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Recent eLetters

Displaying 1-10 letters out of 795 published

  1. In response to the e-letter "An interesting study of the wrong cohort"

    Many thanks for your interest in our study.

    We agree that as a retrospective study that compares head injured patients presenting within and after 24 hours of injury that have undergone CT imaging our study does have limitations. However, there are currently few data to guide clinicians in this area. We found only 2 other retrospective cohort studies and an abstract that assessed such patients in a recently published systematic review {1}. Our study is the first to directly compare patients presenting late after injury with those who don't, to our knowledge, and includes novel findings.

    We agree that it is not possible to estimate the overall prevalence of significant traumatic brain injury in head injury patients presenting after 24 hours of injury from our study. However, our study shows that in patients that undergo CT imaging the prevalence of significant injury is similar in patients presenting within and after 24 hours of injury. The yield from the CT scans performed suggests a similar relation between risk of pathological finding and clinician behaviour, but agree the denominator for those attending late would be needed to confirm this. Our key finding is that absence of NICE guideline indications may not reliably exclude significant injuries in patients presenting after 24 hours of injury.

    We agree with Richard Body (Associate Editor) when he opines that the findings of our study probably call for further research. A prospective study that evaluates all head injured patients presenting late and identifies the risk factors that predict significant injury would inform clinician gestalt. This, in turn, would likely reduce the risk of missing significant injuries in what appears to an important sub-group.

    1. Marincowitz C, Smith CM, Townend W. The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review. Systematic reviews 2015;4(1):165.

    Conflict of Interest:

    We both contributed to the original article.

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  2. An interesting study of the wrong cohort

    I thank the authors for highlighting an ongoing concern I have with NICE head injury guidance - namely that the guidance is based on studies of acute head injuries presenting soon after injury and doesn't take delayed presentations into account. However my concern would be the reverse of their own as I feel if we adhered to NICE guidance in patients presenting after 24 hours we would be performing large numbers of unnecessary investigations for very low yield.

    I cannot help but feel that the entire premise of this paper and conclusions reached are incorrect simply because they look at the wrong cohort.

    The paper examines those patients who underwent a CT of their head and compares between the delayed presentation and early presentation (greater and less than 24 hours respectively) and those that had a NICE indication and those that didn't.

    This is easy data to collect retrospectively and analyse but not the most appropriate.

    What is far more valuable is to know what happened to ALL the patients presenting post head injury - not just those who were selected for a CT. This is far more challenging data to collect due to coding issues, quality of note keeping and the vastly higher number of patients involved.

    Conclusions such as clinicians being aware that 'application of NICE guidance to those presenting >24hrs misses a high proportion of injuries, clinicians appear aware of this and so are more likely to request a CT even though no NICE indication is present' appear invalid. We do not know what proportion of patients with a head injury presented before and after 24 hours we only know those that had a CT performed. The clinicians themselves had already selected a group based upon a combination of NICE guidance and gestalt.

    We can best evaluate the sensitivity and specificity of the NICE guidelines for patients presenting after 24 hours by looking at the unselected head injured patients presenting to the ED. If we evaluate those who a clinician had seen and ordered a CT head on then all we can really comment on is the positive and negative predictive value of the guidelines in the ED clinician selected patient (which one would hope to be an inherently higher disease prevalence group).

    Whilst I agree that there is somewhat of a lacuna in the guidance when it comes to delayed presentations of head injuries, clinical gestalt is key rather than the use of NICE guidance. The data presented does not in my view show a distinct risk profile for those presenting after 24 hours with a head injury (as stated in the conclusions), but instead demonstrates that the negative predictive value of the 2007 NICE Head Injury guidelines in patients at Hull Royal Infirmary who had a CT after presenting >24 hours after head injury to be lower than in those presenting <24 hours after head injury. (7.7% compared with 9.9%).

