Infectious and sepsis presentations to, and hospital admissions from emergency departments in Victoria, Australia

OBJECTIVE

To investigate the frequency and outcomes of adult infectious and sepsis presentations to, and hospital admissions from, Emergency Departments (EDs) in Victoria, Australia.

METHODS

Retrospective cohort study using the Victorian Emergency Minimum Dataset and Victorian Admitted Episodes Dataset. We included adults (age ≥ 18 years) presenting to an ED, or admitted to hospital from ED in Victoria between July 2017 and June 2018. One-year mortality was analysed until June 2019 using the Victorian Death Index, and ICD-10 coding was used to identify cases.

RESULTS

Among 1.28 million ED presentations over 1 year, 12.00% and 0.45% were coded with infectious and sepsis diagnoses, respectively. Despite having lower triage categories, patients with infections were more likely to be admitted to hospital (50.4% vs 44.9%), but not directly to ICU (0.8%). Patients coded with sepsis were assigned higher triage categories and required hospital admission much more frequently (96.4% vs 44.9%), including to ICU (15.9% vs 0.8%). Patients presenting with infections and sepsis had increased risk of 1-year mortality (adjusted hazard ratio 1.44 and 4.13, respectively). Of the 648 280 hospital admissions from the ED, infection and sepsis were coded in 23.69% and 2.66%, respectively, and the adjusted odds ratio for 1-year mortality were 1.64 and 4.79, respectively.

CONCLUSIONS

Infections and sepsis are common causes of presentation to, and admission from the ED in Victoria. Such patients experience higher mortality than non-infectious patients, even after adjusting for age. There is a need to identify modifiable factors contributing to these outcomes.

Attitudes towards artificial intelligence in emergency medicine

OBJECTIVE

To assess Australian and New Zealand emergency clinicians' attitudes towards the use of artificial intelligence (AI) in emergency medicine.

METHODS

We undertook a qualitative interview-based study based on grounded theory. Participants were recruited through ED internal mailing lists, the Australasian College for Emergency Medicine Bulletin, and the research teams' personal networks. Interviews were transcribed, coded and themes presented.

RESULTS

Twenty-five interviews were conducted between July 2021 and May 2022. Thematic saturation was achieved after 22 interviews. Most participants were from either Western Australia (52%) or Victoria (16%) and were consultants (96%). More participants reported feeling optimistic (10/25) than neutral (6/25), pessimistic (2/25) or mixed (7/25) towards the use of AI in the ED. A minority expressed scepticism regarding the feasibility or value of implementing AI into the ED. Multiple potential risks and ethical issues were discussed by participants including skill loss from overreliance on AI, algorithmic bias, patient privacy and concerns over liability. Participants also discussed perceived inadequacies in existing information technology systems. Participants felt that AI technologies would be used as decision support tools and not replace the roles of emergency clinicians. Participants were not concerned about the impact of AI on their job security. Most (17/25) participants thought that AI would impact emergency medicine within the next 10 years.

CONCLUSIONS

Emergency clinicians interviewed were generally optimistic about the use of AI in emergency medicine, so long as it is used as a decision support tool and they maintain the ability to override its recommendations.

Surgical sensation during caesarean section: a qualitative analysis

BACKGROUND

Caesarean section (CS) is a major abdominal surgery performed usually on a young and healthy population under neuraxial anesthesia with little to no sedation. This creates a distinct surgical experience whereby patients are aware of the surgical process, physical sensations, and their environment. This study aimed to provide an in-depth descriptive assessment of subjective surgical experience during CS under regional anaesthesia. We expected the information gained would enhance our current understanding and better alleviate patient anxiety through informed counselling.

METHODS

This qualitative descriptive study was conducted at a Canadian academic centre. Twenty patients participated in semi-structured interviews within a week of CS, using an interview guide developed for this study. Patient medical records were reviewed to collect demographic and surgical information. Thematic analysis was conducted using an inductive approach to determine common themes.

RESULTS

Nine themes were identified. Five themes were identified in the category of surgical sensation and four themes were identified in the category of peri-operative education.

CONCLUSIONS

Patients commonly experienced pressure and movement sensations at varying intensity, and most did not experience pain. Environmental factors, including sounds and distraction by the newborn, affected perception of surgical sensation. Patients wish to receive pre-operative counselling regarding potential surgical sensations, as well as ongoing communication from their anaesthesiologist. These results can be used to guide informed discussions with patients and direct further investigation in this area.

Applications of natural language processing at emergency department triage: A narrative review

INTRODUCTION

Natural language processing (NLP) uses various computational methods to analyse and understand human language, and has been applied to data acquired at Emergency Department (ED) triage to predict various outcomes. The objective of this scoping review is to evaluate how NLP has been applied to data acquired at ED triage, assess if NLP based models outperform humans or current risk stratification techniques when predicting outcomes, and assess if incorporating free-text improve predictive performance of models when compared to predictive models that use only structured data.

