The Toowoomba adult trauma triage tool

Since the introduction of the Australasian Triage Scale (ATS) there has been considerable variation in its application. Improved uniformity in the application of the ATS by triage nurses is required. A reproducible, reliable and valid method to classify the illness acuity of Emergency Department patients so that a triage category 3 by one nurse means the same as a triage category 3 by another, not only in the same ED but also in another institution would be of considerable value to emergency nurses. This has been the driving motivation behind developing the Toowoomba Adult Trauma Triage Tool (TATTT). It is hoped the TATTT will support emergency nurses working in this challenging area by promoting standardisation and decreasing subjectivity in the triage decision process

Proteomic analysis of pollination-induced corolla senescence in petunia

Senescence represents the last phase of petal development during which macromolecules and organelles are degraded and nutrients are recycled to developing tissues. To understand better the post-transcriptional changes regulating petal senescence, a proteomic approach was used to profile protein changes during the senescence of Petunia×hybrida ‘Mitchell Diploid’ corollas. Total soluble proteins were extracted from unpollinated petunia corollas at 0, 24, 48, and 72 h after flower opening and at 24, 48, and 72 h after pollination. Two-dimensional gel electrophoresis (2-DE) was used to identify proteins that were differentially expressed in non-senescing (unpollinated) and senescing (pollinated) corollas, and image analysis was used to determine which proteins were up- or down-regulated by the experimentally determined cut-off of 2.1-fold for P <0.05. One hundred and thirty-three differentially expressed protein spots were selected for sequencing. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to determine the identity of these proteins. Searching translated EST databases and the NCBI non-redundant protein database, it was possible to assign a putative identification to greater than 90% of these proteins. Many of the senescence up-regulated proteins were putatively involved in defence and stress responses or macromolecule catabolism. Some proteins, not previously characterized during flower senescence, were identified, including an orthologue of the tomato abscisic acid stress ripening protein 4 (ASR4). Gene expression patterns did not always correlate with protein expression, confirming that both proteomic and genomic approaches will be required to obtain a detailed understanding of the regulation of petal senescence

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Reliability and validity of the Toowoomba Adult Trauma Triage Tool: a Queensland, Australia study

In Australia a nationally adopted five tiered triage scale called the Australasian triage scale (ATS) is used for the purpose of differentiating patient acuity levels for all patients that present to an emergency department (ED). The scale was formulated with the aim of promoting a standardized approach to triage. Numerous studies now suggest that the ATS has not been successful in achieving this intention. The Toowoomba adult trauma triage tool (TATTT) seeks to address this deficiency by providing an evidence based, reproducible, reliable and valid method of triage categorisation, albeit in a select group of patients. Method: Ten triage nurses from Toowoomba health service (THS) and five from Princess Alexandra Hospital in Queensland, Australia were enrolled in the study. Each participant rated five written simulations before receiving training in the TATTT. Each participant then rated nine written scenarios, five simulated scenarios on video and one computer simulated scenario with the TATTT. Parallel triaging of actual adult injury based presentations to THS ED was also undertaken

Triage nurse perceptions of the use, reliability and acceptability of the Toowoomba Adult Triage Trauma Tool (TATTT)

The 'Toowoomba Adult Triage Trauma Tool' (TATTT) is a computerised clinical decision support tool developed to provide an evidence-based, valid and consistent method of triage assessment and categorisation. The objective of this study was to determine the most appropriate training and testing strategy for implementing the TATTT and to evaluate its acceptability for assisting in the triage prioritisation process. Triage nurses (15) from two hospitals underwent training in the TATTT and were tested on its application. Semi-structured interviews gathered their perceptions of the training, the methods for testing and the acceptability of the TATTT for assisting in triage. The TATTT was viewed positively by all but one of the nurses. Participants believed that it provided clear direction in the triage assessment process, increased their confidence in reaching a decision and would be comfortable in adopting the TATTT in clinical practice. The study has shown that the TATTT is acceptable to users and is viewed as a viable alternative to current triage practice