Infection Control Through Clinical Pipelines Built with Arden Syntax MLM Building Blocks

Healthcare-associated infections (HAIs) may have grave consequences for patients. In the case of sepsis, the 30-day mortality rate is about 25%. HAIs cost EU member states an estimated 7 billion Euros annually. Clinical decision support tools may be useful for infection monitoring, early warning, and alerts. MONI, a tool for monitoring nosocomial infections, is used at University Hospital Vienna, but needs to be clinically and technically revised and updated. A new, completely configurable pipeline-based system for defining and processing HAI definitions was developed and validated. A network of data access points, clinical rules, and explanatory output is arranged as an inference network, a clinical pipeline as it is called, and processed in a stepwise manner. Arden-Syntax-based medical logic modules were used to implement the respective rules. The system was validated by creating a pipeline for the ECDC PN5 pneumonia rule. It was tested on a set of patient data from intensive care medicine. The results were compared with previously obtained MONI output as a suitable reference, yielding a sensitivity of 93.8% and a specificity of 99.8%. Clinical pipelines show promise as an open and configurable approach to graphically-based, human-readable, machine-executable HAI definitions.

Evaluating Cognitive Impairment in a Large Health Care System: The Cognition in Primary Care Program

Background

The prevalence of Alzheimer's disease and related disorders (ADRD) is rising. Primary care providers (PCPs) will increasingly be required to play a role in its detection but lack the training to do so.

Objective

To develop a model for cognitive evaluation which is feasible in primary care and evaluate its implementation in a large health system.

Methods

The Cognition in Primary Care Program consists of web-based training together with integrated tools built into the electronic record. We implemented the program among PCPs at 14 clinics in a large health system. We (1) surveyed PCPs to assess the impact of training on their confidence to evaluate cognition, (2) measured the number of cognitive assessments they performed, and (3) tracked the number of patients diagnosed with mild cognitive impairment (MCI).

Results

Thirty-nine PCPs completed the training which covered how to evaluate cognition. Survey response rate from those PCPs was 74%. Six months after the end of the training, they reported confidence in assessing cognition (mean 4.6 on 5-point scale). Cognitive assessments documented in the health record increased from 0.8 per month before the training to 2.5 in the six months after the training. Patients who were newly diagnosed with MCI increased from 4.2 per month before the training to 6.0 per month in the six months after the training.

Conclusions

This model for cognitive evaluation in a large health system was shown to increase cognitive testing and increase diagnoses of MCI. Such improvements are essential for the timely detection of ADRD.

Key Considerations When Developing and Implementing Digital Technology for Early Detection of Dementia-Causing Diseases Among Health Care Professionals: Qualitative Study

BACKGROUND

The World Health Organization (WHO) promotes using digital technologies to accelerate global attainment of health and well-being. This has led to a growth in research exploring the use of digital technology to aid early detection and preventative interventions for dementia-causing diseases such as Alzheimer disease. The opinions and perspectives of health care professionals must be incorporated into the development and implementation of technology to promote its successful adoption in clinical practice.

OBJECTIVE

This study aimed to explore health care professionals' perspectives on the key considerations of developing and implementing digital technologies for the early detection of dementia-causing diseases in the National Health Service (NHS).

METHODS

Health care professionals with patient-facing roles in primary or secondary care settings in the NHS were recruited through various web-based NHS clinical networks. Participants were interviewed to explore their experiences of the current dementia diagnostic practices, views on early detection and use of digital technology to aid these practices, and the challenges of implementing such interventions in health care. An inductive thematic analysis approach was applied to identify central concepts and themes in the interviews, allowing the data to determine our themes. A list of central concepts and themes was applied systematically to the whole data set using NVivo (version 1.6.1; QSR International). Using the constant comparison technique, the researchers moved backward and forward between these data and evolving explanations until a fit was made.

RESULTS

Eighteen semistructured interviews were conducted, with 11 primary and 7 secondary care health care professionals. We identified 3 main categories of considerations relevant to health care service users, health care professionals, and the digital health technology itself. Health care professionals recognized the potential of using digital technology to collect real-time data and the possible benefits of detecting dementia-causing diseases earlier if an effective intervention were available. However, some were concerned about postdetection management, questioning the point of an early detection of dementia-causing diseases if an effective intervention cannot be provided and feared this would only lead to increased anxiety in patients. Health care professionals also expressed mixed opinions on who should be screened for early detection. Some suggested it should be available to everyone to mitigate the chance of excluding those who are not in touch with their health care or are digitally excluded. Others were concerned about the resources that would be required to make the technology available to everyone.

