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Gu X, Watson C, Agrawal U, Whitaker H, Elson WH, Anand S, Borrow R, Buckingham A, Button E, Curtis L, Dunn D, Elliot AJ, Ferreira F, Goudie R, Hoang U, Hoschler K, Jamie G, Kar D, Kele B, Leston M, Linley E, Macartney J, Marsden GL, Okusi C, Parvizi O, Quinot C, Sebastianpillai P, Sexton V, Smith G, Suli T, Thomas NPB, Thompson C, Todkill D, Wimalaratna R, Inada-Kim M, Andrews N, Tzortziou-Brown V, Byford R, Zambon M, Lopez-Bernal J, de Lusignan S. Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024. JMIR Public Health Surveill 2024; 10:e52047. [PMID: 38569175 PMCID: PMC11024753 DOI: 10.2196/52047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. OBJECTIVE We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. METHODS Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. RESULTS We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. CONCLUSIONS The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.
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Affiliation(s)
- Xinchun Gu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Conall Watson
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Utkarsh Agrawal
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Heather Whitaker
- Statistics, Modelling and Economics Department, UK Health Security Agency, London, United Kingdom
| | - William H Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sneha Anand
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ray Borrow
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester, United Kingdom
| | | | - Elizabeth Button
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Lottie Curtis
- Royal College of General Practitioners, London, United Kingdom
| | - Dominic Dunn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rosalind Goudie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katja Hoschler
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Gavin Jamie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Beatrix Kele
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ezra Linley
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester, United Kingdom
| | - Jack Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gemma L Marsden
- Royal College of General Practitioners, London, United Kingdom
| | - Cecilia Okusi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Omid Parvizi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Catherine Quinot
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | | | - Vanashree Sexton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gillian Smith
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Timea Suli
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Catherine Thompson
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Daniel Todkill
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Rashmi Wimalaratna
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Nick Andrews
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | | | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Maria Zambon
- Virus Reference Department, UK Health Security Agency, London, United Kingdom
| | - Jamie Lopez-Bernal
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care Med 2024; 52:314-330. [PMID: 38240510 DOI: 10.1097/ccm.0000000000006072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, ON, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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3
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU. Crit Care Med 2024; 52:307-313. [PMID: 38240509 DOI: 10.1097/ccm.0000000000006071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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Inada-Kim M, Chmiel FP, Boniface M, Burns D, Pocock H, Black J, Deakin C. Validation of oxygen saturations measured in the community by emergency medical services as a marker of clinical deterioration in patients with confirmed COVID-19: a retrospective cohort study. BMJ Open 2024; 14:e067378. [PMID: 38167289 PMCID: PMC10773313 DOI: 10.1136/bmjopen-2022-067378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES To evaluate oxygen saturation and vital signs measured in the community by emergency medical services (EMS) as clinical markers of COVID-19-positive patient deterioration. DESIGN A retrospective data analysis. SETTING Patients were conveyed by EMS to two hospitals in Hampshire, UK, between 1 March 2020 and 31 July 2020. PARTICIPANTS A total of 1080 patients aged ≥18 years with a COVID-19 diagnosis were conveyed by EMS to the hospital. PRIMARY AND SECONDARY OUTCOME MEASURES The primary study outcome was admission to the intensive care unit (ICU) within 30 days of conveyance, with a secondary outcome representing mortality within 30 days of conveyance. Receiver operating characteristic (ROC) analysis was performed to evaluate, in a retrospective fashion, the efficacy of different variables in predicting patient outcomes. RESULTS Vital signs measured by EMS staff at the first point of contact in the community correlated with patient 30-day ICU admission and mortality. Oxygen saturation was comparably predictive of 30-day ICU admission (area under ROC (AUROC) 0.753; 95% CI 0.668 to 0.826) to the National Early Warning Score 2 (AUROC 0.731; 95% CI 0.655 to 0.800), followed by temperature (AUROC 0.720; 95% CI 0.640 to 0.793) and respiration rate (AUROC 0.672; 95% CI 0.586 to 0.756). CONCLUSIONS Initial oxygen saturation measurements (on air) for confirmed COVID-19 patients conveyed by EMS correlated with short-term patient outcomes, demonstrating an AUROC of 0.753 (95% CI 0.668 to 0.826) in predicting 30-day ICU admission. We found that the threshold of 93% oxygen saturation is prognostic of adverse events and of value for clinician decision-making with sensitivity (74.2% CI 0.642 to 0.840) and specificity (70.6% CI 0.678 to 0.734).
