

68
Decisions Regarding Non-Participation
  • If hospitals with a large percentage of overall
    ER visits refuse to participate it is essential
    to do a careful analysis of the reasons
  • If systematic errors is suspected, interpretation
    might be difficult and international comparisons
    may be jeopardised.
  • E.g.
  • refusing patients come from areas where drug
    and/or alcohol consumption is known to be high

69
Reliability
  • The extent to which repeated measurements used
    under the same conditions produce the same result
  • Or
  • Whether an indicator is consistent across time
    and observers

70
Methods of Measuring Survey Reliability
  • To conduct repeated studies using same
    methodology
  • By using data from different questions within a
    questionnaire
  • Laboratory Confirmation

71
  • Factors Influencing Study Reliability
  • Completeness - proportion of total information
    known
  • All respondents answer questions
  • All targeted respondents take survey
  • Sources of Error
  • Instrument
  • Person
  • MD, Nurse, Med. Rec Clerk
  • Study Subject or Respondent
  • May occur at
  • subject selection
  • data collection (Subjective)
  • Kappa Statistic
  • analysis and interpretation

72
Sources of Error Instrument and Procedures
  • Poor selection of questions and variables (SIDUC)
  • Ambiguous questions (additional questions)
  • Non-response
  • Poor selection of study subjects (friendliest)
  • Failure to validate measurements, recordings
  • lab

73
  • Sources of Error
  • Person
  • Interviewer
  • Inter-observer variation
  • the way medical staff explain and/or ask
    questions
  • Opinions on extent drug/alcohol use contributed
    to injury
  • Subject
  • Inter-subject variation
  • Different Interpretation of questions (what drugs
    were thought of without prompting)
  • willingness, survey environment

74
To Achieve Reliable Data
  • Thorough knowledge of study population
  • Unbiased selection of study subjects
  • Standardized, calibrated and consistent
    instrument(s)
  • Clear, unambiguous questions
  • Minimal personal discomfort or discomfiture
  • Interviewers, recorders thoroughly and equally
    well trained
  • Need to validate

75
Validity
  • The extent to which answers are accurate
    representations of the underlying reality that
    they are intended to measure.
  • In the context of emergency room surveys, the
    degree to which the questionnaire measures the
    aspects of patients drug consumption that it was
    intended to measure.

76
Strategies to Enhance Validity
  • Studies must guarantee anonymity and
    confidentiality
  • One is to use a data collection leader trusted by
    the patients
  • Stress anonymity during the introduction
  • no names or other identification marks should be
    on the questionnaire (SIDUC)
  • The patients must also have enough time to answer
    the questionnaire
  • important that the questionnaire is not too long
  • They must understand the questions
  • They must be willing to answer the questions
    honestly

77
Strategies to Assess Validity
  • Patients willingness to co-operate
  • Patients comprehension
  • Missing data rates
  • Logical consistency
  • Reported willingness to answer honestly
  • The cultural context in which a survey is
    conducted

78
Strategies to Assess Validity Cultural Context
  • Questions must be culturally or locally
    appropriate
  • Use the appropriate street-names or nicknames
    used for different drugs
  • Willingness to admit drug use may be influenced
    by the attitudes towards drugs in a given society
  • perceived risk of substance use, disapproval of
    different kinds of substance use and the
    availability of different drugs differ between
    countries.
  • Low availability Negative attitude less
    willing to admit
  • High availability Positive attitudes more
    willing to admit
  • Survey Tradition
  • Persons in countries where surveys are less
    common may feel less comfortable answering
    questions about sensitive behaviours.

79
Checklist For Survey Methodology
  • Representativeness
  • Define the target population
  • Assess the importance of non-students in the same
    age groups as the target population
  • Decide a proper time for the data collection (if
    international comparisons are planned)
  • Assess the importance of non-participating
    schools/classes
  • Assess the importance of non-participating
    students
  • Reliability
  • Assess reliability (whenever possible by using
    data in the questionnaire)

80
Checklist For Survey Methodology Contd
  • Validity
  • Anonymous and confidential data collection
  • Measure and report
  • Number of eliminated questionnaires
  • Survey leader information (from the classroom
    report)
  • Time to answer the questionnaire
  • Proportion of unanswered questions
  • Logical consistency
  • Possible use of a willingness question
  • Possible reported use of a dummy drug
  • Construct validity

81
The End
82
Really
  • The End
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