Development and implementation of a real time statistical control method to identify the start and end of the winter surge in demand for paediatric intensive care

Winter surge management in intensive care is hampered by the annual variability in the winter surge. We aimed to develop a real-time monitoring system that could promptly identify the start, and accurately predict the end, of the winter surge in a paediatric intensive care (PIC) setting. We adapted a statistical process control method from the stock market called “Bollinger bands” that compares current levels of demand for PIC services to thresholds based on the medium term average demand. Algorithms to identify the start and end of the surge were developed for a specific PIC service: the North Thames Children's Acute Transport Service (CATS) using eight winters of data (2005–12) to tune the algorithms and one winter to test the final method (2013/14). The optimal Bollinger band thresholds were 1.2 and 1 standard deviations above and below a 41-day moving average of demand respectively. A simple linear model was found to predict the end of the surge and overall demand volume as soon as the start had been identified. Applying the method to the validation winter of 2013/14 showed excellent performance, with the surge identified from 18th November 2013 to 4th January 2014. An Excel tool running the algorithms has been in use within CATS since September 2014. There were three factors which facilitated the successful implementation of this tool: the perceived problem was pressing and identified by the clinical team; there was close clinical engagement throughout and substantial effort was made to develop an easy-to-use Excel tool for sustainable use

Prioritization of critically unwell children in low resource primary healthcare centres in Cape Town, South Africa

Background: Every day, sick children die from time sensitive preventable illnesses. Due to an inadequate number of trained healthcare workers and high volumes of children presenting to Primary Healthcare Centres (PHC), waiting times remain high and often result in significant delays for critically ill children. Delays in the recognition of critically unwell children are a key contributing factor to avoidable childhood mortality in Cape Town, South Africa. Methodology: A stepped implementation approach was undertaken to develop and evaluate a context-appropriate prioritization tool to identify and expedite the care of critically ill children PHC in Cape Town, South Africa. Aim 1: To conduct a systematic review of paediatric triage and prioritization tools for low resource settings in order to evaluate the evidence supporting the use of these tools. Aim 2: To perform an exploratory study, to identify barriers to optimal care for critically ill children in the pre-hospital setting in Cape Town, South Africa. Aim 3: To develop an implementable context-appropriate tool to identify and expedite the care of critically ill children in PHC in the City of Cape Town, South Africa. Aim 4: Evaluate the reliability of this tool compared to established triage tools currently used in this setting. Aim 5: Evaluate the impact of implementing this tool, on waiting times for children presenting for care to PHC. Aim 6: Evaluate the effectiveness of this tool post real-world implementation in identifying and expediting the care for critically ill children. Findings: Post real world implementation SCREEN was able to significantly reduce waiting times in PHC for critically ill children. Compared to pre-SCREEN implementation, post-SCREEN the proportion of critically ill children who saw a PN within 10 minutes increased tenfold from 6.4% (pre-SCREEN) to 64% (post-SCREEN) (p<0.001). SCREEN is also able to accurately identify critically ill children, in an audit of 827 patient-charts SCREEN had a sensitivity of 94.2% and a specificity of 88.1% when compared to IMCI. Interpretation: The SCREEN program when implemented in a real-world setting has shown that it can effectively identify and expedite the care of critically ill children in PHC

COVID-19: Preparing for the future: looking ahead to winter 2021/22 and beyond

Despite a highly successful vaccination campaign in the UK, the coronavirus disease 2019 (COVID-19) pandemic is not over, and we are currently seeing rapidly rising infection rates. While there is an understandable and intense desire for ‘normality’ to return, we need to sustain our efforts to limit the transmission and impacts of the virus, particularly for the most vulnerable, for the longer term. To prepare for the winter period and beyond, the priorities over the summer period must be to: Maximise the speed and uptake of COVID-19 vaccination in all eligible age groups, and prepare for possible booster vaccines in priority groups and vaccination against influenza later in the year. Increase the ability of people with COVID-19 to self-isolate through financial and other support, with a particular focus on those in areas of persistent transmission and in the lowest socio-economic groups. Boost capacity in the NHS (staff and beds) to: build resilience against future outbreaks of COVID-19 and other infectious diseases, including through improving infection prevention and control (IPC), increasing vaccination and testing capacity for COVID-19 and influenza, adequately resourcing primary care, and reducing the backlog of non-COVID-19 care. Provide clear guidance about environmental and behavioural precautions (such as the use of face coverings, ventilation and physical distancing) that individuals and organisations can take to protect themselves and others, especially those who are most vulnerable from infection

