Research interrupted: applying the CONSERVE 2021 Statement to a randomized trial of rehabilitation during critical illness affected by the COVID-19 pandemic
Authors: Reid Julie C. , Molloy Alex , Strong Geoff , Kelly Laurel , O’Grady Heather , Cook Deborah , Archambault Patrick M. , Ball Ian , Berney Sue , Burns Karen E. A. , D’Aragon Frederick , Duan Erick , English Shane W. , Lamontagne François , Pastva Amy M. , Rochwerg Bram , Seely Andrew J. E. , Serri Karim , Tsang Jennifer L. Y. , Verceles Avelino C. , Reeve Brenda , Fox-Robichaud Alison , Muscedere John , Herridge Margaret , Thabane Lehana , Kho Michelle E. ,   on behalf of the CYCLE Investigators
Published: September 2022

Abstract
Rationale
The COVID-19 pandemic disrupted non-COVID critical care trials globally as intensive care units (ICUs) prioritized patient care and COVID-specific research. The international randomized controlled trial CYCLE (Critical Care Cycling to Improve Lower Extremity Strength) was forced to halt recruitment at all sites in March 2020, creating immediate challenges. We applied the CONSERVE (CONSORT and SPIRIT Extension for RCTs Revised in Extenuating Circumstance) statement as a framework to report the impact of the pandemic on CYCLE and describe our mitigation approaches.

Methods
On March 23, 2020, the CYCLE Methods Centre distributed a standardized email to determine the number of patients still in-hospital and those requiring imminent 90-day endpoint assessments. We assessed protocol fidelity by documenting attempts to provide the in-hospital randomized intervention (cycling or routine physiotherapy) and collect the primary outcome (physical function 3-days post-ICU discharge) and 90-day outcomes. We advised sites to prioritize data for the study’s primary outcome. We sought feedback on pandemic barriers related to trial procedures.

Results
Our main Methods Centre mitigation strategies included identifying patients at risk for protocol deviations, communicating early and frequently with sites, developing standardized internal tools focused on high-risk points in the protocol for monitoring patient progress, data entry, and validation, and providing guidance to conduct some research activities remotely. For study sites, our strategies included determining how institutional pandemic research policies applied to CYCLE, communicating with the Methods Centre about capacity to continue any part of the research, and developing contingency plans to ensure the protocol was delivered as intended. From 15 active sites (12 Canada, 2 US, 1 Australia), 5 patients were still receiving the study intervention in ICUs, 6 required primary outcomes, and 17 required 90-day assessments. With these mitigation strategies, we attempted 100% of ICU interventions, 83% of primary outcomes, and 100% of 90-day assessments per our protocol.

Conclusions
We retained all enrolled patients with minimal missing data using several time-sensitive strategies. Although CONSERVE recommends reporting only major modifications incurred by extenuating circumstances, we suggest that it also provides a helpful framework for reporting mitigation strategies with the goal of improving research transparency and trial management.

Trial registration
NCT03471247. Registered on March 20, 2018.