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Foster M, Presseau J, McCleary N, Carroll K, McIntyre L, Hutton B, Brehaut J. Audit and feedback to improve laboratory test and transfusion ordering in critical care: a systematic review. Implement Sci 2020; 15:46. [PMID: 32560666 PMCID: PMC7303577 DOI: 10.1186/s13012-020-00981-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/12/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Laboratory tests and transfusions are sometimes ordered inappropriately, particularly in the critical care setting, which sees frequent use of both. Audit and Feedback (A&F) is a potentially useful intervention for modifying healthcare provider behaviors, but its application to the complex, team-based environment of critical care is not well understood. We conducted a systematic review of the literature on A&F interventions for improving test or transfusion ordering in the critical care setting. METHODS Five databases, two registries, and the bibliographies of relevant articles were searched. We included critical care studies that assessed the use of A&F targeting healthcare provider behaviors, alone or in combination with other interventions to improve test and transfusion ordering, as compared to historical practice, no intervention, or another healthcare behaviour change intervention. Studies were included only if they reported laboratory test or transfusion orders, or the appropriateness of orders, as outcomes. There were no restrictions based on study design, date of publication, or follow-up time. Intervention characteristics and absolute differences in outcomes were summarized. The quality of individual studies was assessed using a modified version of the Effective Practice and Organisation of Care Cochrane Review Group's criteria. RESULTS We identified 16 studies, including 13 uncontrolled before-after studies, one randomized controlled trial, one controlled before-after study, and one controlled clinical trial (quasi-experimental). These studies described 17 interventions, mostly (88%) multifaceted interventions with an A&F component. Feedback was most often provided in a written format only (41%), more than once (53%), and most often only provided data aggregated to the group-level (41%). Most studies saw a change in the hypothesized direction, but not all studies provided statistical analyses to formally test improvement. Overall study quality was low, with studies often lacking a concurrent control group. CONCLUSIONS Our review summarizes characteristics of A&F interventions implemented in the critical care context, points to some mechanisms by which A&F might be made more effective in this setting, and provides an overview of how the appropriateness of orders was reported. Our findings suggest that A&F can be effective in the context of critical care; however, further research is required to characterize approaches that optimize the effectiveness in this setting alongside more rigorous evaluation methods. TRIAL REGISTRATION PROSPERO CRD42016051941.
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Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON K1N 6N5 Canada
| | - Nicola McCleary
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Ottawa Hospital Research Institute, Knowledge Synthesis Unit, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Jamie Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
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Franklin BJ, Gandhi TK, Bates DW, Huancahuari N, Morris CA, Pearson M, Bass MB, Goralnick E. Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Qual Saf 2020; 29:1-2. [PMID: 32265256 DOI: 10.1136/bmjqs-2019-009911] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite significant advances, patient safety remains a critical public health concern. Daily huddles-discussions to identify and respond to safety risks-have been credited with enhancing safety culture in operationally complex industries including aviation and nuclear power. More recently, huddles have been endorsed as a mechanism to improve patient safety in healthcare. This review synthesises the literature related to the impact of hospital-based safety huddles. METHODS We conducted a systematic review of peer-reviewed literature related to scheduled, multidisciplinary, hospital-based safety huddles through December 2019. We screened for studies (1) in which huddles were the primary intervention being assessed and (2) that measured the huddle programme's apparent impact using at least one quantitative metric. RESULTS We identified 1034 articles; 24 met our criteria for review, of which 19 reflected unit-based huddles and 5 reflected hospital-wide or multiunit huddles. Of the 24 included articles, uncontrolled pre-post comparison was the prevailing study design; we identified only two controlled studies. Among the 12 unit-based studies that provided complete measures of statistical significance for reported outcomes, 11 reported statistically significant improvement among some or all outcomes. The objectives of huddle programmes and the language used to describe them varied widely across the studies we reviewed. CONCLUSION While anecdotal accounts of successful huddle programmes abound and the evidence we reviewed appears favourable overall, high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles, particularly at the hospital-wide level, is in its earliest stages. Additional rigorous research-especially focused on huddle programme design and implementation fidelity-would enhance the collective understanding of how huddles impact patient safety and other targeted outcomes. We propose a taxonomy and standardised reporting measures for future huddle-related studies to enhance comparability and evidence quality.
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Affiliation(s)
- Brian J Franklin
- University of Michigan Medical School, Ann Arbor, Michigan, USA .,Harvard Business School, Boston, Massachusetts, USA
| | | | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nadia Huancahuari
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Charles A Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | - Michelle Beth Bass
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Märtson AG, Sturkenboom MGG, Stojanova J, Cattaneo D, Hope W, Marriott D, Patanwala AE, Peloquin CA, Wicha SG, van der Werf TS, Tängdén T, Roberts JA, Neely MN, Alffenaar JWC. How to design a study to evaluate therapeutic drug monitoring in infectious diseases? Clin Microbiol Infect 2020; 26:1008-1016. [PMID: 32205294 DOI: 10.1016/j.cmi.2020.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM. OBJECTIVES We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM. SOURCES The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM. CONTENT This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design. IMPLICATIONS This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.
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Affiliation(s)
- A-G Märtson
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - M G G Sturkenboom
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - J Stojanova
- Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
| | - D Cattaneo
- ASST Fatebenefratelli Sacco University Hospital, Unit of Clinical Pharmacology, Department of Laboratory Medicine, Milan, Italy
| | - W Hope
- University of Liverpool, Antimicrobial Pharmacodynamics and Therapeutics, Liverpool, UK; Royal Liverpool Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - D Marriott
- St Vincent's Hospital, Sydney, Australia
| | - A E Patanwala
- The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S G Wicha
- University of Hamburg, Department of Clinical Pharmacy, Institute of Pharmacy, Hamburg, Germany
| | - T S van der Werf
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, the Netherlands
| | - T Tängdén
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - M N Neely
- Children's Hospital of Los Angeles, Laboratory of Applied Pharmacokinetics and Bioinformatics, Los Angeles, CA, USA
| | - J-W C Alffenaar
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands; The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2020; 6:87-94. [PMID: 32133154 PMCID: PMC7056349 DOI: 10.1136/bmjstel-2018-000370] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 01/17/2023]
Abstract
Simulation can offer researchers access to events that can otherwise not be directly observed, and in a safe and controlled environment. How to use simulation for the study of how to improve the quality and safety of healthcare remains underexplored, however. We offer an overview of simulation-based research (SBR) in this context. Building on theory and examples, we show how SBR can be deployed and which study designs it may support. We discuss the challenges of simulation for healthcare improvement research and how they can be tackled. We conclude that using simulation in the study of healthcare improvement is a promising approach that could usefully complement established research methods.