Modelling the Perinatal Network System

The topic is that hospital capacity for patient beds runs short. We wish to predict when this will occur. An inter-disciplinary approach to this problem is taken incorporating a Management Science / Operational Research perspective. The subject is the Perinatal Network System, which is described, analysed and modelled. An illustrative Case Study is taken of an English local neonatal unit, where new-born babies are cared for. The focus is High dependency cots. Recommendations produced are subject to human factors and implementation difficulties. In this work, Systems Thinking facilitates an understanding of relationships; Enterprise Architecture helps embed the context and address complexity; while Clinical Medicine underpins decision-making for individual patients. Research outputs include the Conceptual Research Framework, a Quality Metric, a Cot Predictor Tool and a Markovian model Design, which can be adapted in the future. Furthermore there is the milieu or connective ‘glue’, to provide unity. The methodology or Enterprise Modelling helps address the issue by facilitating understanding of both overview and detail

An investigation into the effects of commencing haemodialysis in the critically ill

&lt;b&gt;Introduction:&lt;/b&gt; We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. &lt;b&gt;Methods:&lt;/b&gt; Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of &gt;+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. &lt;b&gt;Results:&lt;/b&gt; Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (&gt;+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. &lt;b&gt;Conclusions:&lt;/b&gt; Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Advanced airway management for pre-hospital trauma patients

Poor airway management in severely injured patients is a source of significant morbidity and mortality and frequently identified as a cause of preventable death in this group of patients. Traditionally the majority of patients have not received definitive airway management until arrival at hospital and those patients who were sufficiently obtunded on scene to tolerate tracheal intubation without the use of drugs had a universally poor outcome. Pre-hospital Emergency Medicine (PHEM) is now a recognised medical subspecialty and is usually delivered by doctors and paramedics with specific training in this field. The development of this subspecialty has increased the practice of Pre-Hospital Emergency Anaesthesia (PHEA). Despite improvements in the delivery of PHEM and consequently of PHEA, controversy surrounding this intervention exists and it has failed to demonstrate an obvious survival benefit. This thesis sets out to further examine the practice of PHEA and attempt to establish why this intervention does not appear to be reducing mortality in patients who have sustained major trauma. I designed and developed studies to address a number of key questions including whether there is a requirement for PHEA, the potential benefit of it, and to identify areas of practice that can be improved. Through studies conducted at a local and national level I have been able to provide evidence that not only is PHEA an essential and beneficial intervention for a subset of major trauma patients, but also that there is a demand for this intervention which is not met by the current prehospital practice and infrastructure in the UK

Pandemic (H1N1) 2009 influenza outbreak in Australia : impact on emergency departments