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Affiliation(s)
- Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Francis P Chmiel
- School of Electronics and Computer Science, University of Southampton, Southampton, UK
| | - Michael Boniface
- School of Electronics and Computer Science, University of Southampton, Southampton, UK
| | - Daniel Burns
- School of Electronics and Computer Science, University of Southampton, Southampton, UK
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - John Black
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Charles Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK
- Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Murali M, Inada-Kim M. Early warning scores: the case for aggregate vs. single extreme parameter activation to detect patient deterioration. Anaesthesia 2023; 78:803-806. [PMID: 37195103 DOI: 10.1111/anae.16048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Affiliation(s)
- M Murali
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - M Inada-Kim
- Department of Acute Medicine, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
- Department of Clinical and Experimental Sciences, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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6
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Euden J, Thomas-Jones E, Aston S, Brookes-Howell L, Carman J, Carrol E, Gilbert S, Howard P, Hood K, Inada-Kim M, Llewelyn M, McGill F, Milosevic S, Niessen LW, Nsutebu E, Pallmann P, Schmidt P, Taylor-Robinson D, Welters I, Todd S, French N. PROcalcitonin and NEWS2 evaluation for Timely identification of sepsis and Optimal use of antibiotics in the emergency department (PRONTO): protocol for a multicentre, open-label, randomised controlled trial. BMJ Open 2022; 12:e063424. [PMID: 35697438 PMCID: PMC9196199 DOI: 10.1136/bmjopen-2022-063424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Sepsis is a common, potentially life-threatening complication of infection. The optimal treatment for sepsis includes prompt antibiotics and intravenous fluids, facilitated by its early and accurate recognition. Currently, clinicians identify and assess severity of suspected sepsis using validated clinical scoring systems. In England, the National Early Warning Score 2 (NEWS2) has been mandated across all National Health Service (NHS) trusts and ambulance organisations. Like many clinical scoring systems, NEWS2 should not be used without clinical judgement to determine either the level of acuity or a diagnosis. Despite this, there is a tendency to overemphasise the score in isolation in patients with suspected infection, leading to the overprescription of antibiotics and potentially treatment-related complications and rising antimicrobial resistance. The biomarker procalcitonin (PCT) has been shown to be useful in specific circumstances to support appropriate antibiotics prescribing by identifying bacterial infection. PCT is not routinely used in the care of undifferentiated patients presenting to emergency departments (EDs), and the evidence base of its optimal usage is poor. The PROcalcitonin and NEWS2 evaluation for Timely identification of sepsis and Optimal (PRONTO) study is a randomised controlled trial (RCT) in adults with suspected sepsis presenting to the ED to compare standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment with standard clinical management based on NEWS2 scoring alone and compare if this approach reduces prescriptions of antibiotics without increasing mortality. METHODS AND ANALYSIS PRONTO is a parallel two-arm open-label individually RCT set in up to 20 NHS EDs in the UK with a target sample size of 7676 participants. Participants will be randomised in a ratio of 1:1 to standard clinical management based on NEWS2 scoring or standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment. We will compare whether the addition of PCT measurement to NEWS2 scoring can lead to a reduction in intravenous antibiotic initiation in ED patients managed as suspected sepsis, with at least no increase in 28-day mortality compared with NEWS2 scoring alone (in conjunction with local standard care pathways). PRONTO has two coprimary endpoints: initiation of intravenous antibiotics at 3 hours (superiority comparison) and 28-day mortality (non-inferiority comparison). The study has an internal pilot phase and group-sequential stopping rules for effectiveness and futility/safety, as well as a qualitative substudy and a health economic evaluation. ETHICS AND DISSEMINATION The trial protocol was approved by the Health Research Authority (HRA) and NHS Research Ethics Committee (Wales REC 2, reference 20/WA/0058). In England and Wales, the law allows the use of deferred consent in approved research situations (including ED studies) where the time dependent nature of intervention would not allow true informed consent to be obtained. PRONTO has approval for a deferred consent process to be used. Findings will be disseminated through peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER ISRCTN54006056.