CONCLUSIONS

This study highlights the need to design digital health technology in a way that is accessible to all and does not add burden to health care professionals. Further work is needed to ensure inclusive strategies are used in digital research to promote health equity.

Analysis of age at detection and outcomes of dense unilateral congenital cataract surgery for children on the paediatric cataract register

AIM

Analysis of age at time of detection and surgery of dense unilateral cataract and investigation of best-corrected visual acuity (BCVA) in a nationwide register-based cohort study, based on the routine of maternity ward eye screening.

METHODS

Data were derived from the Paediatric Cataract Register (PECARE). All children (n = 54) diagnosed with dense congenital unilateral cataract between January 2007 and September 2014 who had surgery before 1 year of age, and for whom 5-year follow-up records were available, were included.

RESULTS

The majority, 35/54 (65%), were detected and operated on before age 6 weeks and 30/35 (86%) were referred from maternity wards. Visual acuity (VA) ≥ 0.5 (decimal, 0.3 logMAR) was found in 7/53 (13%) of the cohort at age 5 years; further, 19 children achieved VA ≥ 0.1 (decimal, 1.0 logMAR) (36%) and 19 children VA < 0.05 (decimal, 1.30 logMAR) (36%). Ten-year follow-up records were available for 17/53 (32%) children; 1/17 (6%) achieved VA ≥ 0.5 (decimal, 0.3 logMAR), 4/17 (24%) VA ≥ 0.3-<0.5 (decimal, 0.52-0.30 logMAR), 3/17 (18%) VA ≥ 0.05-0.1 (decimal, 1.30-1.0 logMAR) and 10/17 (59%) VA < 0.05 (decimal, 1.30 logMAR).

CONCLUSION

A total of 90% of the children were detected with cataract within 100 days of birth and 80% were operated on within this period. This study showed better visual acuity in those treated for dense unilateral cataracts than previously reported in an earlier Swedish cohort study.

Computerized Clinical Decision Support Systems for the Early Detection of Sepsis Among Adult Inpatients: Scoping Review

Background

Sepsis is a significant cause of morbidity and mortality worldwide. Early detection of sepsis followed promptly by treatment initiation improves patient outcomes and saves lives. Hospitals are increasingly using computerized clinical decision support (CCDS) systems for the rapid identification of adult patients with sepsis.

Objective

This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of adult inpatients with sepsis.

Methods

The protocol for this scoping review was previously published. A total of 10 electronic databases (MEDLINE, Embase, CINAHL, the Cochrane database, LILACS [Latin American and Caribbean Health Sciences Literature], Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and PQDT [ProQuest Dissertations and Theses]) were comprehensively searched using terms for sepsis, CCDS, and detection to identify relevant studies. Title, abstract, and full-text screening were performed by 2 independent reviewers using predefined eligibility criteria. Data charting was performed by 1 reviewer with a second reviewer checking a random sample of studies. Any disagreements were discussed with input from a third reviewer. In this review, we present the results for adult inpatients, including studies that do not specify patient age.

Results

A search of the electronic databases retrieved 12,139 studies following duplicate removal. We identified 124 studies for inclusion after title, abstract, full-text screening, and hand searching were complete. Nearly all studies (121/124, 97.6%) were published after 2009. Half of the studies were journal articles (65/124, 52.4%), and the remainder were conference abstracts (54/124, 43.5%) and theses (5/124, 4%). Most studies used a single cohort (54/124, 43.5%) or before-after (42/124, 33.9%) approach. Across all 124 included studies, patient outcomes were the most frequently reported outcomes (107/124, 86.3%), followed by sepsis treatment and management (75/124, 60.5%), CCDS usability (14/124, 11.3%), and cost outcomes (9/124, 7.3%). For sepsis identification, the systemic inflammatory response syndrome criteria were the most commonly used, alone (50/124, 40.3%), combined with organ dysfunction (28/124, 22.6%), or combined with other criteria (23/124, 18.5%). Over half of the CCDS systems (68/124, 54.8%) were implemented alongside other sepsis-related interventions.

