Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.

BACKGROUND Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10). METHODS Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. RESULTS Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute ( 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. CONCLUSIONS Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization

Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning

Assessing internet-based information used to aid patient decision-making about surgery for perianal Crohn's fistula.

BACKGROUND: Decision-making in perianal Crohn's fistula (pCD) is preference sensitive. Patients use the internet to access healthcare information. The aim of this study was to assess the online information and patient decision aids relating to surgery for pCD. METHODS: A search of Google™ and the Decision Aids Library Inventory (DALI) was performed using a predefined search strategy. Patient-focussed sources providing information about pCD surgery were included in the analysis. Written health information was assessed using the International Patient Decision Aids Standards (IPDAS) and DISCERN criteria. The readability of the source content was assessed using the Flesch-Kincaid score. RESULTS: Of the 201 sources found, 187 were excluded, leaving 14 sources for analysis. Three sources were dedicated to pCD, and six sources mentioned pCD-specific outcomes. The most common surgical intervention reported was seton insertion (n = 13). The least common surgical intervention reported was proctectomy (n = 1). The mean IPDAS and DISCERN scores were 4.43 ± 1.65 out of 12 (range = 2-8) and 2.93 ± 0.73 out of 5 (range = 1-5), respectively. The mean reading ease was US college standard. CONCLUSIONS: We found no patient decision aids relating to surgery for pCD. The online sources relating to surgery for pCD are few, and their quality is poor, as seen in the low IPDAS and DISCERN scores. Less than half of the sources mentioned pCD-specific outcomes, and three sources were solely dedicated to providing information on pCD. Healthcare professionals should look to create a patient tool to assist decision-making in pCD

Physicians&rsquo; attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians

Tanja Birrenbach,1&nbsp;Simone Kraehenmann,1&nbsp;Martin Perrig,1&nbsp;Christoph Berendonk,2&nbsp;Soeren Huwendiek2 1Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; 2Department of Assessment and Evaluation, Institute of Medical Education, Medical Faculty Bern, Bern, Switzerland Background: Little is known about the attitudes toward, use of, and perceived barriers to clinical guidelines in Switzerland, a country with no national guideline agency. Moreover, there is no available data on the objective assessment of guideline knowledge in Switzerland. Therefore, we conducted a study at a large university&rsquo;s Department of General Internal Medicine in Switzerland to assess physicians&rsquo; attitudes toward, use of, perceived barriers to, and knowledge of clinical guidelines.Participants and methods: Ninety-six physicians (residents, n=78, and attendings, n=18) were invited to take part in a survey. Attitudes toward, self-reported use of, and barriers hindering adherence to the clinical guidelines were assessed using established scales and frameworks. Knowledge of the guidelines was objectively tested in a written assessment comprising of 14 multiple-choice and 3 short answer case-based questions.Results: Fifty-five participants completed the survey (residents, n=42, and attendings, n=13; overall response rate 57%). Of these, 50 took part in the knowledge assessment (residents, n=37, and attendings, n=13; overall response rate 52%). Attitudes toward guidelines were favorable. They were considered to be a convenient source of advice (94% agreement), good educational tools (89% agreement), and likely to improve patient quality of care (91% agreement). Self-reported use of guidelines was limited, with only one-third reporting using guidelines often or very often. The main barriers to guideline adherence were identified as lack of guideline awareness and familiarity, applicability of existing guidelines to multimorbid patients, unfavorable guideline factors, and lack of time as well as inertia toward changing previous practice. In the assessment of guideline knowledge, the scores were rather modest (mean &plusmn; standard deviation: 60.5%&plusmn;12.7% correct answers). Conclusion: In general, this study found favorable physician attitudes toward clinical guidelines. However, several barriers hindering guideline implementation were identified. The importance of improving guideline implementation was supported by modest results in a guideline knowledge test. Keywords: clinical guidelines, attitudes, barriers, knowledge, survey, physicians&nbsp

Entwicklung und Evaluation eines Virtual-Reality-Trainings in der Notfallmedizin zur Behandlung von Dyspnoe basierend auf Frameworks für Serious Games

