A meta-analysis of variables that predict significant intracranial injury in minor head trauma.

BACKGROUND: Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury. AIMS: To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population. METHODS: The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected. OUTCOME VARIABLE: CT presence or absence of ICH. RESULTS: Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0). CONCLUSIONS: There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid.

OBJECTIVES: Several decision aids can 'rule in' and 'rule out' acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG. METHODS: We undertook secondary analyses in three prospective diagnostic accuracy studies that included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded clinical features at the time of arrival using a bespoke form. Patients underwent serial troponin sampling and 30-day follow-up for the primary outcome of ACS. The model was derived by logistic regression in one cohort and validated in two similar prospective studies. RESULTS: The HE-MACS model was derived in 796 patients and validated in cohorts of 474 and 659 patients. HE-MACS incorporated age, sex, systolic blood pressure plus five historical variables to stratify patients into four risk groups. On validation, 5.5 and 12.1% (pooled total 9.4%) patients were identified as 'very low risk' (potential immediate rule out) with a pooled sensitivity of 99.5% (95% confidence interval: 97.1-100.0%). CONCLUSION: Using only the patient's history and ECG, HE-MACS could 'rule out' ACS in 9.4% of patients while effectively risk stratifying remaining patients. This is a very promising tool for triage in both the prehospital environment and ED. Its impact should be prospectively evaluated in those settings

Question-Driven Methodology for Analyzing Emergency Room Processes Using Process Mining

[EN] In order to improve the efficiency and effectiveness of Emergency Rooms (ER), it is important to provide answers to frequently-posed questions regarding all relevant processes executed therein. Process mining provides different techniques and tools that help to obtain insights into the analyzed processes and help to answer these questions. However, ER experts require certain guidelines in order to carry out process mining effectively. This article proposes a number of solutions, including a classification of the frequently-posed questions about ER processes, a data reference model to guide the extraction of data from the information systems that support these processes and a question-driven methodology specific for ER. The applicability of the latter is illustrated by means of a case study of an ER service in Chile, in which ER experts were able to obtain a better understanding of how they were dealing with episodes related to specific pathologies, triage severity and patient discharge destinations.This project was partially funded by Fondecyt Grants 1150365 and 11130577 from the Chilean National Commission on Scientific and Technological Research (CONICYT), the Ph.D. Scholarship Program of CONICYT Chile (CONICYT-Doctorado Nacional/2014-63140180), the Ph.D. Scholarship Program of CONICIT Costa Rica and by Universidad de Costa Rica Professor Fellowships.Rojas, E.; Sepúlveda, M.; Munoz-Gama, J.; Capurro, D.; Traver Salcedo, V.; Fernández Llatas, C. (2017). Question-Driven Methodology for Analyzing Emergency Room Processes Using Process Mining. Applied Sciences. 7(3):1-29. https://doi.org/10.3390/app7030302S12973Welch, S. J., Asplin, B. R., Stone-Griffith, S., Davidson, S. J., Augustine, J., & Schuur, J. (2011). Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit. Annals of Emergency Medicine, 58(1), 33-40. doi:10.1016/j.annemergmed.2010.08.040Jansen-Vullers, M., & Reijers, H. (2005). Business Process Redesign in Healthcare: Towards a Structured Approach. INFOR: Information Systems and Operational Research, 43(4), 321-339. doi:10.1080/03155986.2005.11732733Grol, R., & Grimshaw, J. (1999). Evidence-Based Implementation of Evidence-Based Medicine. The Joint Commission Journal on Quality Improvement, 25(10), 503-513. doi:10.1016/s1070-3241(16)30464-3Fernández-Llatas, C., Meneu, T., Traver, V., & Benedi, J.-M. (2013). Applying Evidence-Based Medicine in Telehealth: An Interactive Pattern Recognition Approximation. International Journal of Environmental Research and Public Health, 10(11), 5671-5682. doi:10.3390/ijerph10115671Radnor, Z. J., Holweg, M., & Waring, J. (2012). Lean in healthcare: The unfilled promise? Social Science & Medicine, 74(3), 364-371. doi:10.1016/j.socscimed.2011.02.011Rojas, E., Munoz-Gama, J., Sepúlveda, M., & Capurro, D. (2016). Process mining in healthcare: A literature review. Journal of Biomedical Informatics, 61, 224-236. doi:10.1016/j.jbi.2016.04.007Neumuth, T., Jannin, P., Schlomberg, J., Meixensberger, J., Wiedemann, P., & Burgert, O. (2010). Analysis of surgical intervention populations using generic surgical process models. International Journal of Computer Assisted Radiology and Surgery, 6(1), 59-71. doi:10.1007/s11548-010-0475-yFernandez-Llatas, C., Lizondo, A., Monton, E., Benedi, J.-M., & Traver, V. (2015). Process Mining Methodology for Health Process Tracking Using Real-Time Indoor Location Systems. Sensors, 15(12), 29821-29840. doi:10.3390/s151229769Rebuge, Á., & Ferreira, D. R. (2012). Business process analysis in healthcare environments: A methodology based on process mining. Information Systems, 37(2), 99-116. doi:10.1016/j.is.2011.01.003Partington, A., Wynn, M., Suriadi, S., Ouyang, C., & Karnon, J. (2015). Process Mining for Clinical Processes. ACM Transactions on Management Information Systems, 5(4), 1-18. doi:10.1145/2629446Basole, R. C., Braunstein, M. L., Kumar, V., Park, H., Kahng, M., Chau, D. H. (Polo), … Thompson, M. (2015). Understanding variations in pediatric asthma care processes in the emergency department using visual analytics. Journal of the American Medical Informatics Association, 22(2), 318-323. doi:10.1093/jamia/ocu016Suriadi, S., Andrews, R., ter Hofstede, A. H. M., & Wynn, M. T. (2017). Event log imperfection patterns for process mining: Towards a systematic approach to cleaning event logs. Information Systems, 64, 132-150. doi:10.1016/j.is.2016.07.011De Medeiros, A. K. A., Weijters, A. J. M. M., & van der Aalst, W. M. P. (2007). Genetic process mining: an experimental evaluation. Data Mining and Knowledge Discovery, 14(2), 245-304. doi:10.1007/s10618-006-0061-7Aalst, W. M. P. van der. (2005). Business alignment: using process mining as a tool for Delta analysis and conformance testing. Requirements Engineering, 10(3), 198-211. doi:10.1007/s00766-005-0001-xVan der Aalst, W., Adriansyah, A., & van Dongen, B. (2012). Replaying history on process models for conformance checking and performance analysis. WIREs Data Mining and Knowledge Discovery, 2(2), 182-192. doi:10.1002/widm.1045Song, M., & van der Aalst, W. M. P. (2008). Towards comprehensive support for organizational mining. Decision Support Systems, 46(1), 300-317. doi:10.1016/j.dss.2008.07.00