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Affiliation(s)
- Joanne Euden
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Stephen Aston
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | | | | | - Enitan Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | - Philip Howard
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Matthew Inada-Kim
- Acute Medicine, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
- NHS England and NHS Improvement, University of Southampton, Southampton, UK
| | - Martin Llewelyn
- Infectious Diseases and Therapeutics, Brighton and Sussex Medical School, Brighton, UK
| | - Fiona McGill
- Departments of Infectious Diseases and Medical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Louis Wihelmus Niessen
- Health Economics, Liverpool School of Tropical Medicine, Liverpool, UK
- School of Public Health, Johns Hopkins, Baltimore, Maryland, USA
| | - Emmanuel Nsutebu
- Tropical and Infectious Diseases Division, Sheikh Shakhbout Medical City, Abu Dabi, UAE
| | | | - Paul Schmidt
- Acute Medical Unit, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - David Taylor-Robinson
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Institute for Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Stacy Todd
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Neil French
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Affiliation(s)
- M J Knight
- Department of Respiratory Medicine, West Herefordshire Hospitals NHS Trust, Herts, UK
| | - C P Subbe
- Acute, Respiratory and Intensive Care Medicine, Betsi Cadwaladr University Health Board, Wales, UK
| | - M Inada-Kim
- Acute Medicine, Royal Hampshire County Hospital, Winchester, UK
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Goyal D, Inada-Kim M, Mansab F, Iqbal A, McKinstry B, Naasan AP, Millar C, Thomas S, Bhatti S, Lasserson D, Burke D. Improving the early identification of COVID-19 pneumonia: a narrative review. BMJ Open Respir Res 2021; 8:8/1/e000911. [PMID: 34740942 PMCID: PMC8573292 DOI: 10.1136/bmjresp-2021-000911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
Delayed presentation of COVID-19 pneumonia increases the risk of mortality and need for high-intensity healthcare. Conversely, early identification of COVID-19 pneumonia grants an opportunity to intervene early and thus prevent more complicated, protracted and less successful hospital admissions. To improve the earlier detection of COVID-19 pneumonia in the community we provide a narrative review of current evidence examining the clinical parameters associated with early disease progression. Through an evolving literature review, we examined: the symptoms that may suggest COVID-19 progression; the timing of deterioration; the utility of basic observations, clinical examination and chest X-ray; the value of postexertion oxygen saturations; and the use of CRP to monitor disease progression. We go on to discuss the challenges in monitoring the COVID-19 patient in the community and discuss thresholds for further assessment. Confusion, persistent fever and shortness of breath were identified as worrying symptoms suggestive of COVID-19 disease progression necessitating urgent clinical contact. Importantly, a significant proportion of COVID-19 pneumonia patients appear not to suffer dyspnoea despite severe disease. Patients with this asymptomatic hypoxia seem to have a poorer prognosis. Such patients may present with other signs of hypoxia: severe fatigue, exertional fatigue and/or altered mental status. We found duration of symptoms to be largely unhelpful in determining risk, with evidence of deterioration at any point in the disease. Basic clinical parameters (pulse, respiratory rate, blood pressure, temperature and oxygen saturations (SpO2)) are likely of high value in detecting the deteriorating community COVID-19 patient and/or COVID-19 mimickers/complications (eg, sepsis, bacterial pneumonia and pulmonary embolism). Of these, SpO2 carried the greatest utility in detecting COVID-19 progression. CRP is an early biochemical parameter predictive of disease progression and used appropriately is likely to contribute to the early identification of COVID-19 pneumonia. Identifying progressive COVID-19 in the community is feasible using basic clinical questions and measurements. As such, if we are to limit the mortality, morbidity and the need for complicated, protracted admissions, monitoring community COVID-19 cases for signs of deterioration to facilitate early intervention is a viable strategy.