    Conflict of Interest:

    None declared

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  3. Measuring outcomes of first aid education

    Pocock et al present fascinating insight to the challenges of the pre -hospital environment for undertaking clinical trials (Human factors in pre hospital research: lessons from the PARAMEDIC trial Pocock H, et al, Emerg Med J 2016; 33: 562-568) which explain the lack of clear strategies of the implementation of research protocol on this issue. The need for strong relationships between teams brings into focus the potential to extend this study to incorporate the actions of the first person on the scene. Recognizing the need for 'normalization' of participation in trails reflects a similar challenge to find bystander participants to help us understand lay responder behaviour. Both aspects chime with findings of research from an earlier point in the pre-hospital care process studied by the British Red Cross and published in this journal in 2013 (Can first aid training encourage individuals' propensity to act in an emergency situation? Oliver E, et al, Emerg Med J 2013 pp.emermed-2012).

    The Utstein Formula for Survival (The Formula for Survival in Resuscitation, Soreide E et al, Resuscitation. 84:1487-1493, 2013) models the value of medical science as a multiplicative relationship with educational efficiency and local implementation, yet the volume of research around how to make education for bystanders effective in order to guarantee effective intervention is scant. An analysis of the 2015 International Liaison Committee on Resuscitation's 2015 guidelines identified a lack of research into how best to plan and prepare and how to recognize an emergency. These crucial gaps need to be filled if bystander interventions are to be adequate enough for EMS teams to improve their chances of saving lives.

    New guidelines produced by the International Federation of the Red Cross (International first aid and resuscitation guidelines 2016) include a new chapter on Education reflecting work to date and incorporating evidence for improving educational approaches and strategies. Poignant, though, is the lack of an internationally agreed definition and metric for effective first aid education. We continue to be severely challenged to understand the outcome behaviours of lay responders who have been trained to help and their interaction with the ill or injured. How do we know if first aid education has been effective? What do we mean by effective education? And how could we measure it consistently? How do we get a clear picture of how attitudes and behaviours are related to acquisition of skills and knowledge?

    The volume of medical science relating to emergency response is substantial. Does such dominance limit discussion on educational efficiency and local implementation of lay responder strategies? We urge support for such studies to develop these aspects of survival.

    Emily Oliver Senior Education Research Manager British Red Cross eoliver@redcross.org.uk

    Conflict of Interest:

    None declared

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  4. The effectiveness of primary care services located within EDs - optimising streaming

    The comprehensive review by Ramlakhan et al of the effectiveness of primary care services located within EDs draws mixed conclusions. Whilst initial efficiency savings were identified (both in terms of GP resource utilisation and overall cost) and subsequent hospital admission and referrals appeared reduced, other outcomes proved disappointing or at best equivocal including length of stay, waiting time and patient satisfaction.

    Given the ongoing critical performance challenges faced by hospitals, that not only derive from increasing volumes of attendance (whether through provider-induced demand or otherwise) but also the effect consequently imposed by inefficiencies and the internal degradation of pathways, Emergency Departments need to do something radical. The crucial importance of optimising hospital productivity legitimises the use of novel streaming services that aim both to minimise the effect on the hospital of low acuity patients and, specifically, to de-bulk ED Majors attendance. If a streaming service is to be used, then the same article's review by Abdulwahid et al identifies the positive impact of senior doctor assessment at triage. In contrast to the mainly senior ED clinicians that were reviewed in this paper, our own belief is that senior GPs have a better chance of deflecting or re-directing potential admissions, not least because of clinician awareness of community-based options for care.

    The introduction of a streaming service to the front door of Leicester Royal Infirmary (Europe's busiest ED) has aimed to achieve success using immediate clinical assessment by a senior GP on arrival followed by rapid assessment using 3 other streaming GPs. In a 6 month period this small team managed to treat or redirect 19% of all day time walk in patients that presented (equating to 16,094 patients per year not entering hospital) while only admitting 5% of patients to ED Majors. This scale of success in streaming can result in significant performance advantage for the hospital, both effectively redirecting patients that could be cared for elsewhere and optimising use of internal pathways and thereby improving efficiencies.

    References:

    Ramlakhan S, Mason S, O'Keefe C, et al. Emerg Med J 2016;33:495-503.

    Abdulwahid MA, Booth A, Kuczawski M, et al. Emerg Med J 2016;33:504- 513.