Background: Virtual reality (VR) can offer an innovative approach to providing training in emergency situations, especially in times of COVID-19. There is no risk of infection, and the procedure is scalable and resource-efficient. Nevertheless, the challenges and problems that can arise in the development of VR training are often unclear or underestimated. As an example, we present the evaluation of the feasibility of development of a VR training session for the treatment of dyspnoea. This is based on frameworks for serious games, and provides lessons learned. We evaluate the VR training session with respect to usability, satisfaction, as well as perceived effectiveness and workload of participants. Methods: The VR training was developed using the established framework (Steps 1-4) for serious games of Verschueren et al. and Nicholson's RECIPE elements for meaningful gamification. Primary validation (Step 4) was performed at the University of Bern, Switzerland, in a pilot study without control group, with a convenience sample of medical students (n=16) and established measurement tools. Results: The theoretical frameworks permitted guided development of the VR training session. Validation gave a median System Usability Scale of 80 (IQR 77.5-85); for the User Satisfaction Evaluation Questionnaire, the median score was 27 (IQR 26-28). After the VR training, there was a significant gain in the participants' confidence in treating a dyspnoeic patient (median pre-training 2 (IQR 2-3) vs. post-training 3 (IQR 3-3), p=0.016).Lessons learned include the need for involving medical experts, medical educators and technical experts at an equivalent level during the entire development process. Peer-teaching guidance for VR training was feasible.Conclusion: The proposed frameworks can be valuable tools to guide the development and validation of scientifically founded VR training. The new VR training session is easy and satisfying to use and is effective - and is almost without motion sickness.Hintergrund: Virtual Reality (VR) kann einen innovativen Ansatz in der Ausbildung für Notfallsituationen bieten, insbesondere in Zeiten von COVID-19. Hierbei besteht kein Infektionsrisiko, und das Verfahren ist skalierbar und ressourcenschonend. Allerdings sind die Herausforderungen und Probleme, die bei der Entwicklung von VR-Trainings auftreten können, oft noch unklar oder werden unterschätzt. Wir stellen beispielhaft die Durchführbarkeitsbewertung der Entwicklung eines VR-Trainings vor, das für Trainingszwecke zur Behandlung von Dyspnoe vorgesehen ist. Unsere Bewertung basiert auf Rahmenkonzepten für Serious Games und präsentiert die gewonnenen Erkenntnisse. Wir bewerten die VR-Trainingseinheit hinsichtlich der Benutzerfreundlichkeit und -zufriedenheit sowie hinsichtlich der subjektiven Wirksamkeit und Arbeitsbelastung der Teilnehmenden. Methodik: Das VR-Training wurde anhand des etablierten Rahmenkonzepts (Schritte 1-4) für Serious Games von Verschueren et al. sowie anhand von Nicholsons RECIPE-Elementen für Meaningful Gamification entwickelt. Die primäre Validierung (Schritt 4) erfolgte an der Universität Bern, Schweiz, in einer Pilotstudie ohne Kontrollgruppe mit einer Zufallsstichprobe von Medizinstudierenden (n=16) und etablierten Messinstrumenten. Ergebnisse: Die theoretischen Rahmenkonzepte ermöglichten die zielgerichtete Entwicklung der VR-Trainingseinheit. Die Validierung ergab für die System Usability Scale (SUS) einen Median von 80 (IQR 77,5-85). Für den User Satisfaction Evaluation Questionnaire (USEQ) lag der Median bei 27 (IQR 26-28). Nach dem VR-Training war ein signifikanter Zuwachs an Selbstvertrauen der Teilnehmenden bei der Behandlung von Patienten mit Dyspnoe zu verzeichnen (Median vor dem Training 2 (IQR 2-3) vs. Median nach dem Training 3 (IQR 3-3), p=0,016).Zu den gewonnenen Erkenntnissen gehört die Notwendigkeit, medizinische Experten, medizinisches Lehrpersonal und technische Experten gleichermaßen am gesamten Entwicklungsprozess zu beteiligen. Die Anleitung anhand von Peer-Teaching für das VR-Training war praktikabel.Schlussfolgerung: Die vorgeschlagenen Rahmenkonzepte können wertvolle Hilfsmittel in der gezielten Entwicklung und Validierung von wissenschaftlich fundiertem VR-Training sein. Die neue VR-Trainingseinheit ist einfach und zufriedenstellend in der Anwendung, sie ist effektiv, und darüber hinaus nahezu frei von Anzeichen der Bewegungskrankheit (Kinetosen)

[Eosinophilia, diarrhea and asthma in a young woman]

We present the case of a young woman that was diagnosed with Churg-Strauss syndrome. The classical as well as the atypical symptoms, signs and findings are discussed in the context of clinically relevant differential diagnoses. The diagnostic criteria and the relevant aspects of pathogenesis, clinical course and treatment are reviewed. In addition, the similarities and differences with respect to the other idiopathic interstitial eosinophilic pneumopathies are described

Additional file 1 of Development and usability testing of a fully immersive VR simulation for REBOA training

Additional file 1. Some free-text comments from participants. Free-text responses were collected with an open response item. Comments of the participants generally indicated a good acceptance. However, critical aspects were illuminated as well