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Affiliation(s)
- Guillaume Lamé
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
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Santaeugènia SJ, Mas MA, Tarazona-Santabalbina FJ, García-Lázaro M, Alventosa AM, Gutiérrez-Benito A, Monterde A, Cunill J. Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways. Geriatr Gerontol Int 2020; 20:366-372. [PMID: 32072727 DOI: 10.1111/ggi.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/30/2019] [Accepted: 01/12/2020] [Indexed: 01/24/2023]
Abstract
AIM The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.
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Affiliation(s)
- Sebastià J Santaeugènia
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,Chronic Care Program, Ministry of Health, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic - University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain
| | - Miquel A Mas
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,RE-FiT bcn Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - Francisco J Tarazona-Santabalbina
- Department of Geriatric Medicine, Hospital Universitario de la Ribera, Valencia, Spain.,Valencia Catholic University Saint Vincent Martyr, Valencia, Spain
| | - Manuela García-Lázaro
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Ana Maria Alventosa
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Alícia Gutiérrez-Benito
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Albert Monterde
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Joan Cunill
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
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Kandiyali R, Thom H, Young AE, Greenwood R, Welton NJ. Cost-effectiveness and value of information analysis of a low-friction environment following skin graft in patients with burn injury. Pilot Feasibility Stud 2020; 6:8. [PMID: 32021697 PMCID: PMC6995137 DOI: 10.1186/s40814-019-0543-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 12/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with burn injuries may receive a skin graft to achieve healing in a timely manner. However, in around 7% of cases, the skin graft is lost (fails to attach to the wound site) and a re-grafting procedure is necessary. It has been hypothesised that low-friction (smooth, more slippery) bedding may reduce the risk of skin-graft loss. A before and after feasibility study comparing low-friction with standard bedding in skin-grafted patients was conducted in order to collect proof of concept data. The resulting relative risk on the primary outcome (number of patients with skin graft failure) for the non-randomised study provided no evidence of effect but had a large standard error. The aim of this study is to see if an appropriately powered randomised control trial would be worthwhile. METHODS A probabilistic decision-analytic model was constructed to compare low-friction bedding to standard care in a population of burn patients who have undergone skin grafting. Results from the before and after study were used as model inputs. The sensitivity of results to bias in the relative risk of graft loss was conducted. Low-friction bedding is considered optimal if expected incremental net benefit (INB) is positive. Uncertainty is assessed using cost-effectiveness acceptability curves. Expected Value of Perfect Partial Information (EVPPI) provides an upper bound for the potential net health benefits of new research for given model input. RESULTS At a willingness to pay threshold of £20,000 per QALY, INB = £151 (95% Credible Interval (CrI) -142 to 814), marginally favouring low-friction bedding but with high uncertainty (probability of being cost-effective 70.5%). Expected value of perfect information (EVPI) per patient was £20.29, which results in a population EVPI of £174,765 over a 10-year lifetime for the technology (based on 1000 patients per year who would benefit from the intervention). The parameter contributing most to the uncertainty was the inpatient care cost, i.e. information that could be obtained from the audit of practice and without an expensive trial. These findings were robust to a wide-range of assumptions about the potential bias due to the observational nature of the comparative evidence. CONCLUSIONS Our study results suggest that an RCT (randomised controlled trial) is unlikely to be worthwhile, but there may be value in a study to estimate the re-graft rates and associated costs in this population.
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Affiliation(s)
- Rebecca Kandiyali
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amber E. Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Nicky J. Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Franklin M, Lomas J, Richardson G. Conducting Value for Money Analyses for Non-randomised Interventional Studies Including Service Evaluations: An Educational Review with Recommendations. PHARMACOECONOMICS 2020; 38:665-681. [PMID: 32291596 PMCID: PMC7319287 DOI: 10.1007/s40273-020-00907-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This article provides an educational review covering the consideration of conducting ‘value for money’ analyses as part of non-randomised study designs including service evaluations. These evaluations represent a vehicle for producing evidence such as value for money of a care intervention or service delivery model. Decision makers including charities and local and national governing bodies often rely on evidence from non-randomised data and service evaluations to inform their resource allocation decision-making. However, as randomised data obtained from randomised controlled trials are considered the ‘gold standard’ for assessing causation, the use of this alternative vehicle for producing an evidence base requires careful consideration. We refer to value for money analyses, but reflect on methods associated with economic evaluations as a form of analysis used to inform resource allocation decision-making alongside a finite budget. Not all forms of value for money analysis are considered a full economic evaluation with implications for the information provided to decision makers. The type of value for money analysis to be conducted requires considerations such as the outcome(s) of interest, study design, statistical methods to control for confounding and bias, and how to quantify and describe uncertainty and opportunity costs to decision makers in any resulting value for money estimates. Service evaluations as vehicles for producing evidence present different challenges to analysts than what is commonly associated with research, randomised controlled trials and health technology appraisals, requiring specific study design and analytic considerations. This educational review describes and discusses these considerations, as overlooking them could affect the information provided to decision makers who may make an ‘ill-informed’ decision based on ‘poor’ or ‘inaccurate’ information with long-term implications. We make direct comparisons between randomised controlled trials relative to non-randomised data as vehicles for assessing causation; given ‘gold standard’ randomised controlled trials have limitations. Although we use UK-based decision makers as examples, we reflect on the needs of decision makers internationally for evidence-based decision-making specific to resource allocation. We make recommendations based on the experiences of the authors in the UK, reflecting on the wide variety of methods available, used as documented in the empirical literature. These methods may not have been fully considered relevant to non-randomised study designs and/or service evaluations, but could improve and aid the analysis conducted to inform the relevant value for money decision problem.