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Affiliation(s)
- Daniel Goyal
- Department of Acute Internal Medicine, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Matthew Inada-Kim
- Department of Infection, Antimicrobial Resistance and Deterioration, NHS England, Redditch, Worcestershire, UK.,Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust, Winchester, Hampshire, UK
| | - Fatam Mansab
- Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Amir Iqbal
- Department of Covid-19 Remote Monitoring of Patients During Response & Recovery, NHS Grampian, Aberdeen, Aberdeen, UK
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Adeeb P Naasan
- Department of General Medicine, Islands Hospital, Oban, UK
| | - Colin Millar
- Department of General Medicine, Islands Hospital, Oban, UK
| | - Stephen Thomas
- Department of Respiratory Medicine, Raigmore Hospital, Inverness, Highland, UK
| | - Sohail Bhatti
- Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Daniel Lasserson
- Hospital at Home, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK.,Department of Ambulatory Medicine, University of Warwick, Coventry, West Midlands, UK
| | - Derek Burke
- Department of Clinical Governance, Gibraltar Health Authority, Gibraltar, Gibraltar
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Vindrola-Padros C, Singh KE, Sidhu MS, Georghiou T, Sherlaw-Johnson C, Tomini SM, Inada-Kim M, Kirkham K, Streetly A, Cohen N, Fulop NJ. Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review. EClinicalMedicine 2021; 37:100965. [PMID: 34179736 PMCID: PMC8219406 DOI: 10.1016/j.eclinm.2021.100965] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND the aim of this review was to analyze the implementation and impact of remote home monitoring models (virtual wards) for confirmed or suspected COVID-19 patients, identifying their main components, processes of implementation, target patient populations, impact on outcomes, costs and lessons learnt. METHODS we carried out a rapid systematic review on models led by primary and secondary care across seven countries (US, Australia, Canada, The Netherlands, Ireland, China, UK). The main outcomes included in the review were: impact of remote home monitoring on virtual length of stay, escalation, emergency department attendance/reattendance, admission/readmission and mortality. The search was updated on February 2021. We used the PRISMA statement and the review was registered on PROSPERO (CRD: 42020202888). FINDINGS the review included 27 articles. The aim of the models was to maintain patients safe in the appropriate setting. Most models were led by secondary care and confirmation of COVID-19 was not required (in most cases). Monitoring was carried via online platforms, paper-based systems with telephone calls or (less frequently) through wearable sensors. Models based on phone calls were considered more inclusive. Patient/career training was identified as a determining factor of success. We could not reach substantive conclusions regarding patient safety and the identification of early deterioration due to lack of standardized reporting and missing data. Economic analysis was not reported for most of the models and did not go beyond reporting resources used and the amount spent per patient monitored. INTERPRETATION future research should focus on staff and patient experiences of care and inequalities in patients' access to care. Attention needs to be paid to the cost-effectiveness of the models and their sustainability, evaluation of their impact on patient outcomes by using comparators, and the use of risk-stratification tools.
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Affiliation(s)
- Cecilia Vindrola-Padros
- Department of Targeted Intervention, University College London (UCL), Charles Bell House, 43-45 Foley Street, London W1W 7TY, United Kingdom
| | - Kelly E Singh
- Health Services Management Centre, School of Social Policy, University of Birmingham, Park House, University of Birmingham, Edgbaston, Birmingham B15 2RT, UK
| | - Manbinder S Sidhu
- Health Services Management Centre, School of Social Policy, University of Birmingham, Park House, University of Birmingham, Edgbaston, Birmingham B15 2RT, UK
| | - Theo Georghiou
- Nuffield Trust, 59 New Cavendish Street, London W1G 7LP, UK
| | | | - Sonila M Tomini
- Department of Applied Health Research, University College London, Gower Street London, WC1E 6BT, UK
| | - Matthew Inada-Kim
- Wessex Academic Health and Science Network, National COVID Clinical Reference groups- Primary care, Secondary care, Care homes, National Clinical Lead Deterioration and National Specialist Advisor Sepsis, NHS England and NHS Improvement, McGill ward, Royal Hampshire County Hospital, Romsey Road, Winchester SO21 1QW, UK
| | - Karen Kirkham
- Integrated Care System Clinical Lead, NHSE/I Senior Medical Advisor Primary Care Transformation, Dorset CCG, Vespasian House, Barrack Rd, Dorchester DT1 7TG, UK
| | - Allison Streetly
- Department of Population Health Sciences Faculty of Life Sciences and Medicine King's College London SE1 1UL, UK