Conclusions

The current body of literature investigating the implementation of CCDS systems for the early detection of adult inpatients with sepsis is extremely diverse. There is substantial variability in study design, CCDS criteria and characteristics, and outcomes measured across the identified literature. Future research on CCDS system usability, cost, and impact on sepsis morbidity is needed.

International Registered Report Identifier (IRRID)

RR2-10.2196/24899

Are sociodemographic and anthropometric variables effective in screening probable and confirmed sarcopenia in community-dwelling older adults? A cross-sectional study

BACKGROUND

Screening for probable and confirmed sarcopenia using sociodemographic and anthropometric indicators can be a practical, cheap, and effective strategy to identify and treat older people susceptible to this condition.

OBJECTIVES

To identify cutoff points for sociodemographic and anthropometric variables in screening probable and confirmed sarcopenia in community-dwelling older adults.

DESIGN AND SETTING

This was a cross-sectional study of community-dwelling older adults in Araranguá, Santa Catarina, Brazil.

METHODS

Sociodemographic (age, education) and anthropometric (weight, height, body mass index [BMI], waist circumference [WC], and dominant calf circumference [DCC]) factors were considered as predictors. The outcomes were probable sarcopenia (reduction in muscle strength assessed by time ≥ 15 s in the five-time sit-to-stand test) and confirmed sarcopenia (reduction in strength and muscle mass). Receiver operating characteristic curve analysis was used to analyze the ability to track sociodemographic and anthropometric variables for sarcopenia.

RESULTS

In 308 older adults, WC > 91 cm in women and age > 69 years in men were useful in screening for probable sarcopenia. The variables age, weight, BMI, WC, and DCC can be used to screen for sarcopenia in older women and men.

CONCLUSION

Sociodemographic and anthropometric variables are simple and accessible tools for sarcopenia screening in older adults.

Barriers to the cervical cancer screening attendance among Czech women

OBJECTIVE

The main aim of this study was to find specific barriers to cervical cancer screening attendance that Czech women declare. Furthermore, the objective was to find out whether there are differences between women who do and do not attend screening according to sociodemographic characteristics. Finally, we investigated whether women who do not attend the screening differ by sociodemographic characteristics in declaring particular barriers to attendance.

MATERIALS AND METHODS

Data were collected using a representative questionnaire survey. The women were asked about their previous participation in the cervical cancer screening program. Those who did not attend screening in the past 2 years or those who do not (intend to) attend screening regularly were considered non-attendees. The non-attendees were then asked about their reasons for non-attendance in the screening. First, descriptive statistical methods were used to analyze the data. Second, the differences between the different groups of women were analyzed by Pearsons chi-squared independence test.

RESULTS

In the studied sample population (N = 902), 36.7% were considered non-attendees. Statistically significant differences in sociodemographic characteristics (age, education, marital status, household type) were observed between attendees and non-attendees. The three most common reasons for non-attendance were: "I do not experience any symptoms", "fear of cancer diagnosis", and "fear of the examination procedure". Almost no differences in sociodemographic characteristics in the declaration of particular barriers to attendance were found.

CONCLUSION

We observed differences between women who attended and those who did not attend the screening. However, sociodemographic characteristics do not play an important role once a woman decides not to attend the screening. Therefore, it is essential to communicate cancer prevention throughout the spectrum of Czech women.

Comparison of the quick Sepsis-related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study

BACKGROUND

Quick Sepsis-related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation.

AIM

To compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards.

METHODS

A retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in-hospital mortality with two secondary composite outcomes.

RESULTS

Among 2940 patients with suspected infection, 217 (7.38%) died in-hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in-hospital mortality and secondary outcomes. The area under the receiver-operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74-0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61-0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29-16.75) while it was 0 days for qSOFA (IQR: 0-2.58).

CONCLUSIONS

The ASP demonstrated both greater prognostic accuracy and earlier warning for in-hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

Use and Evaluation of Computerized Clinical Decision Support Systems for Early Detection of Sepsis in Hospitals: Protocol for a Scoping Review

BACKGROUND

Sepsis is a leading cause of death in hospitals, with high associated costs for both patients and health care systems worldwide. Early detection followed by timely intervention is critical for successful sepsis management and, hence, can save lives. Health care institutions are increasingly leveraging clinical data captured in electronic health records for the development of computerized clinical decision support (CCDS) systems aimed at enhancing the early detection of sepsis. However, a comprehensive evidence base regarding sepsis CCDS systems to inform clinical practice, research, and policy is currently lacking.