METHODS

All English language peer-reviewed research that applied an NLP technique to free-text obtained at ED triage was eligible for inclusion. We excluded studies focusing solely on disease surveillance, and studies that used information obtained after triage. We searched the electronic databases MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and Scopus for medical subject headings and text keywords related to NLP and triage. Databases were last searched on 01/01/2022. Risk of bias in studies was assessed using the Prediction model Risk of Bias Assessment Tool (PROBAST). Due to the high level of heterogeneity between studies and high risk of bias, a metanalysis was not conducted. Instead, a narrative synthesis is provided.

RESULTS

In total, 3730 studies were screened, and 20 studies were included. The population size varied greatly between studies ranging from 1.8 million patients to 598 triage notes. The most common outcomes assessed were prediction of triage score, prediction of admission, and prediction of critical illness. NLP models achieved high accuracy in predicting need for admission, triage score, critical illness, and mapping free-text chief complaints to structured fields. Incorporating both structured data and free-text data improved results when compared to models that used only structured data. However, the majority of studies (80%) were assessed to have a high risk of bias, and only one study reported the deployment of an NLP model into clinical practice.

CONCLUSION

Unstructured free-text triage notes have been used by NLP models to predict clinically relevant outcomes. However, the majority of studies have a high risk of bias, most research is retrospective, and there are few examples of implementation into clinical practice. Future work is needed to prospectively assess if applying NLP to data acquired at ED triage improves ED outcomes when compared to usual clinical practice.

Development and validation of a prognostic model for death 30 days after adult emergency laparotomy

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.

Severity of Dementia and Survival in Patients Diagnosed with Colorectal Cancer: A National Cohort Study in England and Wales

AIMS

There is little evidence about the survival of patients with colorectal cancer (CRC) also diagnosed with dementia. We quantified dementia severity and estimated how it is associated with 2-year overall survival.

MATERIALS AND METHODS

Records of patients aged 65 years or older diagnosed with CRC in England and Wales were identified. A novel proxy for dementia severity combined dementia diagnosis in administrative hospital data with Eastern Cooperative Oncology Group performance status. Cox regression was used to estimate hazard ratios with and without risk adjustment.

RESULTS

In total, 4033 of 105 250 CRC patients (3.8%) had dementia recorded. Two-year survival decreased with increasing dementia severity from 65.4% without dementia, 53.5% with mild dementia, 33.0% with moderate dementia to 16.5% with severe dementia (hazard ratio comparing severe with no dementia: 2.97; 95% confidence interval 2.79, 3.16). Risk adjustment for comorbidity and cancer stage reduced this association slightly (hazard ratio 2.52; 95% confidence interval 2.37, 2.68) and additional adjustment for treatment factors reduced it further (hazard ratio 1.60; 95% confidence interval 1.50, 1.70).

CONCLUSIONS

Survival of CRC patients varied strongly according to dementia severity, suggesting that a 'one-size-fits-all' policy for the care of CRC patients with dementia is not appropriate. Comprehensive assessment of cancer patients with dementia that considers dementia severity is essential in a shared decision-making process that ensures patients receive the most appropriate treatment for their individual needs and preferences.

From little things, big things grow: An exploratory analysis of the national cost of peripheral intravenous catheter insertion in Australian adult emergency care

OBJECTIVE

To estimate the total economic impact of peripheral intravenous catheter (PIVC) or cannula insertion and use in adult Australian EDs, including those cannulas that remain unused for therapeutic purposes.

METHODS

Searches on Australian government websites were conducted to find rates of insertion, complications and cost of cannula; following this, gaps in national data sets were filled with MEDLINE and PubMed searches to estimate the total cost of cannula use in Australian EDs. Once the data were collected, totals were combined to establish an estimated cost for the listed categories.

RESULTS

The estimated cost of cannulation in Australia may be up to A$594 million per year, including the cost of insertion (equipment and staff), cost of complications such as Staphylococcus aureus bacteraemia and phlebitis, and patient-centred costs (lost patient productivity, infiltration, occlusion and dislodgement). Approximately A$305.9 million is attributed to unused cannulas and approximately 11 790 days of clinician time is spent annually inserting cannula that remains idle.

CONCLUSION

The figures developed in the present study represent an important educational opportunity to encourage thoughtful consideration of all interventions, no matter how small. ED cannula insertion represents a large economic and health cost to Australia's health system, many of which remain unused. There are no national data sets that record complications associated with PIVCs and we highlight the urgent need for improved data.