Ceramics studio to podiatry clinic: The impact of multi-media resources in the teaching of practical skills across diverse disciplines

This paper draws on the experiences of students from two vastly different disciplines to both explore the theoretical background supporting the use of multimedia resources to teach practical skills and provide a qualitative evaluation of student perceptions and experiences of using bespoke resources. Within ceramics and podiatry, practical skills are traditionally taught via an apprenticeship model within small groups. We explore the practical and pedagogic benefits of developing bespoke multimedia resources to teach practical skills, identifying common themes from these disparate discipline areas. Student focus groups revealed that, practically, the opportunity for repeated viewing at convenient times promoted less reliance on lecturers and better preparation prior to practical demonstrations. Pedagogically, time for reflection and sense making underpinned an increase in confidence which in turn led to increased creativity. The student voice was also used to identify recommendations and challenges driving future change

Performance of triage systems in emergency care: a systematic review and meta-analysis

Objective To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED). Design Systematic review and meta-analysis. Data sources EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018. Eligibility criteria Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded. Review methods Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems’ performance. Results Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems’ performance. Conclusions Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems’ performance and how the performance of existing triage systems can be improved

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

OBJECTIVE: Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect. SETTING: Two English Ambulance Services. PARTICIPANTS: 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. INTERVENTIONS: Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. OUTCOMES: Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. RESULTS: 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%). CONCLUSION: Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely. TRIAL REGISTRATION NUMBER: ISRCTN68087745

Exploring perceptions of parents on the use of emergency department on-site primary care services for the treatment of children with non-urgent conditions

Objective: To understand the reasons parents of children with minor conditions attend the Children’s Emergency Department (ED), and their views about on-site paediatric same day care (SDC) service as an alternative treatment centre. Method: A cross-sectional survey of parents attending an inner-city, district general hospital children’s ED, with children aged under 16 years old who were allocated to low triage categories. A convenience sample of 58 parents of 58 children were recruited. Results: All the 58 responses were analysed. Incomplete questionnaires were not excluded. 47% of attendances were because of minor injury. Most presentations were within 24 hours of the injury or illness. 72% of parents were employed. 91% were registered with a General Practitioner (GP). 29% contacted a GP before the ED visit. The majority of participants who contacted a GP were referred to the ED; others were advised to wait to see if the child’s condition improved and to attend the ED if there were any concerns or the child deteriorated in any way. 50% of those that did not contact GP said the GP surgery was closed and 8% felt the GP could not help. 90% of parents perceived their child’s condition as urgent requiring immediate treatment. 33% of parents said they would be happy for their children to be treated at an on-site Same Day Care (SDC) Centre. Conclusions: The study showed limited access to GP services in the community and dissatisfaction with community services and perceived urgency of treatment prompted parents of children with minor conditions to attend the ED. This could mean significant ED attendance by children with minor conditions. The majority of the parents in the study would welcome an on-site paediatric SDC if appropriate to meet their children’s care needs. Establishing an on-site SDC may help relieve the ED pressures to attend to more clinically urgent and emergency cases

Making a Difference: A Qualitative Study on Care and Priority Setting in Health Care

The focus of the study is the conflict between care and concern for particular patients, versus considerations that take impartial considerations of justice to be central to moral deliberations. To examine these questions we have conducted qualitative interviews with health professionals in Norwegian hospitals. We found a value norm that implicitly seemed to overrule all others, the norm of ‘making a difference for the patients’. We will examine what such a statement implies, aiming to shed some light over moral dilemmas interwoven in bedside rationing

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts.

BACKGROUND: The original Manchester Acute Coronary Syndromes model (MACS) 'rules in' and 'rules out' acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT. METHODS: We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set). RESULTS: At the 'rule out' threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%-99.8%) sensitivity for ACS, 'ruling out' 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%-99.8%) NPV and 98.1% (95.2%-99.5%) sensitivity, 'ruling out' 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would 'rule in' 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation). CONCLUSIONS: T-MACS could 'rule out' ACS in 40% of patients, while 'ruling in' 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources