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.B> 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 orderjust 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 Personnel Costs 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

21. Phase Specific Tasks Time Frame Cost ($US) Planning Data Collection Training Payment to Facilitators Other (Travel etc) Data Handling Coding and Editing Data Entry Post Cleaning Data Analysis Estimated Budget for Bahamas Emergency Room Drug Survey

22. Report Writing Tabulation and Graphics Draft Report Editing of Report Printing and Reproduction • Administrative Costs • ? Coordinator Fees Supervisors Fees Supplies Questionnaire and other Printing General administrative costs Total Estimated Cost Estimated Budget for Bahamas Emergency Room Drug Survey (Cont’d)

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 hospital’s 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

31. Flow Chart of Activities for the Conduct of a E.R. Survey

32. Ethical Considerations • Data must remain completely confidential or completely anonymous • no identifying information on a patient’s 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 A&E 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

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

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

40. Example of A Stem Change

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 A&E 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 Cont’d • 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 • A&E 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. 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 Selection of Survey Leader

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 possiblesince the use of alcohol and other drugs vary at certain identifiable periods. e.g. December (Christmas) ↑ January (Recuperation) ↓ Holidays ↑ Lent ↓