OBJECTIVE

This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for early detection of sepsis in hospitals.

METHODS

The methodology for conducting scoping reviews presented by the Joanna Briggs Institute Reviewer's Manual and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) will be used and adapted as guides. A comprehensive literature search of 10 electronic databases will be conducted to identify all empirical quantitative and qualitative studies that investigate the use of CCDS systems for early detection of sepsis in hospitals. Detailed inclusion and exclusion criteria have been developed. Two reviewers will independently screen all articles based on these criteria. Any discrepancies will be resolved through discussion and further review by a third researcher if required.

RESULTS

Electronic database searches have retrieved 12,139 references after removing 10,051 duplicates. As of the submission date of this protocol, we have completed the title and abstract screening. A total of 372 references will be included for full-text screening. Only 15.9% (59/372) of these studies were focused on children: 11.0% (41/372) for pediatric and 4.8% (18/372) for neonatal patients. The scoping review and the manuscript will be completed by December 2020.

CONCLUSIONS

Results of this review will guide researchers in determining gaps and shortcomings in the current evidence base for CCDS system use and evaluation in the early detection of sepsis. The findings will be shared with key stakeholders in clinical care, research, policy, and patient advocacy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/24899.

Can point-of-care testing shorten hospitalization length of stay? An exploratory investigation of infectious agents using regression modelling

This retrospective study investigates the potential benefits from the introduction of point-of-care tests for rapid diagnosis of infectious diseases. We analysed a sample of 441 hospitalized patients who had received a final diagnosis related to 18 pathogenic agents. These pathogens were mostly detected by standard tests but were also detectable by point-of-care testing. The length of hospital stay was partitioned into pre- and post-laboratory diagnosis stages. Regression analysis and elementary queueing theory were applied to estimate the impact of quick diagnosis on the mean length of stay and the utilization of healthcare resources. The analysis suggests that eliminating the pre-diagnosis times through point-of-care testing could shorten the mean length of hospital stay for infectious diseases by up to 34 per cent and result in an equal reduction in bed occupancy and other resources. Regression and other more sophisticated models can aid the financing decision-making of pilot point-of-care laboratories in healthcare systems.

The serological diagnosis of rheumatoid arthritis: antibodies to citrullinated antigens

BACKGROUND

This article provides an overview of modern serological diagnostic testing for rheumatoid arthritis (RA) involving the detection of antibodies against citrullinated peptides/proteins (ACPA). Recommendations are also given for differential diagnosis and sequential testing in rheumatoid arthritis, with a view towards improving early diagnosis, so that irreparable joint damage can be avoided.

METHODS

Selective literature research, with consideration of the authors' own publications.

RESULTS

Two different, adequately evaluated testing systems, involving the detection of anti-CCP antibodies and of anti-MCV antibodies, are now commercially available and enable routine, relatively highly specific diagnostic testing for RA. Two point-of-care tests (POCT) for the early diagnosis of RA constitute the latest development in serologic diagnostic testing.

CONCLUSIONS

The two ACPA assays now on the market are equally useful for the diagnosis of rheumatoid arthritis. The correlation between RA disease activity and stratification with ACPA has only been demonstrated to date through the detection of anti-MCV antibodies.

The papilla as screening parameter for early diagnosis of glaucoma

INTRODUCTION

In the industrialized countries 67 million people suffer from glaucoma, which represents the third most common cause of blindness and thus has a high economic impact. Early diagnosis of glaucoma, which does not necessarily involve raised intraocular pressure, is essential because by the time the patient notices functional impairment the damage is irreversible. Early treatment can decrease the rate of blindness 20 years later by about 50%.

METHODS

Selective literature review and clinical investigation of early glaucoma detection and of screening methods.

RESULTS

Currently, no evidence-based recommendations for glaucoma screening can be found in the literature. No single method or combination of screening procedures can be recommended unambiguously on economic grounds.

DISCUSSION

From the clinical perspective sensitive, specific, and cost-effective glaucoma screening seems feasible. The high-risk group would need to be defined on the basis of age and family history. A two-stage screening process would then have to be established with initial computer-supported telemedical sorting followed by telemedical ophthalmological diagnosis of cases selected for clarification.