Emergency Room Survey
Survey Planning, Administration
and Cost
SIDUC: AN INTEGRATED SYSTEM OF
DRUG USE SURVEYS
Key Informants
SIDUC STANDARDIZATION
Information
Source
Reference
Population
Analized
Population
Data
Collection
Periodicity
Treatment
Centers
Patients
Patients
Interview
Continue
Interview
Annual
Self
admnistered
Questionnaire
2 years
Emergency
Rooms
Student
Surveys
Household
Surveys
Sample of
Patients
hospitals and
12 to 64 years
Patients
Sample of
Students
Schools &
Grades 8, 10,
classes
12
Population in
Sample of
households
areas,
12 to 64 years Households &
persons
Interview /
Self admin
3 years
EMERGENCY ROOMS

Population of reference:


Analyzed population:


Patients of Emergency Rooms.
a) all patients b) “typical weeks”.
Judgmental sample.
Method of data collection:

Interview & laboratory analysis.
FORENSIC MEDICINE

Population of reference:


Analyzed Population:


Death by accident, homicide, suicide.
a) all , b) “Typical weeks”.
Method of data collection:

Autopsy and laboratory analysis.
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
Session Outline
Core Survey Activities
 Personnel
 Budget
 Schedule

Core Activities
1.
2.
3.
4.
5.
6.
Establishment of Advisory Committee
Develop Proposal
Seek Permission to conduct
Finalize Methodology
Training
Survey Implementation
•
Data Collection, Handling, Analysis, Report
Writing
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
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
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:
Project Personnel
Lead Investigator(s)
 Core Staff

– Site managers
– Data Managers

Data Collection Staff
– Doctors
– Nurses
– Medical Records Clerks

Consultant(s)
Personnel Selection Process
Options
1.
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
3. Individual researchers may take the initiative to conduct
such a survey
2.
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

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.

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
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.
Budget Planning
1.
2.
Personnel Costs
Non-Personnel Costs
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.
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)
Estimated Budget for Bahamas Emergency
Room Drug Survey
Phase
Specific Tasks
Planning
Data Collection
Training
Payment to
Facilitators
Other (Travel etc)
Data Handling
Coding and
Editing
Data Entry
Post Cleaning
Data Analysis
Time
Frame
Cost
($US)
Estimated Budget for Bahamas Emergency
Room Drug Survey (Cont’d)
Report Writing
Tabulation and
Graphics
Draft Report
Editing of Report
Printing and
Reproduction
Administrative
Costs
Coordinator Fees
Supervisors Fees
?
Supplies
Questionnaire and
other Printing
Total Estimated Cost
General
administrative
costs
Survey Scheduling
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)
Survey Scheduling
Hospital Recruitment
 Data Collection
 Analysis and reporting
 Dissemination and utilization activities

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.
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.
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.
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
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
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
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

Emergency Room
Survey
QUESTIONNAIRE
DEVELOPMENT
Factors That Impact Final Content
1.
Amount of time the medical staff can afford to make
available in an A&E setting
–
–
2.
3.
4.
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
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
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

List of Drugs
Alcohol
Cocaine HCl.
Coca Paste
Marijuana
Tranquilizers
Methamphetamines
Solvents and
Inhalants
Hallucinogens
Sedatives
Flunitrazepam
(Rohypnol, etc)
Amphetamines
Crack Cocaine
Heroine
Anticholinergics
Ecstasy
Opium/Morphine
Anti-depressants
Other
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.
Definition of Drugs
Formal Name
Street Name
Cocaine
Coke, crack, white lady,
blow, etc.
Marijuana
Weed, herb, grass, refer,
pot, ganja, etc.
Example of A Stem Change
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 Have you taken any of the
within
the
6
hours following within the 6
preceding your injury
hours
preceding
your
injury
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
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
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.
Emergency Room Survey
Data Collection Procedure
Decisions Prior to Collection
WHAT
 WHO
What data will be collected
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

What data will be collected

Questionnaires
– SIDUC
– Bahamas
Lab confirmation data
 Site reports on:

– # refusals
– # ineligibles
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
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


– More consistency
hospitals

across
Cons
– More expensive
– doubts regarding the ability to
convince
patients
to
participate
Cons:
– Competing interests
– ER
Services
Vs
completion
Research Assistant
Pros:
survey

E.g., Social Workers in
Haiti
When to collect data

SIDUC - Sample
Vs

Institutionalized – routinely collected as
part of diagnosis
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 ↓
Where will data collection take
place

Geographic location
– Islands

Hospitals
– Public
 Princess Margaret (Nassau)
 Rand Memorial (Freeport)
– Private
 Doctors (Nassau)
Activities During Administration
Instructions to the Survey Data Collection
Staff
 Instructions to the patients
 Stress anonymity and confidentiality

Who Should Complete Survey
Inclusion Criteria
2. Exclusion Criteria
1.
•
•
•
•
Persons < 12 years of age
Gynae patients
Language barriers (Non-English speaking)
Unconscious patients (?)
• If hospitalized and no identifiers to follow-up
Patients who Refuse
Concern is due to the possible association
between refusal and drug use:
It is important that the number
documented
 Could compare % refusals from
prevalence areas
 It is important that refusals are
same way in all participating
countries.

of refusals be
low and high
treated in the
hospitals and
Survey Administration:
Instructions 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
To Ensure Anonymity
Following SIDUC Method
 Questionnaires should not contain any identifiers
– Name
– hospital record #, etc.
Survey Administration:
Report
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
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
Overview of
Methodological Issues:
Interpretation Of Data
Overview of Session

Representativeness –

Reliability

Validity –
the extent to which a
sample mirrors the population of interest
–
the extent to which repeated
measurements used under the same conditions produce
the same result
the extent to which answers are accurate
representations of the underlying reality that they are
intended to measure
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

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
Method of Achieving
Representativeness
Random sampling is fundamental to
obtaining a sample that is representative
of the population
 OR
 Sample the entire target group

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
Categories of Response Rates

Institutional Cooperation
– Public and Private Hospitals
Patient Cooperation For Interview
 Proportion Participating in Lab Analysis

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
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
Decisions Regarding NonParticipation
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
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
Methods of Measuring Survey
Reliability
To conduct repeated studies using same
methodology
 By using data from different questions
within a questionnaire
 Laboratory Confirmation

Factors Influencing Study Reliability

Completeness information
proportion
of
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
total
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
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
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
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.
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
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
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.
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)
Checklist For Survey Methodology
Cont’d

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
The End
Really
The End
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