- Deputy National Lead Healthcare Public Health, Public Health England133-155 Waterloo Rd, London SE1 8UG, UK
| | | | - Naomi J Fulop
- Department of Applied Health Research, University College London, Gower Street London, WC1E 6BT, UK
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Redfern OC, Smith GB, Prytherch DR, Meredith P, Inada-Kim M, Schmidt PE. The authors reply. Crit Care Med 2019; 47:e266-e267. [PMID: 30768516 DOI: 10.1097/ccm.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Oliver C Redfern
- Centre for Healthcare Modelling & Informatics, School of Computing, University of Portsmouth, Portsmouth, United Kingdom Centre of Postgraduate Medical Research & Education, Faculty of Health and Social Sciences, University of Bournemouth, Bournemouth, United Kingdom Centre for Healthcare Modelling & Informatics, University of Portsmouth, Portsmouth, United Kingdom Research & Innovation Department, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom Acute Medical Unit, Hampshire Hospitals NHS Foundation Trust, Winchester, United Kingdom Acute Medical Unit, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
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11
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Affiliation(s)
| | - Matthew Inada-Kim
- Hampshire Hospitals NHS Foundation Trust, Winchester, United Kingdom
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12
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Abstract
OBJECTIVES To define the target population of patients who have suspicion of sepsis (SOS) and to provide a basis for assessing the burden of SOS, and the evaluation of sepsis guidelines and improvement programmes. DESIGN Retrospective analysis of routinely collected hospital administrative data. SETTING Secondary care, eight National Health Service (NHS) Acute Trusts. PARTICIPANTS Hospital Episode Statistics data for 2013-2014 was used to identify all admissions with a primary diagnosis listed in the 'suspicion of sepsis' (SOS) coding set. The SOS coding set consists of all bacterial infective diagnoses. RESULTS We identified 47 475 admissions with SOS, equivalent to a rate of 17 admissions per 1000 adults in a given year. The mortality for this group was 7.2% during their acute hospital admission. Urinary tract infection was the most common diagnosis and lobar pneumonia was associated with the most deaths. A short list of 10 diagnoses can account for 85% of the deaths. CONCLUSIONS Patients with SOS can be identified in routine administrative data. It is these patients who should be screened for sepsis and are the target of programmes to improve the detection and treatment of sepsis. The effectiveness of such programmes can be evaluated by examining the outcomes of patients with SOS.
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Affiliation(s)
- Matthew Inada-Kim
- Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester, UK
| | - Bethan Page
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Imran Maqsood
- Oxford Academic Health Science Network, Oxford Science Park, Magdalen Centre, Oxford, UK
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Inada-Kim M, Viswesvaraiah G. Sepsis on the AMU - Time to Pick up the Baton. Acute Med 2015; 14:43-46. [PMID: 26305079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Matthew Inada-Kim
- Wessex Academic Health and Science Network Innovation Centre, Southampton Science Park, Chilworth, Hampshire, UK
| | - Guhavarma Viswesvaraiah
- Wessex Academic Health and Science Network Innovation Centre, Southampton Science Park, Chilworth, Hampshire, UK
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Sujan MA, Chessum P, Rudd M, Fitton L, Inada-Kim M, Cooke MW, Spurgeon P. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy 2014; 20:17-25. [DOI: 10.1177/1355819614560449] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Handover across care boundaries poses additional challenges due to the different professional, organizational and cultural backgrounds of the participants involved. This paper provides a qualitative account of how practitioners in emergency care attempt to align their different individual and organizational priorities and backgrounds when handing over patients across care boundaries (ambulance service to emergency department (ED), and ED to acute medicine). Methods A total of 270 clinical handovers were observed in three emergency care pathways involving five participating NHS organizations (two ambulance services and three hospitals). Half-day process mapping sessions were conducted for each pathway. Semi-structured interviews were carried out with 39 participants and analysed thematically. Results The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other’s goals and constraints as possible ways towards more sustainable improvement. Conclusion Sustainable improvement in handover across boundaries in emergency care might require commitment by leaders from all parts of the local health economy to work as partners to establish a culture of integrated, patient-centred care.
