Falls and Fractures in the Elderly with Sinus Node Disease: The Impact of Pacemaker Implantation

Background. Falls and fractures in the elderly are among the leading causes of disability. We investigated whether pacemaker implantation prevents falls in patients with SND in a large cohort of patients.Methods. Patient demographics and medical history were collected prospectively. Fall history was retrospectively reconstituted from available medical records. The 10-year probability for major osteoporotic fractures was calculated retrospectively from available medical records using the Swiss fracture risk assessment tool FRAX-Switzerland.Results. During a mean observation period of 2.3 years after implantation, the rates of fallers and injured fallers with fracture were reduced to 15% and 6%, respectively. This corresponds to a relative reduction in the number of fallers of 75% (P<0.001) and of injured fallers of 63% (P=0.014) after pacemaker implantation. Similarly, the number of falls was reduced from 60 (48%) before pacemaker implantation to 22 (18%) thereafter (relative reduction 63%,P=0.035) and the number of falls with injury from 22 (18%) to 7 (6%), which corresponds to a relative reduction of 67%,P=0.013.Conclusion. In patients with SND, pacemaker implantation significantly reduces the number of patients experiencing falls, the total number of falls, and the risk for osteoporotic fractures.

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Corrigendum to “Falls and Fractures in the Elderly with Sinus Node Disease: The Impact of Pacemaker Implantation”

Cardiology Research and Practice ◽

10.1155/2017/3297515 ◽

2017 ◽

Vol 2017 ◽

pp. 1-1

Author(s):

Nazmi Krasniqi ◽

Diana Segalada ◽

Thomas F. Lüscher ◽

Kurt Lippuner ◽

Laurent Haegeli ◽

...

Keyword(s):

Sinus Node ◽

Pacemaker Implantation ◽

The Elderly ◽

Node Disease ◽

Sinus Node Disease ◽

The Impact

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151 Optimising Bone Health on Sheffield Frailty Unit Through Quality Improvement

Age and Ageing ◽

10.1093/ageing/afab030.112 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

C M Orton ◽

N E Sinson ◽

R Blythe ◽

J Hogan ◽

N A Vethanayagam ◽

...

Keyword(s):

Quality Improvement ◽

Fracture Risk ◽

Fragility Fracture ◽

Bone Health ◽

Assessment Tool ◽

Health Assessment ◽

Fragility Fractures ◽

Improvement Project ◽

Number Of Patients ◽

Fracture Risk Assessment Tool

Abstract Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method & Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.

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POS0131 10-YEAR PROBABILITY OF A MAJOR OSTEOPOROTIC FRACTURES IN WOMEN WITH OSTEOARTHRITIS OF THE KNEE JOINT

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.3446 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 277.2-277

Author(s):

E. Usova ◽

O. Malyshenko ◽

M. Letaeva ◽

J. Averkieva ◽

M. Koroleva ◽

...

Keyword(s):

