key: cord-0997035-2je27f1o
authors: Baker, Edward; Lee, Geraldine
title: Reflecting on the challenges of sustaining emergency care research during the Covid-19 pandemic
date: 2020-07-13
journal: Int Emerg Nurs
DOI: 10.1016/j.ienj.2020.100894
sha: b172e50854036ea5f7a4b1b3f4d08b39e28c4de7
doc_id: 997035
cord_uid: 2je27f1o

nan

International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen Editorial Reflecting on the challenges of sustaining emergency care research during the Covid-19 pandemic As many parts of the world start to establish a 'new normal' during the Covid-19 pandemic, it is important for all to take time to reflect on what has happened and what the future holds in store for both academic and clinical emergency care. Although for many the focus has been on the fast-evolving pace that healthcare has been forced to adapt to meet the needs of the population, research practice in this area has been required to adapt at a similar speed. Although there have been many exemplifiers of excellent research work undertaken and disseminated throughout the pandemic, it has been a challenging time at the research interface. This has been particularly true for both researchers focused on non-Covid-19 research and research active clinical staff who have redeployed their time to clinical practice. It is important to acknowledge these challenges and consider how these affect the quality and production of new knowledge in a post pandemic world. There is no doubt that Covid-19 has impacted on global research, but these reflections are based on the current challenges that are ongoing currently in the UK.

Naturally, gaining insight and solutions to fight this virus is pertinent as we need to understand the epidemiological, biological, psychological, social and economic impacts that challenges us all. Although many will experience mild or no Covid-19 symptoms, there are still a significant number of people globally requiring hospitalisation and critical care. Almost every day there are further developments in both technological and epidemiological aspects of Covid-19, particularly relating to characteristics, diagnostics and treatments. This has resulted in a growth in new knowledge that is unparalleled in the history of healthcare research. Currently, local data suggests that mortality and new infection rates are generally decreasing but it is important to note that there has been an over-whelming demand for critical care beds and mechanical ventilation globally with many countries acknowledging the difficult decisions to be made about how to allocate limited resources. Although often not discussed in the media, low to middle income countries will have faced even greater challenges and it is increasingly clear that this is only the start of a long journey to recovery for the global community. It is equally as important to take time to reflect on how the Covid-19 pandemic is changing the research landscape and consider how the process of conducting research will be different in the new post-pandemic world.

To date, governments and funding bodies have re-directed funding and re-focused research priorities towards work relating to the pandemic. Where many research active healthcare professionals have been concerned about research development, for many funders there currently appears to be business continuity as other non-Covid-19 funding streams have continued to open calls and offer awards. Internationally, many ethics committees have been required to enact rapid review processes to ensure that studies can be approved within shortened timelines. Research active clinicians and planned studies have had to change substantially, and clinical research staff have been required to set up new studies relating to Covid-19. It is excellent that these processes have been achieved within a short space of time, but this is likely to have placed high levels of pressure on ethics committees and local clinical research teams. These teams have had the responsibility of making research happen, whilst maintaining patient safety and ensuring research governance is adhered to. In the post-pandemic period, provided there is sustained rigour, it will be interesting to see if these expedited processes can be implemented in day to day research practice.

The rapid research processes that have been seen during this pandemic have resulted in large volumes of new knowledge and evidence being available over a relatively short space of time. Although the increase in availability of Covid-19 research has enabled widely accessible Open Access study data, concerns have been raised relating to the quality of some published studies. This has highlighted the need for high research standards and rigour to be maintained in studies undertaken during global emergencies [1] . To combat this, journals must carefully balance the need for rapid publication of data whilst upholding the need for strong peer review processes to ensure that research methods and reporting are maintained at the high standards required. It is essential that researchers learn from this pandemic and ensure that enough planning, governance and infrastructure is in place in preparation for future global emergencies [1] .

For many healthcare researchers globally, the set-up of new non-Covid-19 research studies and ongoing recruitment to established research studies has been suspended. Whilst it is essential and correct that the national and global research priorities have been diverted towards the escalating pandemic, we need to acknowledge the potential impact of suspending non-Covid-19 related research. Globally, this suspension of research activity has been enacted by ethics committees, funders and study sponsors. Although it is impossible to comprehend the scope of these disruptions to 'normal' healthcare research, some researchers have voiced concerns about the long-term implications. These include delayed completion of academic studies, research studies and budgetary and financial difficulties [2] . It would be short-sighted not to acknowledge that the suspension of research will alter the development of new healthcare evidence and knowledge for many years to come [3] . In recent weeks there has been a move to re-commence established research studies in many clinical settings but in the UK, many academic researchers who have not been able to continue working have been 'furloughed' by their employer. Furlough is a current process whereby individuals who are unable to work due to the pandemic have a https://doi.org/10.1016/j.ienj.2020.100894

International Emergency Nursing 51 (2020) 100894 1755-599X/ © 2020 Elsevier Ltd. All rights reserved. T proportion of their salaries subsidised by the government. Although this process supports employers to maintain some level of financial stability and provides income support to the individual, this precludes them from undertaking any aspect of their work. As with any process that interrupts an individual's employment, this must be very unsettling and there must be many academic researchers worldwide who are feeling insecure due to interruptions with their normal working lives.

There are also many research active clinicians globally that have been redeployed back into the main clinical workstream during the Covid-19 pandemic to ensure that there is a sustained workforce to provide the health systems response to the pandemic. This has been challenging in many ways as healthcare professionals have often had to pause their research work and take on clinical roles that are outside their normal sphere of work. As the pandemic continues to develop globally some staff are now returning to their pre-Covid-19 roles but for many, the possibility of another wave of infections makes recommencing research activity and the future of some studies unclear.

Many countries have reported changes in the numbers and types of presentation to the emergency care setting during the pandemic and it is important that we recognise the impact that these changes will have had on established research activity. The UK Royal College of Emergency Medicine (RCEM) has reported reduced attendances to Emergency Departments nationally across all spectrums of illness and injury [4] . Similarly, in Italy, the fear of becoming infected with the virus resulted in substantial delays in presentation for children and adolescents highlighting this to be an international concern [5] . The observed changes to the workload within the department, including the rapid increase in numbers of patients presenting with symptoms of Covid-19 requiring critical care and respiratory isolation has certainly introduced new challenges to managing emergency care on a global scale [6] . During the early weeks of lockdown, several UK cardiologists commented on social media that there had been a noticeable decrease in Acute Coronary Syndrome (ACS) presentations. Could it really be that there are fewer cardiac events occurring? This seems highly unlikely. It is probably more likely that individuals experiencing chest pain and cardiovascular symptoms have avoided attending emergency departments due to the virus. Similarly, since March 2020, there have global reports of decreased numbers of severely injured patients presenting to global trauma services. This is likely to be associated to the introduced social isolation with restrictions on movement and public activities [7] . Unlike the cardiovascular emergencies who maybe avoiding hospital admissions, it appears that the international major trauma picture has temporarily changed with lower numbers of people are being injured.

Although patterns and numbers of emergency department presentations may well be normalising, the impact on established research is likely to be significant. For non-Covid-19 studies that have continued to recruit new participants and/or collect data during the pandemic, this is likely to have impacted on all aspects of the research process. Researchers must now consider the potential confounding factors that may impact on the generalisability and transferability of these data into the post-Covid-19 world.

The psychological burden of this pandemic has been widespread across all sections of society and researchers have not been exempt from this. Another concern is the emergence of mental health issues and the possibility of PTSD developing in healthcare workers and this is currently under investigation. There have been many challenges for all to overcome including relocating study offices to individuals' homes, isolating away from loved ones and friends, restrictions on leisure activities and working in ways that have not been possible before. Amongst the population, these factors alongside the ongoing work-related insecurity and fear of contracting the disease could put every person at risk of mental health sequelae. Equally, for research students worldwide, the potential interruption in doctoral studies has been and remains a matter of great concern for most. It has been great to see research teams pull together over recent months to provide pastoral support to both research students and established researchers alike.

There are many questions relating to how the research landscape will look when this pandemic is over, and life returns to a degree of normality. Of course, no-one can possibly know the answer to these questions as the pandemic continues to evolve on a weekly basis but there have been many positives changes to the way we are working. It is important to consider how these can be incorporated into a new way of working in the post-pandemic phase. One example of this in the research setting is the move towards online and remote data collection where possible and feasible. This has the potential to open research studies to a more geographically diverse population whilst reducing the burden for researchers themselves [8] . If nothing else, this pandemic has shown us that we have to be open to new ways of achieving research goals that probably include less face to face elements than before Covid-19.

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