    Conflict of Interest:

    Dr Martin McGrath and Dr Stuart Maitland-Knibb are directors of Lakeside+ Ltd, the company providing the streaming service described at LRI.

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  5. The diagnostic difficulties of lunate and perilunate dislocations.

    I read with interest your recent case report of a perilunate dislocation. This case highlights the importance of careful assessment of often complex wrist X-rays. As a small point, I would however disagree that the 'spilled teacup sign' is a sign of a perilunate dislocation. This sign is a radiological sign of a lunate rather than perilunate dislocation. The key to distinguishing between between both is to first determine what is centred over the radius on the lateral view. If the capitate is centred over the radius and the lunate is tilted out with the 'spilled teacup' sign, a lunate dislocation is diagnosed. If the lunate centres over the distal radius and the capitate is dorsal, a perilunate dislocation is diagnosed, as your case illustrates.

    Conflict of Interest:

    None declared

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  6. POLST CAn Help Paramedics with End-of-Life Dilemmas

    Murphy-Jones and Timmons described paramedics' experiences of end-of- life decision making with regard to nursing home residents, including the challenges faced by paramedics when patients lacked decision making capacity and the resultant stress from uncertainty about appropriate treatments. [1] Among the solutions suggested, an essential, straightforward and well-tested tool for the perplexed paramedic was not available to EMTs in London. Emergency medical providers in the United States report that that Physicians Orders for Life-Sustaining Treatment (POLST) Paradigm forms both increase the likelihood that the wishes of patients with advanced illness and frailty will be honored and decrease the family and health professional angst of end-of-life decision-making in moments of crisis. POLST orders have been shown to be effective in providing clear instructions to emergency medical providers and in making sure patient wishes at end-of-life are honored -- whether for comfort care or more intensive treatment. [2] [3] [4] The POLST Paradigm is an approach to end-of-life planning for those with advanced illness through a process of shared decision-making between a patient and his/her health care professional. As a result of these conversations, patient wishes are documented in a POLST form, [5] which translates the shared decisions into actionable medical orders, indicating a patient's wishes regarding treatments that are commonly used in a medical crisis. As a medical order, emergency personnel - such as paramedics, EMTs, and emergency physicians - must follow these orders in the absence of other information. The orders address preferences regarding cardiopulmonary resuscitation (CPR), other medical interventions such as intubation and mechanical ventilation, and artificially administered nutrition. The orders are signed by a physician (and is some jurisdictions a nurse practitioner or physician assistant) with the concurrence of the patient or legally recognized decision maker. The POLST form is distinctive, often brightly colored and can be displayed prominently so that it can be easily identified by the emergency medical personnel. The POLST Paradigm has been successfully implemented in the vast majority of states in the US, and is being adopted in a growing number of countries. We encourage health systems to adopt and emergency medical providers who care for patients at the end-of-life to learn more about the POLST Paradigm and how it can provide medical orders and direction when an emergent situation faces providers, patients and families. [6]

    Arthur R. Derse, MD, JD Terri A. Schmidt, MD Susan W. Tolle, MD

    [1] Murphy-Jones G, Timmons. Paramedics' experiences of end-of-life care decision making with regard to nursing home residents: an exploration of influential issues and factors. ] doi:10.1136/emermed-2015-205405

    [2] Schmidt TA, Zive D, Fromme EK, Cook JNB, Tolle SW. Physician Orders for Life-Sustaining Treatment (POLST): Lessons learned from analysis of the Oregon POLST Registry. Resuscitation. 2014; 85:480-485.

    [3] Richardson DK, Fromme E, Zive D, Fu R, Newgard CD. Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon. Ann. Emerg. Med. 2014; 63:375- 383.

    (4) Schmidt TA, Hickman SE, Tolle SW, Brooks HS. The Physician Orders for Life-Sustaining Treatment (POLST) Program: Oregon Emergency Medical Technicians'' Practical Experiences and Attitudes. JAGS. 2004; 52, 1430- 1434.

    [5] Oregon POLST Form http://static1.squarespace.com/static/52dc687be4b032209172e33e/t/56e9951204426272fccd1067/1458148629767/Printing+POLST+instructions+3 -16-2016.pdf Accessed June 17, 2016.