The Role of Maternal Grandmothers' Childcare Provision for Korean Working Adult Daughters

Despite the Korean government's investment in childcare facilities for dual-earner households, maternal grandmothers are increasingly taking on the responsibility of caring for their grandchildren. This trend is examined in the current research. While many studies have been conducted on grandparents' experiences providing childcare for their grandchildren, significantly less research has been conducted on adult daughters' experiences with their mothers' childcare provision. This study utilized the concepts of intergenerational solidarity and a life-course approach to understand the experiences of 24 working adult daughters in Korea (ages 30-43) whose mothers provide childcare. Three major themes were identified following a grounded theory approach: gratitude vs. guilt, dependence vs. independence, and closeness vs. disagreement. The results indicated that adult daughters were found to have ambivalence toward their mothers, reflecting the lack of alternative options for childcare. The results from this study suggest that not only improving the quality of public childcare services, but also diversifying services to reflect the needs of dual-income families.

Iatrogenic and spontaneous preterm birth in England: a population-based cohort study

OBJECTIVE

To describe the rates of and risk factors associated with iatrogenic and spontaneous preterm birth and the variation in rates between hospitals.

DESIGN

Cohort study using electronic health records.

SETTING

English National Health Service.

POPULATION

Singleton births between 1^st April 2015 and 31^st March 2017.

METHODS

Multivariable Poisson regression models were used to estimate adjusted risk ratios (adjRR) to measure association with maternal demographic and clinical risk factors.

MAIN OUTCOME MEASURES

Preterm births (<37 weeks gestation) were defined as iatrogenic or spontaneous according to mode of onset of labour.

RESULTS

6.1% of births were preterm and of these, 52.8% were iatrogenic. The proportion of preterm births that were iatrogenic increased after 32 weeks. Both sub-groups are associated with previous preterm birth, extremes of maternal age, socioeconomic deprivation and smoking. Iatrogenic preterm birth was associated with higher BMI (adjRR BMI >40 1.59 (1.50, 1.69)), and previous caesarean (adjRR 1.88 (1.83, 1.95)). Spontaneous preterm birth was less common in women with a higher BMI (adjRR BMI>40 0.77 (0.70, 0.84)) and in women with a previous caesarean (adjRR 0.87 (0.83, 0.90)). More variation between NHS hospital trusts was observed in rates of iatrogenic, compared to spontaneous, preterm births.

CONCLUSIONS

Just over half of all preterm births resulted from iatrogenic intervention. Iatrogenic births have overlapping but different patterns of maternal demographic and clinical risk factors to spontaneous preterm births. Iatrogenic and spontaneous sub-groups should therefore be measured and monitored separately, as well as in aggregate, to facilitate different prevention strategies. This is feasible using routinely acquired hospital data.

Learning practices of experienced healthcare teams and dyads in acute care settings: a scoping review

OBJECTIVES

To map the evidence on learning practices currently used by experienced healthcare teams and dyads. The hypothesis is that through reviewing the literature we will identify the number and array of current learning practices. Through the lens of collaboration, the authors' goal is to map current practice to guide future research, policy and practice.

SETTING

The review included studies from North America, Europe, Australasia and Asia. All studies were conducted in acute care settings such as operating rooms, emergency rooms, intensive care units and simulation centres.

PARTICIPANTS

The participants were experienced healthcare professionals who work in acute care settings of any age or any sex. The group was interprofessional including two or more disciplines and/or professions. Characteristics of the participants who were excluded were students, novices, healthcare professionals who work in non-acute care settings and single profession studies.

PRIMARY AND SECONDARY OUTCOME MEASURES

Aligned to the protocol quantitative and qualitative analyses were conducted. Thematic analysis was used to evaluate and categorise the study findings. Secondary outcome measures were the different types of learning practices used together to produce excellence.

RESULTS

Most empirical studies were qualitative studies (46%), 31% were mixed methods and 23% were quantitative studies. There were also 24 reviews and 10 commentaries. The most frequent learning practices were structured observation and case scenarios (21%) followed by audio/video analysis and surveys (17%). Next was interviews and didactic presentations (12%) followed by prebriefing/debriefing and checklists (11%). Other learning practices accounted for less than 10%. Overall, 84 of the 86 publications, examined learning practices of teams larger than two participants.

CONCLUSIONS

While the quality of studies was high, and there was a broad range of empirical studies, reviews and commentaries, there was no consensus on best practice in determining which learning practices to use and measurement of the effect of these practices.