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Affiliation(s)
- Matthew Franklin
- Health Economics and Decision Science (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, West Court, 1 Mappin Street, Sheffield, S1 4DT UK
| | - James Lomas
- Centre for Health Economics, University of York, Heslington, York UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York UK
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Katelaris AL, Andrews RM, McAnulty J. The impact of rapid molecular diagnostic testing for respiratory viruses on outcomes for emergency department patients. Med J Aust 2019; 212:94-94.e1. [PMID: 31821557 DOI: 10.5694/mja2.50443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anthea L Katelaris
- Health Protection NSW, Sydney, NSW.,National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
| | - Ross M Andrews
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT.,Menzies School of Health Research, Charles Darwin University, Tiwi, NT
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Ng JH, Song YL, Yap AUJ. Effects of bicuspid extractions and incisor retraction on upper airway of Asian adults and late adolescents: A systematic review. J Oral Rehabil 2019; 46:1071-1087. [PMID: 31281971 PMCID: PMC6851666 DOI: 10.1111/joor.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/23/2019] [Accepted: 06/28/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This systematic review aimed to assess the effects of bicuspid extractions and incisor retraction on airway dimension, hyoid position and breathing of adults and late adolescents. METHODS The review was conducted according to PRISMA guidelines. Eight databases including PubMed, EMBASE, Web of Science and Scopus were searched to August 2018. Minimum age of participants was 16 years. The intervention was dual-arch bicuspid extractions with incisor retraction. Outcomes were airway dimension, hyoid position and breathing assessment. RESULTS All nine publications meeting inclusion criteria were from Asia. They were divided into three Asian subregions. All East Asian lateral cephalometric studies reported anteroposterior airway narrowing at the oropharynx and sometimes the hypopharynx. However, the narrowing was small, comparable to measurement errors, and highly variable. Two out of three East Asian computed tomography (CT) studies described reductions in airway dimensions. The single functional breathing study showed increased simulated flow resistance after incisor retraction in East Asians. South Asian studies had mixed findings, with some reporting significant airway narrowing. The single study from West Asia found no significant airway or hyoid changes. CONCLUSIONS Airway response to bicuspid extractions and incisor retraction varied substantially when assessed with cephalometry. CT measurements present larger effect sizes and smaller variations, providing stronger evidence of airway narrowing. Orthodontic extractions for incisor retraction may be more frequently indicated in Asia, and East Asians seem particularly susceptible to airway narrowing and postero-inferior hyoid movement with incisor retraction. Better designed CT studies are needed for confirmation due to small effect size and large variability.
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Affiliation(s)
- Jing Hao Ng
- National Dental Centre SingaporeSingaporeSingapore
| | - Yi Lin Song
- National Dental Centre SingaporeSingaporeSingapore
| | - Adrian U. J. Yap
- National Dental Centre SingaporeSingaporeSingapore
- Department of Dentistry, Ng Teng Fong General HospitalNational University Health SystemSingaporeSingapore
- Faculty of DentistryNational University of SingaporeSingaporeSingapore
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Mackie S, Moy F, Kamona S, Jones P. Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars. Emerg Med Australas 2019; 32:25-32. [PMID: 31257718 DOI: 10.1111/1742-6723.13329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present study investigated the impact of introducing C-MAC videolaryngoscopy as the standard method of visualising glottic structures on first-pass intubation success of emergency medicine (EM) registrars in a large tertiary academic hospital in New Zealand. METHODS In this retrospective cohort study, all patients receiving attempted orotracheal intubation in Auckland City Hospital ED 1 year prior to and 1 year after the introduction of C-MAC videolaryngoscopy were compared. The primary outcome was first-pass intubation success rates by EM registrars. Secondary outcomes were first-pass success rates by all intubators, and incidence of any complication of intubation. RESULTS There were 163 intubations by EM registrars from June 2015 to August 2017. There was a clinically important and statistically significant improvement in first-pass success from 59.2% (95% confidence interval [CI] 44.1-68.8%) to 85.1% (95% CI 76.0-91.2%, P < 0.001) after the introduction of C-MAC. In multivariate analysis, the independent predictors of success were: Airway Not Predicted Difficult, odds ratio (OR) 2.49 (95% CI 1.06-5.85, P = 0.037); and use of videolaryngoscope, OR 4.49 (95% CI 1.85-10.91, P = 0.001). Overall, complications of intubation improved significantly after introduction of C-MAC (28.9%, 95% CI 19.9-40.0% prior to C-MAC introduction; 16.1%, 95% CI 9.7-25.3% after; P = 0.048). CONCLUSION This is the first published study specifically addressing EM registrar intubation success rates in New Zealand, adding to the existing body of data suggesting that videolaryngoscopy may improve success rates for novice intubators.
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Affiliation(s)
- Stephanie Mackie
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Fen Moy
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Sinan Kamona
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
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Trubey R, Huang C, Lugg-Widger FV, Hood K, Allen D, Edwards D, Lacy D, Lloyd A, Mann M, Mason B, Oliver A, Roland D, Sefton G, Skone R, Thomas-Jones E, Tume LN, Powell C. Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review. BMJ Open 2019; 9:e022105. [PMID: 31061010 PMCID: PMC6502038 DOI: 10.1136/bmjopen-2018-022105] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children. DESIGN Systematic review. DATA SOURCES British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018. ELIGIBILITY CRITERIA We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered. DATA EXTRACTION AND SYNTHESIS Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale. RESULTS 36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration. CONCLUSION There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base. PROSPERO REGISTRATION NUMBER CRD42015015326.