    [6] National POLST Paradigm, http://www.polst.org/ Accessed June 16, 2016.

    Conflict of Interest:

    None declared

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  7. Designing urgent primary care centres located at hospital sites: the devil is in the details

    We have read with great interest the review of Ramlakhan et al. (2016)1 on the effectiveness of co-locating emergency departments (ED) and primary care centres and the findings of the authors that the evidence is inconclusive. Yet, we are confident that there are more hints and clues in the available evidence for policy guidance than was done in the paper by Ramlakhan et al. (2016). We will illustrate this with a recent policy analysis carried out in Belgium.2 As Burke (2016)3 states in his editorial it is key to determine the goals of your policy intervention (e.g. improved access; improved flow; reduced costs; improved patient satisfaction) and to monitor the implementation of new models. That is exactly what we have proposed by recommending a 'proof of concept evaluation' for 24/7 GP posts that are co-located with the ED (with one entrance and a joint triage area) in order to substitute ED care by primary care. Indeed, substituting more expensive ED resources by primary care resources seems a legitimate policy goal. Belgium has a very high self-referral rate (71%) and a large share of ED contacts are ambulatory contacts (77%). Furthermore, estimates of inappropriate ED contacts (40-56%) are higher than the internationally reported figures of 20-40%.4 As in other countries there is an ever increasing use of EDs which is in Belgium mainly observed for ambulatory and self-referred ED contacts. In addition, previous policy measures such as large investments in out-of-hours GP posts were unsuccessful in stopping this increasing trend. Most of these out-of-hours GP posts were not located at hospital sites. In the rare occasions where a GP post was co-located with an ED they had separate entrances and triage zones not resulting in substitution.5 Why did our policy recommendation to install GP posts on ED-sites deviate from the inconclusive findings in the Ramlakhan et al. (2016) review? Our review of the literature showed that 'design elements' are essential for successful substitution of ED care by primary care. We believe that these design elements are insufficiently analysed in the Ramlakhan et al. (2016) study. In their review several divergent models of co-location were assessed simultaneously (e.g. nurse-led walk-in clinics instead of GP-lead urgent care centres; models with separate entrances and triage areas for the primary care centre and the ED instead of one central entrance and joint triage area; or even models without a triage function). When analysing these studies more in-depth, it is clear that these design elements are making the difference in substituting ED by primary care. Indeed, 'the devil is in the details'. A difference in prescriptions of medical imaging and laboratory tests can, for instance, be observed when the initial triage process was carried out by trained nurses while this was not the case when triage was done by a receptionist. Moreover, three recent studies which were not included (van Gils-van Rooij (2015)6 for the Netherlands; Cowling et al. (2016)7 for England; Eichler et al. (2014)8 for Switzerland) showed that: a co-location of GP posts with one entrance and joint triage area is effective in reducing the number of self-referred ED contacts; the largest portion of contacts triaged towards the GP does only require care from the GP; and that GPs prescribe less medical imaging and lab tests compared to emergency physicians. We also acknowledge that the literature is not straightforward. Indeed, several reviews9 10 illustrated that an expansion of the available services might unmask latent demand and will increase the overall burden on the emergency care system even more. However, it cannot be concluded from the available studies that this increase in activity is caused by overuse (e.g. shift from regular GP contacts towards urgent care centres) nor by underuse. To account for these and other potential unintended effects we recommend a 'proof of concept' evaluation where these (un- )intended are carefully monitored.

    Reference List

    1. Ramlakhan S, Mason S, O'Keeffe C, et al. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016.

    2. Van den Heede K, Dubois C, Devriese S, et al. Organisation and payment of emergency care services in Belgium: current situation and options for reform. Health Services Research (HSR). Brussels: Belgian Health Care Knowledge Centre (KCE), 2016.

    3. Burke D. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016.

    4. Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009;25(1):7-28.

    5. Philips H, Remmen R, Van Royen P, et al. What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care. BMC health services research 2010;10:222.