First Leptophobic Dark Matter Search from the Coherent-CAPTAIN-Mills Liquid Argon Detector

We report the first results of a search for leptophobic dark matter (DM) from the Coherent-CAPTAIN-Mills (CCM) liquid argon (LAr) detector. An engineering run with 120 photomultiplier tubes (PMTs) and 17.9×10^{20} protons on target (POT) was performed in fall 2019 to study the characteristics of the CCM detector. The operation of this 10-ton detector was strictly light based with a threshold of 50 keV and used coherent elastic scattering off argon nuclei to detect DM. Despite only 1.5 months of accumulated luminosity, contaminated LAr, and nonoptimized shielding, CCM's first engineering run has already achieved sensitivity to previously unexplored parameter space of light dark matter models with a baryonic vector portal. With an expected background of 115 005 events, we observe 115 005+16.5 events which is compatible with background expectations. For a benchmark mediator-to-DM mass ratio of m_{V_{B}}/m_{χ}=2.1, DM masses within the range 9  MeV≲m_{χ}≲50  MeV are excluded at 90% C. L. in the leptophobic model after applying the Feldman-Cousins test statistic. CCM's upgraded run with 200 PMTs, filtered LAr, improved shielding, and 10 times more POT will be able to exclude the remaining thermal relic density parameter space of this model, as well as probe new parameter space of other leptophobic DM models.

Face Value: Remote facial expression analysis adds predictive power to perceived effectiveness for selecting anti-tobacco PSAs

Perceived effectiveness (PE) is a validated tool for predicting the potential impact of anti-tobacco public service announcements (PSAs). We set out to evaluate the added predictive value of facial expression analysis when combined with PE in a remote (online) survey. Each of 302 tobacco users watched 3 PSAs and allowed transmission of webcam videos from which metrics for "attention" (head position) and "facial action units" (FAU) were computed. The participants completed scales for their subjective emotions, willingness to share on social media, and intention to quit smoking using the Tobacco Free Florida website. Based on PE, both ready to quit (RTQ) and not ready (NR) respondents favored the same PSAs but RTQs assigned higher PE scores. Negative PSAs ("sad" or "frightening") were more compelling overall but RTQs also favored surprising ads and were more willing to share them on social media. Logistic regression showed that the combination of Attention + FAU+ PE (AUC = .816, p < .0001) outperformed single factors or factor combinations in distinguishing RTQ from NR. This study demonstrates that on-line assessment of facial expressions enhances the predictive value of PE and can be deployed on large remote samples.

A234 IN VITRO GUT MICROBIOME AND METABOLITE RESPONSES TO RESISTANT STARCH ARE INDIVIDUALIZED

Background

Gut microbes degrade and ferment resistant starch (RS) into metabolites that help maintain gut homeostasis. Clinical trials have evaluated RS for various health conditions, but individuals respond to RS with profound variability. The reason for this variability is unclear.

Aims

Using in vitro culturing methods and multi-omic analyses, we hypothesize that individuals will elicit variable responses to RS with respect to overall fermentation, bacterial composition, short chain acid production, and metabolite flux.

Methods

As part of an ongoing clinical trial, we have selected 4 pediatric patients with inflammatory bowel disease to better understand microbiome-RS interactions. We cultured stools anaerobically using a high-throughput platform (“RapidAIM”) with 9 different pre-digested RS. After 18-hour incubations, media supernatants were used to measure pH and perform targeted and semi-targeted metabolomic analyses with a panel of 116 compounds. Bacterial pellets were isolated for 16S rRNA gene sequencing analyses to evaluate changes in microbiome compositions. Data were analyzed with generalized linear mixed models, principal component analysis (PCA), random forest (RF) classification with feature selection, and network construction with graphical lasso.

Results

Changes in several microbiome parameters were different across individuals, including the magnitude of pH changes, metabolite signatures, and relative abundances of important bacterial taxa. Bacterial species known to degrade RS were more abundant in individuals showing stronger RS fermentation. Inter-individual discrimination was accomplished with PCA and RF, from which we could identify metabolite signatures. The robustness of microbiome networks corresponded to RS fermentation and butyrate production.

Conclusions

We report a novel perspective on how individuals respond to RS’ differently. Butyrate remains an important hub of the microbiome architecture with respect to RS fermentation. Future work will interrogate the roles of individualized metabolomic responses on host physiology. In vivo responses to RS are being evaluated in an ongoing clinical trial.

Funding Agencies

CCC, CIHRGenome Ontario, Genome Canada

751 Improving Engagement with Home-Based Surgical Skills Simulation

Introduction

Surgical simulation has been repeatedly shown to facilitate technical skill acquisition. However, trainee engagement with self-directed practice remains variable, despite access to resources. Understanding the motivators and barriers to participation is crucial to develop modules which can effectively meet the learning needs of current, and future, surgical trainees. The aim of this qualitative study was to examine factors which influence trainee engagement with home-based surgical skills simulation.

Method

A series of one-to-one semi-structured interviews were conducted remotely with ST3 vascular trainees who had previously consented to take part in a national programme of home-based technical skills simulation. Interview data was transcribed and thematically analysed.

Results

12 trainees were interviewed during a 4-week period. Overall, trainees valued simulation but found it difficult to balance against clinical commitments and mandatory training requirements, particularly if there were limited opportunities for skill transfer to the real-world environment. Although simulation was acknowledged to be a safe environment for experiential learning, trainees alluded to an underlying culture of perfection which limited willingness to learn from mistakes, even within a simulated setting. In addition, traditional attitudes about the apprenticeship model of surgical training prevail, with simulation often viewed as inferior to learning “on the job” in theatre.

Conclusions

Trainee engagement with home-based surgical skills simulation may be influenced by a range of systemic factors. In future, formal certification of simulation modules, mandating simulated competencies and curricular integration may help improve participation, as well as supporting cultural shift towards recognition of simulation as a vital component of modern surgical training.

Associations between ethnicity and admission to intensive care among women giving birth: a cohort study

OBJECTIVE

To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period.

DESIGN

Cohort study.

SETTING

Maternity and intensive care units in England and Wales.

POPULATION OR SAMPLE

A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit.

METHODS

Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data.

MAIN OUTCOME MEASURES

Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth.

RESULTS

In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups.

CONCLUSIONS

Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission.

TWEETABLE ABSTRACT

Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

Emergency medicine patient wait time multivariable prediction models: a multicentre derivation and validation study

OBJECTIVE

Patients, families and community members would like emergency department wait time visibility. This would improve patient journeys through emergency medicine. The study objective was to derive, internally and externally validate machine learning models to predict emergency patient wait times that are applicable to a wide variety of emergency departments.

METHODS

Twelve emergency departments provided 3 years of retrospective administrative data from Australia (2017-2019). Descriptive and exploratory analyses were undertaken on the datasets. Statistical and machine learning models were developed to predict wait times at each site and were internally and externally validated. Model performance was tested on COVID-19 period data (January to June 2020).

RESULTS

There were 1 930 609 patient episodes analysed and median site wait times varied from 24 to 54 min. Individual site model prediction median absolute errors varied from±22.6 min (95% CI 22.4 to 22.9) to ±44.0 min (95% CI 43.4 to 44.4). Global model prediction median absolute errors varied from ±33.9 min (95% CI 33.4 to 34.0) to ±43.8 min (95% CI 43.7 to 43.9). Random forest and linear regression models performed the best, rolling average models underestimated wait times. Important variables were triage category, last-k patient average wait time and arrival time. Wait time prediction models are not transferable across hospitals. Models performed well during the COVID-19 lockdown period.

CONCLUSIONS

Electronic emergency demographic and flow information can be used to approximate emergency patient wait times. A general model is less accurate if applied without site-specific factors.

Stroke Code From EMS to Thrombectomy: An Interdisciplinary In Situ Simulation for Prompt Management of Acute Ischemic Stroke

INTRODUCTION

Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times.

METHODS

An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness.

RESULTS

Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership.

DISCUSSION

Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.

Optimising expert dyad performance in acute care settings: a scoping review protocol

INTRODUCTION

When there is miscommunication and poor coordination between experienced clinician dyads, teamwork suffers. Research on expert learning practices for the smallest team, and arguably the most important team, the healthcare dyad, is limited. The objective of this study is to map the extent and range of evidence available on learning practices which experienced dyads use, to achieve excellent performance, and to identify the gaps in effective practice. This will guide future research, policy and practice.

METHODS AND ANALYSIS

We are using the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews Extension Fillable Checklist, searching for literature that meets the inclusion criteria. The searches will be conducted using Maastricht University's Libsearch, which includes MEDLINE, Education Resources Information Center and PsycINFO and a second search on Web of Science online databases. We will search grey literature and references of selected sources. Search limits include sources from 2016 to 2021, using English language only. A data extraction tool was developed, and charting will use a thematic analysis approach.

IMPLICATIONS AND DISSEMINATION

This review will be the first to examine the learning practices that experienced dyads use, which ensures excellent performance in acute care settings. The findings will be used to develop best-practices and shared with New York City hospital system. Dissemination will occur through peer-reviewed publications and at healthcare conferences.

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review

BACKGROUND:

Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants.

METHODS:

Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 –2019. Results were combined using descriptive statistics.

RESULTS:

Fourteen studies encompassed 546 stroke cases in preterm infants between 23 –36 weeks gestational ages and birth weights between 450 –3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis.

CONCLUSION:

This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.

