The development and validation of a modified Situation-Background-Assessment-recommendation (SBAR) communication tool for reporting early signs of deterioration in patients

Includes bibliographical referencesBackground: Errors in communication are prevalent in healthcare and affect patient safety and cause unnecessary patient deaths. Reporting early signs of physiological or clinical deterioration could improve patient safety and prevent 'failure to rescue' or unexpected intensive care admissions, cardiac arrest or death. The structured Situation-Background-Assessment-Recommendation (SBAR) communication tool enables nurses to provide doctors with pertinent information about a deteriorating patient in a logical order, based on a complete assessment. In addition, nurses have increased confidence in their findings and are better able to initiate a call and to convince a doctor to provide orders promptly or see a patient. Aim: The aim of this sub-study of a randomized controlled trial was to develop and validate a modified SBAR communication tool incorporating components of a local MEWS vital signs observations chart. Methods: The modified SBAR communication tool was developed following a review of available published examples and validated by employing a mixed methods approach: 1) cognitive interviews (n=3 nurses, 2 doctors), 2) determining the index of content validity with nurses (n=5), physicians (n=5) and surgeons (n=8) and 3) inter-rater reliability testing, with calculation of kappa values (n=2 nurses). Results: Cognitive interviews prompted more changes to the modified SBAR communication tool than determined by the content validity index. For cognitive interviews, there were 15/42 (35.71 %) modifications: 11 items were added (26.19 %) and three removed, (7.14 %) resulting in 49 items whereas for content validity index there were 4/49 (8.16%) modifications, 5/49 (10.20%) items removed and one item added (2.04%). Four of 49 items (8.16%) rated as relevant by <70% of nurses and doctors were revised or deleted. No additional modifications were needed following review by surgeons, as all items were rated as relevant by the pre-determined ≥70% of experts. Inter-rater reliability of the SBAR tool was established by two nurses who were mostly in substantial to full agreement on 37/45 items on the modified tool. The exceptions were: 'Calling from' (Cohen's Kappa-0.05) and 'this is a change from' (Cohen's Kappa-0.07), representing agreement below the level of chance. However, the high percentage agreement and nature of the questions suggest that the questions are sound. Percentage agreement amongst participants for these items was 91 % (95% confidence interval (CI): 71 to 99 ) and 86% (95% CI: 65 to 97 ) respectively. Deciding whether a doctor should see the patient now (Cohen's Kappa 0.09) or in the next 30 minutes, achieved fair agreement (Cohen's Kappa 0.20). This reflects a difference in clinical judgement as the decision when to call for assistance depended on the individual nurse's clinical judgement. IRR was not possible to test on 4/45 items, as those items required a response by the person being summoned. Overall, nine of 42 items were removed, 12 were added and 19 substantially modified, leaving 45 items. Conclusion: The modified SBAR communication tool was valid and reliable for use in a local context in conjunction with the Cape Town Modified Early Warning Score (MEWS) vital EWS) vital signs chart

Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial

Abstract Background Nurses’ recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries. Methods We tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed. Results We recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06–1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and “looks unwell”. SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38–6.86)). Conclusions The revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses’ ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses’ reporting behaviour. Trial registration Pan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org

Protein 3D Structure Computed from Evolutionary Sequence Variation

The evolutionary trajectory of a protein through sequence space is constrained by its function. Collections of sequence homologs record the outcomes of millions of evolutionary experiments in which the protein evolves according to these constraints. Deciphering the evolutionary record held in these sequences and exploiting it for predictive and engineering purposes presents a formidable challenge. The potential benefit of solving this challenge is amplified by the advent of inexpensive high-throughput genomic sequencing

Minimal information for studies of extracellular vesicles 2018 (MISEV2018):a position statement of the International Society for Extracellular Vesicles and update of the MISEV2014 guidelines

The last decade has seen a sharp increase in the number of scientific publications describing physiological and pathological functions of extracellular vesicles (EVs), a collective term covering various subtypes of cell-released, membranous structures, called exosomes, microvesicles, microparticles, ectosomes, oncosomes, apoptotic bodies, and many other names. However, specific issues arise when working with these entities, whose size and amount often make them difficult to obtain as relatively pure preparations, and to characterize properly. The International Society for Extracellular Vesicles (ISEV) proposed Minimal Information for Studies of Extracellular Vesicles (“MISEV”) guidelines for the field in 2014. We now update these “MISEV2014” guidelines based on evolution of the collective knowledge in the last four years. An important point to consider is that ascribing a specific function to EVs in general, or to subtypes of EVs, requires reporting of specific information beyond mere description of function in a crude, potentially contaminated, and heterogeneous preparation. For example, claims that exosomes are endowed with exquisite and specific activities remain difficult to support experimentally, given our still limited knowledge of their specific molecular machineries of biogenesis and release, as compared with other biophysically similar EVs. The MISEV2018 guidelines include tables and outlines of suggested protocols and steps to follow to document specific EV-associated functional activities. Finally, a checklist is provided with summaries of key points

Imidazo[2,1-b]benzothiazol derivatives as potential allosteric inhibitors of the glucocorticoid receptor

Glucocorticoid receptor (GCR) transactivation reporter gene assays were used as an initial high-throughput screening on a diversified library of 1200 compounds for their evaluation as GCR antagonists. A class of imidazo[2,1-b]benzothiazole and imidazo[2,1-b]benzoimidazole derivatives were identified for their ability to modulate GCR transactivation and anti-inflammatory transrepression effects utilizing GCR and NF-\u3baB specific reporter gene assays. Modeling studies on the crystallographic structure of the GCR ligand binding domain provided three new analogues bearing the tetrahydroimidazo[2,1-b]benzothiazole scaffold able to antagonize the GCR in the presence of dexamethasone (DEX) and also defined their putative binding into the GCR structure. Both mRNA level measures of GCR itself and its target gene GILZ, on cells treated with the new analogues, showed a GCR transactivation inhibition, thus suggesting a potential allosteric inhibition of the GCR

A deterministic particle approximation for non-linear conservation laws

We review our analytical and numerical results obtained on the microscopic Follow-The-Leader (FTL) many particle approximation of one-dimensional conservation laws. More precisely, we introduce deterministic particle schemes for the Hughes model for pedestrian movements and for two vehicular traffic models that are the scalar Lighthill–Whitham–Richards model (LWR) and the 2×2 system Aw–Rascle–Zhang model (ARZ). Their approximation is performed by a set of ODEs, determining the motion of platoons of possible fractional vehicles or pedestrians seen as particles. Convergence results of the schemes in the many particle limit are stated. The numerical simulations suggest the consistency of the schemes