    6. van Gils-van Rooij ES, Yzermans CJ, Broekman SM, et al. Out-of- Hours Care Collaboration between General Practitioners and Hospital Emergency Departments in the Netherlands. J Am Board Fam Med 2015;28(6):807-15.

    7. Cowling TE, Ramzan F, Ladbrooke T, et al. Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data. Emerg Med J 2016;33(3):200-7.

    8. Eichler K, Hess S, Chmiel C, et al. Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study. Emerg Med J 2014;31(10):818-23.

    9. Ismail SA, Gibbons DC, Gnani S. Reducing inappropriate accident and emergency department attendances: A systematic review of primary care service interventions. British Journal of General Practice 2013;63(617):e813-e20.

    10. Morgan SR, Chang AM, Alqatari M, et al. Non-emergency department interventions to reduce ED utilization: a systematic review. Academic Emergency Medicine 2013;20(10):969-85.

    Conflict of Interest:

    None declared

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  8. Primary care services located with EDs: Effectiveness depends on matching patients to the right clinician

    We read with interest the paper by Ramlakhan et al (10.1136/emermed- 2015-204900) on the effectiveness of primary care services located in EDs. We have just completed a test cycle week of a GP led model for managing lower acuity patients who present to the Clinical Decisions Unit (CDU) at the Glenfield Hospital, Leicester; however, we reached different conclusions. The CDU is a cardiorespiratory unit that receives mixed acuity urgent patients 24 hours a day from a range of sources (999 ambulance, GP referrals and transfers from both the local ED department and Urgent Care Centre located on the same site two miles away), but not self-referrals. The specialist teams are unable to rapidly manage and discharge low acuity patients because the hospital processes and IT systems were not designed for this purpose, resulting in overcrowding and inefficiency. A GP/specialist nurse 'fast track' area was created to rapidly diagnose (with access to chest x-ray and bloods), and discharge safely, all patients triaged by experienced nurses at the 'front door' as potentially fit for same day discharge using the primary care IT system (SystmOne). 67 patients comprising approximately 30-40% of total attendances were seen and 88% were discharged (mean of 116 minutes compared with up to 6 hours at peak periods of activity). No adverse events or seven day readmissions have been reported. Both patient and staff satisfaction was high. The overall proportion of patients who left the department in less than 6 hours (throughput/flow) increased by around 10% easing pressure on specialists who could then focus on the sicker cohort of patients. GPs handle low acuity problems faster because that fits in with their training and skill set (they appraise rapidly and decide). It is a matter of 'right patient in front of the right clinician'. We are planning a further eight week pilot to consider the cost effectiveness of our model, greater integration with the local urgent care system and the best clinician to triage on arrival.

    Conflict of Interest:

    None declared

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  9. Bland-Altman comparison of haemodynamic monitoring methods; not simply a matter of black and white.

    This comparison of non-invasive haemodynamic devices, although valuable, demonstrates some methodological aspects of the Bland-Altman method that should be considered to ensure the accuracy of any proposed conclusions.

    The statistical minimum for comparison of two medical device measurement methods includes reporting mean ?SD values for both methods, correlation, and Bland-Altman bias and precision, mean % differences between methods, and concordance analysis using four quandrant plots if haemodynamic changes were measured in the same subjects during the repeated observations.(1) Of critical importance for application of Bland- Altman statistics is the range of outputs over which the comparison was made. Repeated measures comparing CO values within a narrow "normal range" provide little useful information,(2) as the mean differences between measures will be small and discrimination will be weak. Additionally it is at high and low outputs that accuracy is the most critical and clinically consequential.

    The authors observed USCOM measures were "considerably" lower than NICCOMO measures, which were similar to the values they expected. However the clinical characteristics of the patients are not described, the mean CO and SVR values or SD were not reported, and no quantitative Bland- Altman values nor CO ranges presented. Further upon proposing disagreement between the two methods, no reference was made to normal USCOM reference values.(3) If any differences existed between the USCOM reference normal values and the USCOM Green study normal values, then operator error may have affected the results, and the disagreement is explained, and the conclusion prefaced with an "in our hands" caveat. Conversely, if the USCOM values by Green et al. agreed with the previously published normal USCOM values, and the patient cohorts were substantially clinically matched, then the conclusion is an error in the measurements by NICCOMO, a possibility not raised by the authors.

    Regardless, this comparison of repeated measures in a single series of subjects is only designed to demonstrate agreement between two methods, and not determine which technology is the most reliable, particularly if the endpoint is attainment of arbitrary and undefined expected values. Clinical accuracy is related to a more extensive and rigorous series of comparisons and proofs involving multiple animal and human studies and comparisons across a range of age groups and clinical applications, and across wide ranges of cardiac outputs against multiple technologies.

    Doppler ultrasound has a long history of reliability and clinical utility for flow measurements.(4) The USCOM 1A, a transcutaneous Doppler monitoring technology has been validated against flow probes in animals across a 6 fold range of outputs during application of inotropes and vasopressors,(5) and from 0.12L/min to 18.7L/min in humans.(6,7) It has been validated against invasive standards and non-invasive standards in approximately 100 studies, and found to provide reliable measures across a range of outputs and ages.(8,9,10) It has been demonstrated to reliably measure CI and SVI and detect fluid responsiveness with approximately 90% sensitivity in patients with AF, free breathing and ventilated patients, patients on vasoactive and particularly those with dynamic circulation such as those with sepsis and septic shock where the autonomic nervous system is active.(11) Further the device is recommended in the paediatric sepsis guidelines as a means of monitoring disease progress and titration of therapy,(12) improves outcomes in paediatric septic shock,(13) and has been recommended as a pregnancy monitoring method for early detection of pre-eclampsia.(14)

    Hodgson et al.,(15) compared inter-rater reliability of stroke volume measurements at baseline and following passive leg raising measurements, by emergency physicians and found a 6% error (r=0.96) between measures by different operators and concluded that "following a training period of less than 5 h, USCOM stroke volume measurements demonstrated excellent inter-rater reliability". This confirmed the feasibility of the USCOM technology in the emergency setting, an assessment not completed in the current study despite the title.

    So the USCOM is comprehensively validated, while NICCOMO is a test technology, and its disagreement with USCOM suggests further evaluation in animals and humans, across a wide range of outputs and diseases is required before its utilisation could be countenanced in emergency medicine.

    Comparison of method studies are technically difficult, and involve establishing a reference standard, USCOM, and then comparing paired measures from a proposed test technique, NICCOMO, acquired under identical conditions. Bland-Altman comparison can only determine if the two methods agree or disagree.(2) If the comparison demonstrates disagreement, as the authors propose, then the appropriate scientific conclusion is that, as the reference method has superior validation and clinical proof, the test method doesn't agree with the reference method "in our hands", and is therefore not valid. However additional studies of any new technology may be worthwhile if a suspicion of occult potential clinical utility persists.