Management of patients presenting with low back pain to a private hospital emergency department in Melbourne, Australia

OBJECTIVE

Recent studies suggest many patients with non-specific low back pain presenting to public hospital EDs receive low-value care. The primary aim was to describe management of patients presenting with low back pain to the ED of a private hospital in Melbourne, Australia, and received a final ED diagnosis of non-specific low back pain. We also determined predictors of hospital admission.

METHODS

Retrospective review of patients who presented with low back pain and received a final ED diagnosis of non-specific low back pain to Cabrini Malvern ED in 2015. Demographics, lumbar spinal imaging, pathology tests and medications were extracted from hospital records. Multivariate logistic regression was used to determine independent predictors of hospital admission.

RESULTS

Four hundred and fifty presentations were included (60% female); 238 (52.9%) were admitted to hospital. One hundred and seventy-seven (39.3%) patients received lumbar spine imaging. Two hundred and eighty (62.2%) patients had pathology tests and 391 (86.9%) received medications, which included opioids (n = 298, 66.2%), paracetamol (n = 219, 48.7%), NSAIDs (n = 161, 35.8%), benzodiazepines (n = 118, 26.2%) and pregabalin (n = 26, 5.8%). Predictors of hospital admission included older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.05), arrival by ambulance (OR 2.03, 95% CI 1.06-3.90) and receipt of pathology tests (OR 3.32, 95% CI 2.01-5.49) or computed tomography scans (OR 1.86, 95% CI 1.12-3.11).

CONCLUSION

We observed high rates of imaging, pathology tests and hospital admissions compared with previous public hospital studies, while medication use was similar. Implementation of strategies to optimise evidence-based ED care is needed to reduce low-value care and improve patient outcomes.

Displaying emergency patient estimated wait times: A multi-centre, qualitative study of patient, community, paramedic and health administrator perspectives

OBJECTIVE

EDs have the potential ability to predict patient wait times and to display this to patients and other stakeholders. Little is known about whether consumers and stakeholders would want this information and how wait time predictions might be used. The aim of the present study was to gain perspectives from consumers and health services personnel regarding the concept of emergency wait time visibility.

METHODS

We conducted a qualitative interview and focus group study in 2019. Participants included emergency medicine patients, families, paramedics, well community members, and hospital/paramedic administrators from multiple EDs and organisations in Victoria, Australia. Transcripts were coded and themes presented.

RESULTS

One focus group and 103 semi-structured interviews were conducted in 2019 including 32 patients, 22 carers/advocates and 21 paramedics in the ED; 20 health service administrators (paramedic and hospital) and 15 community members. Consumers and paramedics face physical and psychological difficulties when wait times are not visible. Consumers believe about a 2-h wait is tolerable, beyond this most begin to consider alternative strategies for seeking care. Consumers want to see triage to doctor times; paramedics want door-to-off stretcher times (for all possible transport destinations); with 47 of 50 consumers and 30 of 31 paramedics potentially using this information. About 28 of 50 consumers would use times to inform facility or provider choice, another 19 of 50 want information once in the waiting room. During prolonged waits, 51 of 52 consumers would continue to seek care.

CONCLUSIONS

Consumers and paramedics want wait time information visibility. They would use the information in a variety of ways, both pre-hospital and while waiting for care.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

Hemispheric asymmetry in ocean change and the productivity of ecosystem sentinels

Climate change and other human activities are causing profound effects on marine ecosystem productivity. We show that the breeding success of seabirds is tracking hemispheric differences in ocean warming and human impacts, with the strongest effects on fish-eating, surface-foraging species in the north. Hemispheric asymmetry suggests the need for ocean management at hemispheric scales. For the north, tactical, climate-based recovery plans for forage fish resources are needed to recover seabird breeding productivity. In the south, lower-magnitude change in seabird productivity presents opportunities for strategic management approaches such as large marine protected areas to sustain food webs and maintain predator productivity. Global monitoring of seabird productivity enables the detection of ecosystem change in remote regions and contributes to our understanding of marine climate impacts on ecosystems.

Fundamental underpinnings of simulation education: describing a four-component instructional design approach to healthcare simulation fellowships

Although in 2020, there are more than 120 healthcare simulation fellowships established globally, there is a paucity of literature on how to design fellowship programs most effectively, to equip graduates with the knowledge, skills, and attitudes of a competent simulation educator. Offering a systematic structure to approach simulation fellowship programmatic design may aid in better achieving program goals. In this manuscript, we present the application of the 4-component instructional design model as a blueprint to the development of Simulation Education Fellowships. We offer examples used at the NYC Health + Hospitals simulation fellowship to illustrate how the 4-component model informs fellowship program design which promotes the development of a simulation educator. This manuscript will provide a roadmap to designing curricula and assessment practices including self-reflective logbooks to focus the path toward achieving desired skills and shape future conversations around programmatic development.