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Affiliation(s)
- Rob Trubey
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Chao Huang
- Hull York Medical School, University of Hull, Hull, UK
| | | | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Davina Allen
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Dawn Edwards
- Department of Paediatrics, Morriston Hospital, Swansea, UK
| | - David Lacy
- Wirral University Teaching Hospital, Wirral, UK
| | - Amy Lloyd
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mala Mann
- University Library Services, Cardiff University, Cardiff, UK
| | | | - Alison Oliver
- Department of Paediatric Intensive Care, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Gerri Sefton
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Richard Skone
- Department of Paediatric Intensive Care, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | | | - Lyvonne N Tume
- Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK
| | - Colin Powell
- Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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63
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Smith S, Carlton E. Introducing quality improvement to the Emergency Medicine Journal. Emerg Med J 2019; 36:258-263. [PMID: 31015212 DOI: 10.1136/emermed-2019-208609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Simon Smith
- Emergency Department, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Edward Carlton
- Emergency Department, North Bristol NHS Trust, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
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64
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Platter MEM, Kurvers RAJ, Janssen L, Verweij MMJ, Barten DG. The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study. Am J Emerg Med 2019; 38:191-197. [PMID: 30745074 DOI: 10.1016/j.ajem.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Crowding is a growing concern in general and pediatric Emergency Departments (EDs). The Emergency Care Access Point (ECAP) - a collaboration between general practitioners and the ED - has been established to reduce the number of self-referrals and non-urgent ED visits. The aim of this study was to determine the impact of an ECAP on pediatric attendances in the ED. METHODS Retrospective analysis of 3997 pediatric patients who visited the ED of a regional teaching hospital in the Netherlands, one year before and one year after the implementation of an ECAP. Patient characteristics, presented complaints and diagnoses, throughput times, and follow-up between the study groups were compared, both during office hours and after-hours. RESULTS After ECAP implementation, a 16.3% reduction in pediatric ED visits was observed. ECAP implementation was associated with a decline in self-referrals by 97.2%. Presented complaints, ED diagnoses and acuity were similar pre- and post-ECAP. However, consultations and follow-up were required more frequently. The admission rate during nights increased (49.3% versus 64.0%). Overall admission rates were similar. CONCLUSIONS The implementation of an ECAP was associated with a reduction of pediatric ED use, including a considerable but expected decline in pediatric self-referrals. Patient acuity pre- and post-ECAP was similar. Our results suggest that this primary care intervention might help reduce the workload in a pediatric ED. Future studies are warranted to further investigate this hypothesis and to evaluate the impact of an ECAP in other healthcare settings. These future efforts need to include patient oriented outcomes.
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Affiliation(s)
- Mireille E M Platter
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands; Department of Pediatrics, VieCuri Medical Center, Venlo, the Netherlands
| | - Roel A J Kurvers
- Department of Pediatrics, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Loes Janssen
- Department of Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | | | - Dennis G Barten
- Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands.
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65
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Torri E, Rigoni M, Dorigoni S, Peterlana D, Cozzio S, Nollo G, Spagnolli W. A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy. PLoS One 2019; 14:e0211548. [PMID: 30703156 PMCID: PMC6354996 DOI: 10.1371/journal.pone.0211548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC). METHODS The SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient's admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model. RESULTS We managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01). CONCLUSIONS Redesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances.
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Affiliation(s)
- Emanuele Torri
- Autonomous Province of Trento, Dipartimento Salute e Politiche Sociali, Trento, Italy
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
| | - Marta Rigoni
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
- * E-mail:
| | - Stefania Dorigoni
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Dimitri Peterlana
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Susanna Cozzio
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
| | - Giandomenico Nollo
- Fondazione Bruno Kessler, Healthcare Research and Innovation Program – HTA Unit, Trento, Italy
- Università degli Studi di Trento, Dipartimento di Ingegneria Industriale – BIOtech Labs, Trento, Italy
| | - Walter Spagnolli
- Azienda Provinciale per i Servizi Sanitari, Ospedale “S. Chiara” Trento, U.O. Medicina Interna, Trento, Italy
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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67
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Wong DC, Knight J, Birks J, Tarassenko L, Watkinson PJ. Impact of Electronic Versus Paper Vital Sign Observations on Length of Stay in Trauma Patients: Stepped-Wedge, Cluster Randomized Controlled Trial. JMIR Med Inform 2018; 6:e10221. [PMID: 30381284 PMCID: PMC6236204 DOI: 10.2196/10221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/22/2022] Open
Abstract
Background Electronic recording of vital sign observations (e-Obs) has become increasingly prevalent in hospital care. The evidence of clinical impact for these systems is mixed. Objective The objective of our study was to assess the effect of e-Obs versus paper documentation (paper) on length of stay (time between trauma unit admission and “fit to discharge”) for trauma patients. Methods A single-center, randomized stepped-wedge study of e-Obs against paper was conducted in two 26-bed trauma wards at a medium-sized UK teaching hospital. Randomization of the phased intervention order to 12 study areas was computer generated. The primary outcome was length of stay. Results A total of 1232 patient episodes were randomized (paper: 628, e-Obs: 604). There were 37 deaths in hospital: 21 in the paper arm and 16 in the e-Obs arm. For discharged patients, the median length of stay was 5.4 (range: 0.2-79.0) days on the paper arm and 5.6 (range: 0.1-236.7) days on the e-Obs arm. Competing risks regression analysis for time to discharge showed no difference between the treatment arms (subhazard ratio: 1.05; 95% CI 0.82-1.35; P=.68). A greater proportion of patient episodes contained an Early Warning Score (EWS) ≥3 using the e-Obs system than using paper (subhazard ratio: 1.63; 95% CI 1.28-2.09; P<.001). However, there was no difference in the time to the subsequent observation, “escalation time” (hazard ratio 1.05; 95% CI 0.80-1.38; P=.70). Conclusions The phased introduction of an e-Obs documentation system was not associated with a change in length of stay. A greater proportion of patient episodes contained an EWS≥3 using the e-Obs system, but this was not associated with a change in “escalation time.” Trial Registration ISRCTN Registry ISRCTN91040762; http://www.isrctn.com/ISRCTN91040762 (Archived by WebCite at http://www.webcitation.org/72prakGTU)
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Affiliation(s)
- David Cw Wong
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Julia Knight
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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24-hour access outpatient clinic for patients with exacerbation of chronic disease: a before-after cohort study of differences in acute healthcare utilisation. BMC Health Serv Res 2018; 18:663. [PMID: 30153833 PMCID: PMC6114062 DOI: 10.1186/s12913-018-3475-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/16/2018] [Indexed: 11/16/2022] Open
Abstract
Background Chronic diseases are becoming more common due to an increasing ageing population. Patients with chronic conditions managed in outpatient clinics account for a large share of healthcare costs. We developed a 24-h access outpatient clinic offering 24-h telephone support and triaged access to the hospital for patients with acute exacerbation of four selected chronic diseases. The aim of this study was to conduct a 1-year before-after study of the acute healthcare utilisation in patients offered the 24-h access outpatient clinic intervention. Methods The study was conducted as an observational register-based cohort study. Data from the patient administrative register and the Danish National Health Service Register were extracted 12 months before and 12 months after implementation of the 24-h access intervention. Patients with chronic obstructive pulmonary disease, chronic liver disease, inflammatory bowel disease and heart failure managed in hospital outpatient clinics were enrolled in the study. Differences in healthcare utilisation were analysed for all patients, including the subgroup of high-risk patients with at least one acute admission in the year before enrolment. Results Length-of-stay remained unchanged for all diagnostic groups, except for patients with heart failure in whom a statistically significant reduction was observed. Statistically significant reductions of length of stay and acute admissions were observed in all high-risk groups, except for patients with chronic liver disease. A statistically significant reduction in the number of contacts to out-of-hours primary care was seen in patients with chronic obstructive pulmonary disease, whereas the level remained unchanged in the other diagnostic groups. Similar patterns were also seen in high-risk patients. Conclusions The 24-h access outpatient clinic did not increase the use of acute healthcare services inpatients with chronic disease. Significant reductions in hospital utilisation were seen in high-risk patients. These preliminary results should be interpreted with caution due to the observational before-after design of the study.