Executive summary\ud Objective:\ud The aims of this study were to identify the impact of Pandemic (H1N1) 2009 Influenza on Australian Emergency Departments (EDs) and their staff, and to inform planning, preparedness, and response management arrangements for future pandemics, as well as managing infectious patients presenting to EDs in everyday practice.\ud Methods\ud This study involved three elements:\ud 1. The first element of the study was an examination of published material including published statistics. Standard literature research methods were used to identify relevant published articles. In addition, data about ED demand was obtained from Australian Government Department of Health and Ageing (DoHA) publications, with several state health departments providing more detailed data.\ud 2. The second element of the study was a survey of Directors of Emergency Medicine identified with the assistance of the Australasian College for Emergency Medicine (ACEM). This survey retrieved data about demand for ED services and elicited qualitative comments on the impact of the pandemic on ED management.\ud 3. The third element of the study was a survey of ED staff. A questionnaire was emailed to members of three professional colleges—the ACEM; the Australian College of Emergency Nursing (ACEN); and the College of Emergency Nursing Australasia (CENA). The overall response rate for the survey was 18.4%, with 618 usable responses from 3355 distributed questionnaires. Topics covered by the survey included ED conditions during the (H1N1) 2009 influenza pandemic; information received about Pandemic (H1N1) 2009 Influenza; pandemic plans; the impact of the pandemic on ED staff with respect to stress; illness prevention measures; support received from others in work role; staff and others’ illness during the pandemic; other factors causing ED staff to miss work during the pandemic; and vaccination against Pandemic (H1N1) 2009 Influenza. Both qualitative and quantitative data were collected and analysed.\ud Results:\ud The results obtained from Directors of Emergency Medicine quantifying the impact of the pandemic were too limited for interpretation. Data sourced from health departments and published sources demonstrated an increase in influenza-like illness (ILI) presentations of between one and a half and three times the normal level of presentations of ILIs. Directors of Emergency Medicine reported a reasonable level of preparation for the pandemic, with most reporting the use of pandemic plans that translated into relatively effective operational infection control responses. Directors reported a highly significant impact on EDs and their staff from the pandemic. Growth in demand and related ED congestion were highly significant factors causing distress within the departments. Most (64%) respondents established a ‘flu clinic’ either as part of Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments.\ud the ED operations or external to it. They did not note a significantly higher rate of sick leave than usual.\ud Responses relating to the impact on staff were proportional to the size of the colleges. Most respondents felt strongly that Pandemic (H1N1) 2009 Influenza had a significant impact on demand in their ED, with most patients having low levels of clinical urgency. Most respondents felt that the pandemic had a negative impact on the care of other patients, and 94% revealed some increase in stress due to lack of space for patients, increased demand, and filling staff deficits. Levels of concern about themselves or their family members contracting the illness were less significant than expected. Nurses displayed significantly higher levels of stress overall, particularly in relation to skill-mix requirements, lack of supplies and equipment, and patient and patients’ family aggression. More than one-third of respondents became ill with an ILI. Whilst respondents themselves reported taking low levels of sick leave, respondents cited difficulties with replacing absent staff. Ranked from highest to lowest, respondents gained useful support from ED colleagues, ED administration, their hospital occupational health department, hospital administration, professional colleges, state health department, and their unions. Respondents were generally positive about the information they received overall; however, the volume of information was considered excessive and sometimes inconsistent. The media was criticised as scaremongering and sensationalist and as being the cause of many unnecessary presentations to EDs. Of concern to the investigators was that a large proportion (43%) of respondents did not know whether a pandemic plan existed for their department or hospital. A small number of staff reported being redeployed from their usual workplace for personal risk factors or operational reasons. As at the time of survey (29 October –18 December 2009), 26% of ED staff reported being vaccinated against Pandemic (H1N1) 2009 Influenza. Of those not vaccinated, half indicated they would ‘definitely’ or ‘probably’ not get vaccinated, with the main reasons being the vaccine was ‘rushed into production’, ‘not properly tested’, ‘came out too late’, or not needed due to prior infection or exposure, or due to the mildness of the disease.\ud Conclusion:\ud Pandemic (H1N1) 2009 Influenza had a significant impact on Australian Emergency Departments. The pandemic exposed problems in existing plans, particularly a lack of guidelines, general information overload, and confusion due to the lack of a single authoritative information source. Of concern was the high proportion of respondents who did not know if their hospital or department had a pandemic plan. Nationally, the pandemic communication strategy needs a detailed review, with more engagement with media networks to encourage responsible and consistent reporting. Also of concern was the low level of immunisation, and the low level of intention to accept vaccination. This is a problem seen in many previous studies relating to seasonal influenza and health care workers. The design of EDs needs to be addressed to better manage infectious patients. Significant workforce issues were confronted in this pandemic, including maintaining appropriate staffing levels; staff exposure to illness; access to, and appropriate use of, personal protective equipment (PPE); and the difficulties associated with working in PPE for prolonged periods. An administrative issue of note was the reporting requirement, which created considerable additional stress for staff within EDs. Peer and local support strategies helped ensure staff felt their needs were provided for, creating resilience, dependability, and stability in the ED workforce. Policies regarding the establishment of flu clinics need to be reviewed. The ability to create surge capacity within EDs by considering staffing, equipment, physical space, and stores is of primary importance for future pandemics