256 Antimicrobial Stewardship in Skin Cancer Surgery. Assessing Best Practice in Reducing Significant Post-Operative Complications

Introduction

Antibiotic prescription is variable and with the growing frequency of antibiotic resistance, responsible use of antibiotics is necessary in keeping with Public Health England (PHE) Antimicrobial Stewardship guidelines. An audit was conducted to assess current practice of prophylactic antibiotics prescription in Skin Cancer Surgery in the department of Oral & Maxillofacial surgery.

Method

A retrospective case note review of patients who had undergone reconstructive surgery following skin cancer excision, recorded use of systemic and topical antibiotics and infective outcomes. Inclusion criteria were patients that had undergone surgical excision and reconstruction of skin cancer, followed by a wound assessment in an outpatient’s clinic with the outcome measure of infection defined by PHE Surgical Site Infection guidelines. A standard of 5% infection rate which is recognised by the British Association of Dermatologists was used.

Results

There was a 2% significant post op infection rate in patients with topical antibiotics used and 4.5% where neither systemic nor topical antibiotics were used. Immunocompromised patients had no increased incidence in significant post op infections occurring in either group.

Conclusions

The standard was met illustrating the low infection rate following reconstruction of Skin Cancer defects with or without prophylactic antibiotics and support a more discerning approach to antimicrobial prescribing.

525 Automated Continuous Instrument Tracking in Laparoscopic Box Trainers Predicts Performance at Assessment: A Prospective Cohort Study in Core Surgical Trainees

Introduction

Box-trainers enable deliberate practice of laparoscopic skills and can be equipped with instrument tracking metrics to provide feedback. However, the relationship between metrics, assessment outcomes and practice are unclear.

Method

Core surgical trainees were provided take-home box trainers with SurgTrac™ instrument tracking metrics for practice (eoSurgical Ltd., Scotland, UK). Practice was incentivised by certification and video assessment of a basic task, peg capping. Assessment was by consultant general surgeons, using objective structured assessment of technical skills (OSATS). The following metrics were analysed: task duration, distance moved by instruments, average instrument speed, average instrument acceleration, left- or right-handedness and instrument smoothness. Metrics were correlated to OSATS scores using regression analysis. Threshold for significance was p = 0.05.

Results

During the study period, there were 1639 peg capping performances by 85 trainees; 103 video recordings were submitted for assessment. All metrics were significantly associated with OSATS score, except instrument acceleration. The multiple linear regression model was highly correlated with actual scores (Pearson correlation 0.658; p &lt; 0.001). Practice was positively correlated with regression model predicted OSATS score (regression analysis; ANOVA p &lt; 0.001).

Conclusions

Instrument tracking metrics reliably predict OSATS performance and practice improves predicted score. Trainees can use metrics in unsupervised practice and gauge whether they are improving as expected.

Soman-induced toxicity, cholinesterase inhibition and neuropathology in adult male Göttingen minipigs

Animal models are essential for evaluating the toxicity of chemical warfare nerve agents (CWNAs) to extrapolate to human risk and are necessary to evaluate the efficacy of medical countermeasures. The Göttingen minipig is increasingly used for toxicological studies because it has anatomical and physiological characteristics that are similar to those of humans. Our objective was to determine whether the minipig would be a useful large animal model to evaluate the toxic effects of soman (GD). We determined the intramuscular (IM) median lethal dose (LD50) of GD in adult male Göttingen minipigs using an up-and-down dosing method. In addition to lethality estimates, we characterized the observable signs of toxicity, blood and tissue cholinesterase (ChE) activity and brain pathology following GD exposure. The 24 h LD50 of GD was estimated to be 4.7 μg/kg, with 95 % confidence limits of 3.6 and 6.3 μg/kg. As anticipated, GD inhibited ChE activity in blood and several tissues. Neurohistopathological analysis showed neurodegeneration and neuroinflammation in survivors exposed to 4.7 μg/kg of GD, including in the primary visual cortex and various thalamic nuclei. These findings suggest that the minipig will be a useful large animal model for assessing drugs to mitigate neuropathological effects of exposure to CWNAs.

Debrief it all: a tool for inclusion of Safety-II

Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work.

A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.

Being Your Best: protocol for a feasibility study of a codesigned approach to reduce symptoms of frailty in people aged 65 years or more after transition from hospital

INTRODUCTION

The population is ageing, with increasing health and supportive care needs. For older people, complex chronic health conditions and frailty can lead to a cascade of repeated hospitalisations and further decline. Existing solutions are fragmented and not person centred. The proposed Being Your Best programme integrates care across hospital and community settings to address symptoms of frailty.