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69
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De Freitas L, Goodacre S, O’Hara R, Thokala P, Hariharan S. Interventions to improve patient flow in emergency departments: an umbrella review. Emerg Med J 2018; 35:626-637. [DOI: 10.1136/emermed-2017-207263] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 05/28/2018] [Accepted: 06/03/2018] [Indexed: 01/08/2023]
Abstract
ObjectivesPatient flow and crowding are two major issues in ED service improvement. A substantial amount of literature exists on the interventions to improve patient flow and crowding, making it difficult for policymakers, managers and clinicians to be familiar with all the available literature and identify which interventions are supported by the evidence. This umbrella review provides a comprehensive analysis of the evidence from existing quantitative systematic reviews on the interventions that improve patient flow in EDs.MethodsAn umbrella review of systematic reviews published between 2000 and 2017 was undertaken. Included studies were systematic reviews and meta-analyses of quantitative primary studies assessing an intervention that aimed to improve ED throughput.ResultsThe search strategy yielded 623 articles of which 13 were included in the umbrella review. The publication dates of the systematic reviews ranged from 2006 to 2016. The 13 systematic reviews evaluated 26 interventions: full capacity protocols, computerised provider order entry, scribes, streaming, fast track and triage. Interventions with similar characteristics were grouped together to produce the following categories: diagnostic services, assessment/short stay units, nurse-directed interventions, physician-directed interventions, administrative/organisational and miscellaneous. The statistical evidence from 14 primary randomised controlled trials (RCTs) was evaluated to determine if correlation or clustering of observations was considered. Only the fast track intervention had moderate evidence to support its use but the RCTs that assessed the intervention did not use statistical tests that considered correlation.ConclusionsOverall, the evidence supporting the interventions to improve patient flow is weak. Only the fast track intervention had moderate evidence to support its use but correlation/clustering was not taken into consideration in the RCTs examining the intervention. Failure to consider the correlation of the data in the primary studies could result in erroneous conclusions of effectiveness.
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70
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Ngo H, Forero R, Mountain D, Fatovich D, Man WN, Sprivulis P, Mohsin M, Toloo S, Celenza A, Fitzgerald G, McCarthy S, Hillman K. Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013. PLoS One 2018; 13:e0193902. [PMID: 29538401 PMCID: PMC5851625 DOI: 10.1371/journal.pone.0193902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/22/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. METHODS A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. FINDINGS There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most 'crowded' ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. CONCLUSIONS The FHR had a consistent effect on 'flow' measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.
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Affiliation(s)
- Hanh Ngo
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Roberto Forero
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - David Mountain
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Sir Charles Gairdner Hospital, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Daniel Fatovich
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency, University of Western Australia, Nedlands, Perth, WA, Australia
| | - Wing Nicola Man
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
| | - Peter Sprivulis
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Mohammed Mohsin
- Psychiatry Research and Teaching Unit, SWSLHD, NSW Health, Liverpool, Sydney, NSW, Australia
- School of Psychiatry, Faculty of Medicine, UNSW, Kensington, Sydney, NSW, Australia
| | - Sam Toloo
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Nedlands, Perth, WA, Australia
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
| | - Gerard Fitzgerald
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Sally McCarthy
- Australasian College for Emergency Medicine, West Melbourne, Melbourne, VIC, Australia
- Emergency Care Institute, NSW Agency for Clinical Innovation, Chatswood, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Randwick, Sydney, NSW Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, UNSW Australia, SWS Clinical School, Liverpool, Sydney, NSW, Australia
- Ingham Institute for Applied Research. Liverpool Hospital, Liverpool, Sydney, NSW, Australia
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Park SH, Han K. Methodologic Guide for Evaluating Clinical Performance and Effect of Artificial Intelligence Technology for Medical Diagnosis and Prediction. Radiology 2018; 286:800-809. [DOI: 10.1148/radiol.2017171920] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Seong Ho Park
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea (S.H.P.); and Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.)
| | - Kyunghwa Han
- From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea (S.H.P.); and Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, South Korea (K.H.)