    References: 1. J. Zhang J, Critchley LAH, Huang L. Five algorithms that calculate cardiac output from the arterial waveform: a comparison with Doppler ultrasound. Brit J Anaesth 2015;1-11: doi: 10.1093/bja/aev254 2. Olofsen E, Dahan A, Borsboom G. Improvements in the application and reporting of advanced Bland-Altman method of comparison. J Clin Monit Comput 2015;29:127-139. 3. Phillips RA, Smith BE, West MJ, Rainer T, Brierley J, Harris T, He S, Burstow DJ, Fraser JF. New noninvasive haemodynamic nomograms to simplify hypertensive management in neonates, children and adults. J Hypertension 2012;30(suppl 1):538 4. Sotamura S. Ultrasonic Doppler method for the inspection of cardiac functions. J Acoust Soc Am 1957;29:1181-1185. 5. Phillips RA, Hood SG, Jacobson BM, West MJ, Wan L, May CN. Pulmonary artery catheter (PAC) accuracy and efficacy compared with flow probe and transcutaneous Doppler (USCOM): An ovine validation. Crit Care Res Prac 2012; doi:10.1155/2012/621496 6. Phillips RA, Paradisis M, Evans NJ, Southwell DL, Burstow DJ, West MJ. Validation of USCOM CO Measurements in Preterm Neonates by Comparison with Echocardiography. 26th ISICEM 2006, Critical Care 2006;10(Suppl1):144. 7. Su BC, Yu HP, Yang MW, Lin CC, Kao MC, Chang CH, Lee WC. Reliability of A New Ultrasonic Cardiac Output Monitor in Recipients of Living Donor Liver Transplantation. Liver Transpl 2008;14:1029-1037 8. Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM). Anaesthesia 2012; doi:10.1111/j.1365-2044.2012.07311.x 9. Beltramo F, Menteer J, Razavi A, Khemani RG, Szmuszkovic J, Newth CJL, Ross PA. Validation of an ultrasound cardiac output monitor as a bedside tool for pediatric patients. Ped Cardiol 2015, DO I 10.1007/s00246-015- 1261-y 10. Wong LS, Yong BH, Young KK, Lau LS, Cheng KL, Man JS, Irwin MG. Comparison of the USCOM Ultrasound Cardiac Output Monitor with Pulmonary Artery Catheter Thermodilution in Patients Undergoing Liver Transplantation. Liver Transpl 2008;14:1038-1043 11. Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study. Critical Care 2009;39:666-688 12. Brierley J, Carcillo J, Choong K, et al. 2007 American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock* Crit Care Med. 2009; 37(2):666-688 13. Deep A, Goonasekera CDA, Wang Y, Brierley J. Evolution of haemodynamics and outcome of fluid refractory septic shock in children. Int Care Med 2013 DOI 10.1007/s00134-013-3003-z. 14. Gagliardo G, Lo Presto D, Tiralongo GM, Pisanai I, Scala RL, Novelli GP, Vasopollo B, Velensise H. Cardiac output and systemic vascular resistance as a target for the intrauterine treatment of fetal growth restriction. J Preg Hypertension 2015 5:133(267-POS). doi:10.1016/j.preghy.2014.10.273 15. Hodgson LE, Venn R, Forni LG, Samuels TL, Wakeling HG. Measuring the cardiac output in acute emergency admissions: use of the non-invasive ultrasonic cardiac output monitor (USCOM) with determination of the learning curve and inter-rater reliability. J Int Care Soc 2015, DOI: 10.1177/1751143715619186

    Conflict of Interest:

    Employee and shareholder of Uscom Limited

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  10. Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper

    Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper

    Lillitos et al are to be congratulated on a most helpful paper clarifying whether disease severity and the need for hospital admission can be predicted using two similar PEWS systems (Brighton PEWS and COAST - the Children's Observation And Severity Tool).

    There has been a proliferation in the uptake and usage of Paediatric Early Warning Scores (PEWS) in recent years, as part of the patient safety agenda. Their original (dare I say, intended) purpose was to detect early deterioration in hospitalised children, prompting timely interventions and predicting the need for possible Paediatric Intensive Care admission whereas increasingly, PEWS are being employed generically in paediatric practice in the UK. Like Cinderella's slipper (following the spirit of this season), Early Warning systems are attractive, colourful and everybody wants to claim them for their own, with Ambulance Call Response/Prioritisations, Hospital Admissions, ED Triage Systems, Telephone Triage and Decision Making algorithms, Minor Injury/Walk-in centres (to name but a few potential suitors) all seeking to shoe-horn their patient's demographics into one of the currently available scoring systems, in some situations avoiding the need for proper face-to-face clinical assessment.

    Of particular importance was the author's subdivision of presenting complaints into both minor and significant "Medical" and "Surgical" conditions which highlights some of the limitations of Early Warning Scores.

    It is reassuring to find that both the Brighton and COAST scores were good at detecting significant respiratory illnesses, (Brighton and COAST ROC scores yielding AUCs of 0.9 and 0.87, respectively). Whilst intended to be universally applicable, both these scores have an inherent respiratory design-bias, measuring multiple respiratory parameters (respiratory rate, moderate-severe respiratory distress, supplemental oxygen (Brighton), hypoxia (saturations ?92% in air (COAST))), both expected and desirable qualities given the prevalence of respiratory illness encountered in acute "paediatric practice" (asthma/wheeze, bronchiolitis, croup, URTI, LRTI etc.)