METHODS AND ANALYSIS

A multicentre pragmatic mixed methods study aiming to recruit 80 community-dwelling patients aged ≥65 years recently discharged from hospital. Being Your Best is a codesigned 6-month programme that provides referral and linkage with existing services comprising four modules to prevent or mitigate symptoms of physical, nutritional, cognitive and social frailty. Feasibility will be assessed in terms of recruitment, acceptability of the intervention to participants and level of retention in the programme. Changes in frailty (Modified Reported Edmonton Frail Scale), cognition (Mini-Mental State Examination), functional ability (Barthel and Lawton), loneliness (University of California Los Angeles Loneliness Scale-3 items) and nutrition (Malnutrition Screening Tool) will also be measured at 6 and 12 months.

ETHICS AND DISSEMINATION

The study has received approval from Monash Health Human Research Ethics Committee (RES-19-0000904L). Results will be disseminated through peer-reviewed journals, conference and seminar presentations.

TRIAL REGISTRATION NUMBER

ACTRN12620000533998; Pre-results.

"A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing

BACKGROUND

The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly.

METHODS

We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding.

RESULTS

In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units.

CONCLUSION

The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.

Advance care planning practices in the nursing home setting: A secondary analysis

BACKGROUND AND OBJECTIVES

Advance care planning is intended to support resident's preferences regarding health decisions, even when they can no longer participate. Little is known about the power discourses influencing how residents, family-members, and healthcare workers engage in advance care planning and how advance care directives are used if conflict arises. A large critical ethnographic study was conducted exploring decision making when a resident's health deteriorates in the nursing home setting. Advance care planning practices were not the focus of the original study, but the richness of the data warranted further exploration. A new research question was developed to inform a secondary analysis: How does advance care planning influence the relationship between resident values and clinical expertise when determining a direction of care at the time of a resident deterioration?

RESEARCH DESIGN AND METHODS

A secondary analysis of data from an ethnographic study involving 184 hours of participatory observation, 40 semi-structured interviews and advance care planning policies and document review undertaken in in two nursing homes in Melbourne, Australia.

RESULTS

Advance care planning may result in inaccurate documentation of residents' preferences and devalue clinical decision-making and communication with residents and family-members at the time of deterioration.

DISCUSSION AND IMPLICATIONS

Advance care planning may contribute towards a reductionist approach to decision-making. There is an urgent need for the development of evidence-based policy and legislation to support residents, families, and healthcare workers to make appropriate decisions, including withholding invasive treatment when a resident deteriorates.

Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

Astrocyte-Derived Exosomes in an iPSC Model of Bipolar Disorder

Bipolar I Disorder (BP) is a serious, recurrent mood disorder that is characterized by alternating episodes of mania and depression. To begin to identify novel approaches and pathways involved in BP, we have obtained skin samples from BP patients and undiagnosed control (C) individuals, reprogrammed them to form induced pluripotent stem cells (iPSC), and then differentiated the stem cells into astrocytes. RNAs from BP and C astrocytes were extracted and RNAseq analysis carried out. 501 differentially expressed genes were identified, including genes for cytoskeletal elements, extracellular matrix, signaling pathways, neurodegeneration, and notably transcripts that identify exosomes. When we compared highly expressed genes using hierarchial cluster analysis, "Exosome" was the first and most highly significant cluster identified, p < 5 × 10^-13, Benjamini correction. Exosomes are membrane-bound vesicles that package and remove toxic proteins from cells and also enable cell to cell communication. They carry genetic material, including DNA, mRNA and microRNAs, proteins, and lipids to target cells throughout the body. Exosomes are released by cortical neurons and astrocytes in culture and are present in BP vs C postmortem brain tissue. Little is known about what transcripts and proteins are targeted to neurons, how they regulate biological functions of the acceptor cell, or how that may be altered in mood disorders. Since astrocyte-derived exosomes have been suggested to promote neuronal plasticity, as well as to remove toxic proteins in the brain, alterations in their function or content may be involved in neurodevelopmental, neuropathological, and neuropsychiatric conditions. To examine exosome cargos and interactions with neural precursor cells, astrocytes were differentiated from four bipolar disorder (BP) and four control (C) iPSC lines. Culture supernatants from these astrocytes were collected, and exosomes isolated by ultra-centrifugation. Western blot analysis demonstrated the presence of the exosome markers CD9, CD81, and Hsp70. Nanosight technology was used to characterize exosomes from each astrocyte cell line, suggesting that exosomes were slightly more concentrated in culture supernatants derived from BP compared with C astrocytes but there was no difference in the mean sizes of the exosomes. Analysis of their function in neuronal differentiation is being carried out by labeling exosomes derived from bipolar patient and control astrocytes and adding them to control neural progenitor cells. Given the current interest in clearing toxic proteins from brains of patients with neurodegenerative disorders, exosomes may present similar opportunities in BP.