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72
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Albalawi Z, Laffin M, Gramlich L, Senior P, McAlister FA. Enhanced Recovery After Surgery (ERAS ®) in Individuals with Diabetes: A Systematic Review. World J Surg 2018; 41:1927-1934. [PMID: 28321553 DOI: 10.1007/s00268-017-3982-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prevalence of diabetes in surgical patients is 10-40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation. METHODS MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials. SELECTION CRITERIA Randomized controlled trials (RCT) looking at individuals with diabetes undergoing surgery randomized to ERAS® or conventional care. Non-randomized controlled trials, controlled before-after studies, interrupted time series, and cohort studies with concurrent controls were also considered. Two authors independently screened studies. RESULTS The electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS®, did not include patients with diabetes, or used an uncontrolled observational design. CONCLUSIONS To date, the effects of ERAS® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.
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Affiliation(s)
- Zaina Albalawi
- Department of Medicine, University of Alberta, Edmonton, Canada. .,Endocrinology and Metabolism, Alberta Health Services, Edmonton, Canada.
| | - Michael Laffin
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada.,Gastroenterology, University of Alberta, Edmonton, Canada
| | - Peter Senior
- Department of Medicine, University of Alberta, Edmonton, Canada.,Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Department of Medicine, University of Alberta, Edmonton, Canada.,General Internal Medicine, University of Alberta, Edmonton, Canada
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Assessing a population-level policy intervention seeking to avert in-hospital clinical deterioration. Resuscitation 2017; 121:A8-A9. [PMID: 28964801 DOI: 10.1016/j.resuscitation.2017.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 11/23/2022]
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Perrin G, Korb-Savoldelli V, Karras A, Danchin N, Durieux P, Sabatier B. Cardiovascular risk associated with high sodium-containing drugs: A systematic review. PLoS One 2017; 12:e0180634. [PMID: 28683120 PMCID: PMC5500347 DOI: 10.1371/journal.pone.0180634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/19/2017] [Indexed: 11/27/2022] Open
Abstract
Background Excess dietary sodium is associated with increased blood pressure (BP). Some drugs are associated with high sodium intake (in particular effervescent tablets), but the cardiovascular risk associated with such high sodium-containing drugs (HSCD) is largely underevaluated. Objectives To summarize the evidence for a potential cardiovascular risk associated with exposure to HSCD, and to highlight possible risk factors associated with this iatrogenic issue; in general and/or specific populations. Methods We conducted a systematic review, by searching electronic databases including MEDLINE, EMBASE, Web of Science, CENTRAL and grey literature between 1960 and 2015. We included studies that reported modification of cardiovascular parameters or incidence/prevalence of cardiovascular outcomes, between a group of subjects exposed to HSCD relative to a non-exposed group. The threshold used to identify HSCD was 391 mg/day. We did not consider studies evaluating exposure to sodium as an active ingredient or those focusing on dialysis solutions or enteral/parenteral nutrition. Study quality was assessed using the EPHPP tool. Results A total of eight studies met our inclusion criteria. Four reported results for short-term exposure to HSCD (≤ 7 days) on BP fluctuations. One study reported an elevation of BP (associated sodium intake: 1,656 mg/day). Four studies evaluated a long-term exposure (≥ 2 years or discontinuation of a chronic treatment). Two studies reported iatrogenic risk. For these studies, drug associated sodium intake was high (> 1,500 mg/day) in patients with comorbidities (in particular, diabetes mellitus and hypertension). Conclusion Despite numerous study limitations, this systematic review suggests three potential synergistic risk factors for cardiovascular complications after exposure to HSCD: a high sodium intake (≥ 1,500 mg/day), a long duration of exposure, and the presence of comorbidities. Further studies are required to characterize this iatrogenic risk. Trial registration PROSPERO CRD42016047086.
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Affiliation(s)
- Germain Perrin
- Department of Pharmacy, Georges Pompidou European Hospital, Paris, France.,INSERM UMR 1138 Team 22: Information Sciences to Support Personalized Medicine, Paris Descartes University, Paris, France
| | - Virginie Korb-Savoldelli
- Department of Pharmacy, Georges Pompidou European Hospital, Paris, France.,Faculty of Pharmacy, Clinical Pharmacy Department, Paris Saclay University, Châtenay-Malabry, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou European Hospital, Paris, France.,Paris Descartes University, Paris, France
| | - Nicolas Danchin
- Paris Descartes University, Paris, France.,Department of Cardiology, Georges Pompidou European Hospital, Paris, France
| | - Pierre Durieux
- INSERM UMR 1138 Team 22: Information Sciences to Support Personalized Medicine, Paris Descartes University, Paris, France.,Department of Biomedical Informatics and Public Health, Georges Pompidou European Hospital, Paris, France
| | - Brigitte Sabatier
- Department of Pharmacy, Georges Pompidou European Hospital, Paris, France.,INSERM UMR 1138 Team 22: Information Sciences to Support Personalized Medicine, Paris Descartes University, Paris, France
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Wong D, Bonnici T, Knight J, Gerry S, Turton J, Watkinson P. A ward-based time study of paper and electronic documentation for recording vital sign observations. J Am Med Inform Assoc 2017; 24:717-721. [PMID: 28339626 PMCID: PMC7651906 DOI: 10.1093/jamia/ocw186] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/09/2016] [Accepted: 12/23/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice. METHODS Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors. RESULTS In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33). DISCUSSION Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied. CONCLUSION Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality.
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Affiliation(s)
- David Wong
- Yorkshire Centre for Health Informatics, Leeds Institute of Data Analytics, Worsley Building, University of Leeds, Leeds, UK
| | - Timothy Bonnici
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Oxford, UK
| | - Julia Knight
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Oxford, UK
| | - Stephen Gerry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James Turton
- Brasenose College, University of Oxford, Oxford, UK
| | - Peter Watkinson
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Oxford, UK
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76
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Dutta D, Hellier K, Obaid M, Deering A. Evaluation of a single centre stroke service reconfiguration - the impact of transition from a combined (acute and rehabilitation) stroke unit to a hyperacute model of stroke care. Future Healthc J 2017; 4:99-104. [PMID: 31098443 PMCID: PMC6502622 DOI: 10.7861/futurehosp.4-2-99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We reorganised the combined (acute and rehab) stroke unit (SU) at Gloucestershire Royal Hospital into a hyperacute stroke unit (HASU) and a rehab SU where patients are moved after spending about 72 hours on HASU. Continuous monitoring of physiological variables was introduced and consultant job plans were reorganised to provide a HASU physician of the week model with enhanced 7-day senior presence along with redistribution of junior medical staff. Sentinel Stroke National Audit Programme (SSNAP) data for 14 months preceding the reorganisation (n=1,049) and 14 months after (n=974) were accessed for outcomes. More patients were admitted directly to the HASU with favourable reductions in time to computerised tomography scanning and stroke consultant assessment after the change. There were significant reductions in length of stay, pneumonia and urinary tract infections at 7 days and a favourable shift in modified Rankin scores (odds ratio 1.60, 95% confidence interval 1.36-1.89, p<0.001) on discharge from hospital.