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Affiliation(s)
- Mark A Sujan
- Associate Professor of Patient Safety, Warwick Medical School, University of Warwick, UK
| | - Peter Chessum
- Lead Advanced Clinical Practitioner, Heart of England NHS Foundation Trust, UK
| | - Michelle Rudd
- Consultant Nurse Emergency Care, United Lincolnshire Hospitals NHS Trust, UK
| | - Laurence Fitton
- Consultant in Emergency Care, Oxford Radcliffe Hospitals NHS Trust, UK
| | - Matthew Inada-Kim
- Consultant in Acute Medicine, Hampshire Hospitals NHS Foundation Trust, UK
| | - Matthew W Cooke
- Professor of Emergency Medicine, Warwick Medical School, University of Warwick, UK
| | - Peter Spurgeon
- Professor of Clinical Healthcare Management, Warwick Medical School, University of Warwick, UK
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Sujan M, Spurgeon P, Inada-Kim M, Rudd M, Fitton L, Horniblow S, Cross S, Chessum P, W Cooke M. Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research. Health Services and Delivery Research 2014. [DOI: 10.3310/hsdr02050] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and objectivesHandover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover.MethodsThree NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways.ResultsHandover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows.ConclusionsThe research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | | | - Matthew Inada-Kim
- Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester, UK
| | - Michelle Rudd
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - Larry Fitton
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - Simon Horniblow
- United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, UK
| | - Steve Cross
- United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, UK
| | - Peter Chessum
- Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, UK
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Sujan MA, Chessum P, Rudd M, Fitton L, Inada-Kim M, Spurgeon P, Cooke MW. Emergency Care Handover (ECHO study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J 2013; 32:112-8. [PMID: 24026973 PMCID: PMC4316834 DOI: 10.1136/emermed-2013-202977] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Inadequate handover in emergency care is a threat to patient safety. Handover across care boundaries poses particular problems due to different professional, organisational and cultural backgrounds. While there have been many suggestions for standardisation of handover content, relatively little is known about the verbal behaviours that shape handover conversations. This paper explores both what is communicated (content) and how this is communicated (verbal behaviours) during different types of handover conversations across care boundaries in emergency care. Methods Three types of interorganisational (ambulance service to emergency department (ED) in ‘resuscitation’ and ‘majors’ areas) and interdepartmental handover conversations (referrals to acute medicine) were audio recorded in three National Health Service EDs. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis. Results 203 handover conversations were analysed. Handover conversations involving ambulance services were predominantly descriptive (60%–65% of utterances), unidirectional and focused on patient presentation (75%–80%). Referrals entailed more collaborative talk focused on the decision to admit and immediate care needs. Across all types of handover, only 1.5%–5% of handover conversation content related to the patient's social and psychological needs. Conclusions Handover may entail both descriptive talk aimed at information transfer and collaborative talk aimed at joint decision-making. Standardisation of handover needs to accommodate collaborative aspects and should incorporate communication of information relevant to the patient's social and psychological needs to establish appropriate care arrangements at the earliest opportunity.
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Affiliation(s)
- Mark A Sujan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Chessum
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - Michelle Rudd
- United Lincolnshire Hospitals NHS Trust, Lincoln, Lincolnshire, UK
| | | | | | - Peter Spurgeon
- Warwick Medical School, University of Warwick, Coventry, UK
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Joynt KE, Le ST, Inada-Kim M, Jha AK. Abstract 142: Which Hospitals Fail to Improve Readmission Rates? Circ Cardiovasc Qual Outcomes 2012. [DOI: 10.1161/circoutcomes.5.suppl_1.a142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
The 30-day readmission rate in the Medicare population is near 18%, with an associated cost of $16 billion dollars annually. Policy makers have become focused on trying to identify successful strategies to reduce both the clinical and economic burden of rehospitalizations, and to this end, the Affordable Care Act sets up penalties for hospitals with high readmission rates. Despite the national attention to readmissions, there are many hospitals that have failed to improve their readmission rates. Understanding who these persistently poor-performing hospitals are is key to helping them improve.
Methods:
We used national Medicare data from 2007 through 2009 to calculate mean readmission rates across six common conditions (heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, stroke and gastrointestinal bleeding) for all acute-care hospitals in the U.S. We identified poor baseline performers as those hospitals with performance in the worst quartile of readmission rates in 2007. We then categorized these hospitals into two groups: those who improved by 2009 and those who did not. We compared the characteristics of hospitals and markets in each of these groups.