    Importantly, both local and regional experience and reviews of adverse incidents, morbidity and mortality have anecdotally found PEWS scores to be less reliable in the early detection of neurological conditions, surgical conditions and blunt and penetrating trauma (where compensatory mechanisms delay physiological abnormalities until disease progression has advanced) and again the authors should be thanked for quantifying these reported observations (they describe AUC's of i) 0.48AVERAGED for significant neurology, 0.56 for general surgical conditions, 0.65 for significant trauma and 0.7 for head injury; Table 3). (I suspect that in major trauma, simple descriptors such as "fall from height", "ejected through windscreen" might well outperform medical COAST/PEWS systems).

    The study also validates what has been termed the "currency of COAST" - that a high COAST score (a score ?3) must be taken seriously. (Due to the score's poor specificity, the converse is not true - a low score does not exclude significant illness/the need for admission). By choosing to use the PEWS/COAST score at Triage, the authors were reliant solely on abnormal physiological findings at one isolated point in time (influenced by external factors such as crying and fever etc.) whereas tracking scores over a period of observation or on an admissions/inpatient wards may have revealed the trends of deterioration described in the early papers that supported the introduction of PEWS systems (1). Even so, like other clinical descriptors (e.g. haemorrhagic rash, shock, unresponsive, fitting) the chosen individual trigger parameters would be expected to prompt an appropriate nursing/medical response e.g. this child's heart rate is abnormally high, their respiratory rate is depressed, their conscious level diminished etc. (Previous authors have discussed the possible merits of using aggregate weighted scores rather than single clinical parameters but neither approach has been found to be superior to the other (2); aggregate scores are certainly more complex, less user- friendly and suggest a knowledge and appreciation of disease processes that - if universal- is at best, currently poorly understood i.e. what happens to "normal" heart rates in an unwell/injured 5-year old as their condition progresses).

    One of the study's shortcomings was to "wrongly" assign each child with a universal score of "1" for parental concern, "on the basis that parents/carers, by bringing their child to the ED, were by default concerned". Parents do sometimes make uninformed choices when presenting to ED; 60% of parents whose children had ATS (Australasian Triage System) category 4 and 5 scores described the severity of their child's illness as the primary (or secondary) reason for ED attendance (3). The intension behind the "Doctor/Nurse/Family concern" trigger was to appreciate the importance of gut feelings - something subjective, often unquantifiable and unmeasurable - to prompt an appropriate clinical response. (Van den Bruel, A et al's paper helpfully supports this approach (4)). [Within the confines of a retrospective study, the authors can legitimately claim that they unfortunately had no alternative]. As an advocate of PEWS scores (I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010), I do question how often these scoring systems have identified a child that would not otherwise have been identified and am concerned that, in the headlong rush to employ a PEWS system in any and every clinical setting, their value has been overstated at the expense of comprehensive nursing observations and medical assessments. They do most certainly i) have an important role to play in ensuring deteriorating trends are appreciated, communicated and acted upon by nursing and medical teams and ii) can be useful when used as a safety netting tool but, paraphrasing social media, might I suggest that we.... "Don't confuse my early warning score for years of clinical training and experience!"

    Dr Julian Sandell, Consultant in Paediatric Emergency Medicine, Poole Hospital NHS Foundation Trust, and author of the Children's Observation And Severity Tool (COAST), 2010

    www.institute.nhs.uk/safer_care/paediatric_safer_care/pews_charts.html

    REFERENCES: (1) Detecting and managing deterioration in children. Monaghan A. Paediatric Nursing. 2005 Feb;17(1):32-35 (2) "Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration". Chapman SM et al. Intensive Care Med. 2010 Apr;36(4):600-11. Epub 2009 Nov 26. (3)Why parents present to ED for non-urgent care. Williams A et al. ADC 2009;94:817-820 (4)Clinicians' gut feeling about serious infections in children: observational study. Van den Bruel, A et al. BMJ 2012;345:e6144

    Conflict of Interest:

    I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010

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