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Affiliation(s)
- Dipankar Dutta
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Kate Hellier
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Mudhar Obaid
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Arnold Deering
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
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77
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Abstract
A short cut review was carried out to establish whether the use of preprocedural checklists prior to intubation of critically ill patients outside a theatre environment can reduce the incidence of adverse events. Four directly relevant papers were found using the reported search strategy and presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that preprocedural checklists may reduce adverse events in these patients, but that the evidence level is low and further matched cohort studies are needed to prove effectiveness.
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78
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Long E, Babl FE, Angley E, Duke T. A prospective quality improvement study in the emergency department targeting paediatric sepsis. Arch Dis Child 2016; 101:945-50. [PMID: 27045118 DOI: 10.1136/archdischild-2015-310234] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/11/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Quality improvement sepsis initiatives in the paediatric emergency department have been associated with improved processes, but an unclear effect on patient outcome. We aimed to evaluate and improve emergency department sepsis processes and track subsequent changes in patient outcome. STUDY DESIGN A prospective observational cohort study in the emergency department of The Royal Children's Hospital, Melbourne. Participants were children aged 0-18 years of age meeting predefined criteria for the diagnosis of sepsis. The following shortcomings in management were identified and targeted in a sepsis intervention: administration of antibiotics and blood sampling for a venous gas at the time of intravenous cannulation, and rapid administration of all fluid resuscitation therapy. The primary outcome measure was hospital length of stay. RESULTS 102 patients were enrolled pre-intervention, 113 post-intervention. Median time from intravenous cannula insertion to antibiotic administration decreased from 55 min (IQR 27-90 min) pre-intervention to 19 min (IQR 10-32 min) post-intervention (p≤0.01). Venous blood gas at time of first intravenous cannula insertion was performed in 60% of patients pre-intervention vs 79% post-intervention (p≤0.01). Fluids were administered using manual push-pull or pressure-bag methods in 31% of patients pre-intervention and 84% of patients post-intervention (p≤0.01). Median hospital length of stay decreased from 96 h (IQR 64-198 h) pre-intervention to 80 h (IQR 53-167 h) post-intervention (p=0.02). This effect persisted when corrected for unequally distributed confounders between pre-intervention and post-intervention groups (uncorrected HR: 1.36, 95% CI 1.04 to 1.80, p=0.02; corrected HR: 1.34, 95% CI 1.01 to 1.80, p=0.04). CONCLUSIONS Use of quality improvement methodologies to improve the management of paediatric sepsis in the emergency department was associated with a reduction in hospital length of stay.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Eleanor Angley
- Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia Pediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, Victoria, Australia
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79
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Kliemann N, Wardle J, Johnson F, Croker H. Reliability and validity of a revised version of the General Nutrition Knowledge Questionnaire. Eur J Clin Nutr 2016; 70:1174-1180. [PMID: 27245211 PMCID: PMC5014128 DOI: 10.1038/ejcn.2016.87] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 04/20/2016] [Accepted: 04/27/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES The General Nutrition Knowledge Questionnaire (GNKQ) was developed in the 1990s and has been widely used. Since then advances in understanding of associations between diet and disease have led to changes in dietary recommendations. This study reports the validity and reliability of an updated version of the GNKQ, bringing it into line with current nutritional advice. METHODS/SUBJECTS Following a review of current recommendations, the revised version of the GNKQ (GNKQ-R) was created, consisting of 88 items and four sections. Reliability and validity of the GNKQ-R were determined in four validation studies: (1) reliability was examined using an online sample (n=266), (2) construct validity was assessed with 96 Dietetics students and 89 english students using the 'known-groups' method, (3) associations between nutrition knowledge and socio-demographic characteristics were examined using the previously described samples and (4) sensitivity to change was tested by measuring GNKQ-R scores pre- and post-exposure to online nutrition information in written (n=65) and video (n=41) formats. RESULTS The reliability was >0.7 in all sections. Dietetics students scored significantly higher than english students. As predicted, GNKQ-R scores were significantly higher among females vs males, people with a degree vs without, and people with very good vs poor or good health status. They were lower in those older than 50 years vs younger adults. GNKQ-R scores were significantly greater after the nutrition interventions in both written and video formats. CONCLUSIONS The GNKQ-R is a valid measure of nutrition knowledge that is consistent, reliable and sensitive to change.
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Affiliation(s)
- N Kliemann
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - J Wardle
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - F Johnson
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - H Croker
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
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Bhattarai N, McMeekin P, Price C, Vale L. Economic evaluations on centralisation of specialised healthcare services: a systematic review of methods. BMJ Open 2016; 6:e011214. [PMID: 27154484 PMCID: PMC4861117 DOI: 10.1136/bmjopen-2016-011214] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To systematically review and appraise the quality of economic evaluations assessing centralisation of specialised healthcare services. METHODS A systematic review to identify economic evaluations on centralisation of any specialised healthcare service. Full economic evaluations comparing costs and consequences of centralisation of any specialised healthcare service were eligible for inclusion. Methodological characteristics of included studies were appraised using checklists adapted from recommended guidelines. RESULTS A total of 64 full-text articles met the inclusion criteria. Two studies were conducted in the UK. Most of the studies used volume of activity as a proxy measure of centralisation. The methods used to assess centralisation were heterogeneous. Studies differed in terms of study design used and aspect of centralisation they considered. There were major limitations in studies. Only 12 studies reported the study perspective. Charges which are not true representation of costs were used by 17 studies to assess cost outcomes. Only 10 reported the detailed breakdown of the cost components used in their analysis. Discounting was necessary in 14 studies but was reported only in 7 studies. Sensitivity analyses were included by less than one-third of the studies. The applicability of the identified studies to a setting other than the one they were conducted in is questionable, given variations in the organisation of services and healthcare costs. Centralisation as a concept has also been variably and narrowly defined as activity of specific services which may not reflect the wider aspects of centralisation. CONCLUSIONS Confounded and biased information coming from studies without standardised methods may mislead decision-makers towards making wrong decisions on centralisation. It is important to improve the methodology and reporting of economic evaluations in order to provide more robust and transferable evidence. Wider aspects of healthcare centralisation should be considered in the estimates of costs and health outcomes.