Results:
Our sample was comprised of 869 poor-performing acute-care hospitals. Baseline median composite readmission rates were 27.8% (IQR 25.8%-32.5%). Of these, 214 (24.6%) hospitals failed to improve their readmission rates by 2009; the median 2009 readmission rate for persistently poor performers was 32.0% (IQR 27.1%-38.0%) while the rate fo hospitals that improved was 20.9% (IQR 18.5%-23.6%). Persistently poor performers were more likely to be small hospitals (71% versus 32%, p<0.001), publicly owned (32% versus 21%, p=0.003), rural (43% versus 18%, p=0.02), non-teaching hospitals (86% versus 74%, p<0.001). They were less likely to have a medical intensive care unit (20% versus 52%, p=0.001). Persistently poor performers were located in areas with fewer specialist physicians (7 per 100,000 population versus 9 per 100,000 population, p<0.001) and lower median income ($33,299 versus $34,523, p<0.001). In multivariate logistic regression analyses, the strongest predictors of being a persistently poor performer were being a small hospital (odds ratio 13.3, p<0.001) and lacking a medical intensive care unit (odds ratio 2.9, p<0.001).
Conclusions and Implications:
Between 2007 and 2009, small, public, non-teaching hospitals were far less likely to improve their readmission rates than others; in general, persistently poor performers were hospitals with lower resource levels and more socioeconomically disadvantaged populations. As hospitals face looming penalties for high readmission rates, our findings raise concern about the ability of the small, worst-performing hospitals and those with poor resource bases to improve their outcomes, and thus raise concerns about the potential of readmissions penalties to widen disparities in care. Policymakers may need to consider coupling readmission penalties with programs and resources to help these vulnerable hospitals improve in order to avoid unintended consequences of this policy initiative.
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Kim YT, Kim HC, Inada-Kim M, Jung SS, Yun YH, Jho MJ, Sandstrom K. Evaluation of tissue mimicking quality of tofu for biomedical ultrasound. Ultrasound Med Biol 2009; 35:472-481. [PMID: 19101073 DOI: 10.1016/j.ultrasmedbio.2008.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 04/14/2008] [Accepted: 09/05/2008] [Indexed: 05/27/2023]
Abstract
The tissue mimicking quality of tofu has been evaluated in terms of acoustic properties and acousto/thermal conversion as functions of frequency and diffraction corrected intensity over the 2 MHz to 18 MHz range using three unfocussed transducers with center frequencies of 5 MHz, 10 MHz and 15 MHz. The density and acoustic velocity were close to the American Institute of Ultrasound in Medicine (AIUM) recommended values for the soft tissue, however, the attenuation increases nonlinearly with frequency as alpha = 0.56 x f(1.3). As a result, the temperature rise in tofu due to ultrasound absorption is expressed by the product of the acousto/thermal conversion factor and the attenuation/diffraction corrected acoustic intensity. The decrease of temperature rise with depth measured by embedded thermocouples agrees with the theoretical exponential decrease of the attenuation/diffraction corrected acoustic intensity. The heat capacity per unit mass of tofu is 0.76 cal/g degrees C (equivalent to 3.18 J/g degrees C) of which about 76% is water. The nonlinear frequency dependence of attenuation in tofu as f(1.3) correctly describes the frequency dependence of temperature rise. The present results suggest that tofu may only be used in a limited low MHz range in view of the estimation of temperature rise and penetration depth due to nonlinear frequency dependence of attenuation.
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Affiliation(s)
- Yong Tae Kim
- Division of Physical Metrology, Korea Research Institute of Standards and Science, Yusong, Daejeon, Republic of Korea.
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19
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Barton IK, Inada-Kim M. Acute peritoneal dialysis: how to do it. Br J Hosp Med (Lond) 1997; 57:134-6. [PMID: 9166372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The decline in the use of acute peritoneal dialysis which has followed the recent advances in extracorporeal renal replacement therapy has left many clinicians unfamiliar with an invaluable therapeutic tool. This article is a timely reminder of both the underlying theory and the practical aspects of this technique.
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Affiliation(s)
- I K Barton
- Department of Medicine, Whipps Cross Hospital, London
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