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Affiliation(s)
- Nawaraj Bhattarai
- Health Economics Group Newcastle, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Health Economics Group Newcastle, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
- Faculty of Health and Life Sciences, University of Northumbria in Newcastle, Newcastle upon Tyne, UK
| | - Christopher Price
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics Group Newcastle, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Sofjan AK, Musgrove RJ, Garey KW. Impact of New Diagnostic Approaches for Invasive Candidiasis on Antifungal Stewardship. CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0257-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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83
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Bonnici T, Gerry S, Wong D, Knight J, Watkinson P. Evaluation of the effects of implementing an electronic early warning score system: protocol for a stepped wedge study. BMC Med Inform Decis Mak 2016; 16:19. [PMID: 26860362 PMCID: PMC4748571 DOI: 10.1186/s12911-016-0257-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background An Early Warning Score is a clinical risk score based upon vital signs intended to aid recognition of patients in need of urgent medical attention. The use of an escalation of care policy based upon an Early Warning Score is mandated as the standard of practice in British hospitals. Electronic systems for recording vital sign observations and Early Warning Score calculation offer theoretical benefits over paper-based systems. However, the evidence for their clinical benefit is limited. Previous studies have shown inconsistent results. The majority have employed a “before and after” study design, which may be strongly confounded by simultaneously occurring events. This study aims to examine how the implementation of an electronic early warning score system, System for Notification and Documentation (SEND), affects the recognition of clinical deterioration occurring in hospitalised adult patients. Methods This study is a non-randomised stepped wedge evaluation carried out across the four hospitals of the Oxford University Hospitals NHS Trust, comparing charting on paper and charting using SEND. We assume that more frequent monitoring of acutely ill patients is associated with better recognition of patient deterioration. The primary outcome measure is the time between a patient’s first observations set with an Early Warning Score above the alerting threshold and their subsequent set of observations. Secondary outcome measures are in-hospital mortality, cardiac arrest and Intensive Care admission rates, hospital length of stay and system usability measured using the System Usability Scale. We will also measure Intensive Care length of stay, Intensive Care mortality, Acute Physiology and Chronic Health Evaluation (APACHE) II acute physiology score on admission, to examine whether the introduction of SEND has any effect on Intensive Care-related outcomes. Discussion The development of this protocol has been informed by guidance from the Agency for Healthcare Research and Quality (AHRQ) Health Information Technology Evaluation Toolkit and Delone and McLeans’s Model of Information System Success. Our chosen trial design, a stepped wedge study, is well suited to the study of a phased roll out. The choice of primary endpoint is challenging. We have selected the time from the first triggering observation set to the subsequent observation set. This has the benefit of being easy to measure on both paper and electronic charting and having a straightforward interpretation. We have collected qualitative measures of system quality via a user questionnaire and organisational descriptors to help readers understand the context in which SEND has been implemented. Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0257-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Timothy Bonnici
- Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - David Wong
- Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK.
| | - Julia Knight
- Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
| | - Peter Watkinson
- Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
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Tavender EJ, Bosch M, Fiander M, Knott JC, Gruen RL, O'Connor D. Implementation research in emergency medicine: a systematic scoping review. Emerg Med J 2015; 33:652-9. [PMID: 26353921 DOI: 10.1136/emermed-2015-205053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/21/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Implementation research aims to increase the uptake of research findings into clinical practice to improve the quality of healthcare. This scoping systematic study aims to assess the volume and scope of implementation research in emergency medicine (EM) to obtain an overview and inform future implementation research. METHODS Studies were identified by searching electronic databases and reference lists of included studies for the years 2002, 2007 and 2012. Titles/abstracts were screened, full papers checked and data extracted by one author, with a random sample checked by a second author. RESULTS A total of 3581 citations were identified with 197 eligible papers included. The number of papers significantly increased over time from 26 in 2002 to 77 in 2007 and 94 in 2012 (p<0.05). Eighty-two (42%) focused on identifying evidence-practice gaps, 77 (39%) evaluated the effectiveness of implementation interventions and 38 (19%) explored barriers and enablers to change. Only two papers explicitly stated that theory was used. Five of the 77 effectiveness studies used a randomised design and few provided sufficient detail about the intervention undergoing evaluation. CONCLUSIONS Although there was a significant increase in the number of implementation research papers, most studies focused on identifying evidence-practice gaps or used weak study designs to evaluate the effects of implementation interventions. Recommendations for improving implementation research in EM include identifying barriers and enablers to implementation, using theory in areas where proven important gaps exist, improving the reporting of the content of interventions and using rigorous study designs to evaluate their effectiveness.
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Affiliation(s)
- Emma J Tavender
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia National Trauma Research Institute, The Alfred & Monash University, Melbourne, Australia
| | - Marije Bosch
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia National Trauma Research Institute, The Alfred & Monash University, Melbourne, Australia
| | | | - Jonathan C Knott
- Department of Medicine and Radiology, Melbourne Medical School, The University of Melbourne, Melbourne, Australia Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L Gruen
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia National Trauma Research Institute, The Alfred & Monash University, Melbourne, Australia Department of Trauma, The Alfred Hospital, Melbourne, Australia
| | - Denise O'Connor
- Australasian Cochrane Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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