Risk Assessment ◽

Knee Joint ◽

Fracture Risk ◽

Proximal Femur ◽

Assessment Tool ◽

Osteoporotic Fractures ◽

Control Group ◽

Major Osteoporotic Fractures ◽

Fracture Risk Assessment Tool ◽

Clinically Significant

Background:The relationship between osteoporosis and osteoarthritis (OA) is complex and contradictory. Some studies suggest a protective effect of OA in osteoporosis [1-2]. However, other studies show that increased bone mineral density (BMD) in OA not only does not reduce the risk of fractures, but can also increase it [3-4].Objectives:To assess the 10-year probability of osteoporotic fractures using the FRAX calculator in women with OA of the knee joint.Methods:The study included 22 women (average age 63.7±1.01 years) diagnosed with ACP of the knee joint according to the ACR criteria (1991). The Control Group included 24 conditionally healthy women without OA knee joint, with an average age of 63.6±1.37 years.The BMD (g/cm2) and the T-criterion (standard deviation, SD) of the neck of the femur and lumbar spine (LI-LIV) were evaluated by the method of two-power X-ray absorption (DXA) (apparatus «Lunar Prodigy Primo», USA). 10-year probability of major osteoporotic fractures (clinically significant fracture of the spine, distal fracture of the forearm, fracture of the proximal femur, or fracture of the shoulder) and fracture of the proximal thigh with the FRAX calculator (version 3.5 for Russian population).Results:An osteopenic syndrome in the cohort under investigation was found in 42 (91.3%) patients, of whom osteopenia in 24 (52.2%) women and osteoporosis in 18 (39.1%). A normal BMD is registered in 4 (8.7%) patients.In the group of patients with knee joint OA, only 2 (9.1%) of women had a normal BMD, 11 (50.0%) of osteoporosis, and 9 (40.9%). Osteopenic syndrome is generally found in 20 (90,9%) patients.In the control group, osteopenic syndrome has been diagnosed in 22 (91,7%) of whom: osteopenia in 13 (54.2%), osteoporosis in 9 (37.5%) patients. Two (8.3%) women had a normal BMD. There were no statistically significant differences in the structure of the osteopenic syndrome among the studied groups (p=0.961).An analysis of the 10-year probability of major osteoporotic fractures found that women with OA knee joint had the above probability of 12.3±0.91, and in the control group 14.2±1.06 (p=0.085).The 10-year probability of fracture of the proximal femur in women with OA was statistically less significant than in the control group: 1.55 (0.70;1.98) and 2.10 (1.20;2.95), (p=0.031), respectively.Conclusion:The total incidence of the osteopenic syndrome in the cohort under investigation was 91.3% (90.9% in women with OA, 91.7% in the control group). The frequency of registration of osteopenia and osteoporosis in women with OA did not differ statistically significantly from the control group. The probability of major osteoporotic fractures within 10 years was comparable in these groups. The probability of a proximal femur fracture in women with OA was statistically significant, but not clinically significant, compared to the control group.References:[1]Yamamoto Y, Turkiewicz A, Wingstrand H, et al. Fragility Fractures in Patients with Rheumatoid Arthritis and Osteoarthritis Compared with the General Population. J Rheumatol. 2015 Nov;42(11):2055-8.[2]Vala CH, Kärrholm J, Kanis JA, et al. Risk for hip fracture before and after total knee replacement in Sweden. Osteoporos Int. 2020 May;31(5):887-895.[3]Kim BY, Kim HA, Jung JY, et al. Clinical Impact of the Fracture Risk Assessment Tool on the Treatment Decision for Osteoporosis in Patients with Knee Osteoarthritis: A Multicenter Comparative Study of the Fracture Risk Assessment Tool and World Health Organization Criteria. J Clin Med. 2019 Jun 26;8(7):918.[4]Soh SE, Barker AL, Morello RT, et al. Applying the International Classification of Functioning, Disability and Health framework to determine the predictors of falls and fractures in people with osteoarthritis or at high risk of developing osteoarthritis: data from the Osteoarthritis Initiative. BMC Musculoskelet Disord. 2020 Feb 29;21(1):138.Disclosure of Interests:None declared

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Radiology of Osteoporosis

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2015.02.002 ◽

2016 ◽

Vol 67 (1) ◽

pp. 28-40 ◽

Cited By ~ 15

Author(s):

Thomas M. Link

Keyword(s):

Computed Tomography ◽

Fracture Risk ◽

New Technologies ◽

Assessment Tool ◽

Quantitative Computed Tomography ◽

Osteoporotic Fractures ◽

Fragility Fractures ◽

Bone Architecture ◽

Mineral Density ◽

Fracture Risk Assessment Tool

The radiologist has a number of roles not only in diagnosing but also in treating osteoporosis. Radiologists diagnose fragility fractures with all imaging modalities, which includes magnetic resonance imaging (MRI) demonstrating radiologically occult insufficiency fractures, but also lateral chest radiographs showing asymptomatic vertebral fractures. In particular MRI fragility fractures may have a nonspecific appearance and the radiologists needs to be familiar with the typical locations and findings, to differentiate these fractures from neoplastic lesions. It should be noted that radiologists do not simply need to diagnose fractures related to osteoporosis but also to diagnose those fractures which are complications of osteoporosis related pharmacotherapy. In addition to using standard radiological techniques radiologists also use dual-energy x-ray absorptiometry (DXA) and quantitative computed tomography (QCT) to quantitatively assess bone mineral density for diagnosing osteoporosis or osteopenia as well as to monitor therapy. DXA measurements of the femoral neck are also used to calculate osteoporotic fracture risk based on the Fracture Risk Assessment Tool (FRAX) score, which is universally available. Some of the new technologies such as high-resolution peripheral computed tomography (HR-pQCT) and MR spectroscopy allow assessment of bone architecture and bone marrow composition to characterize fracture risk. Finally radiologists are also involved in the therapy of osteoporotic fractures by using vertebroplasty, kyphoplasty, and sacroplasty. This review article will focus on standard techniques and new concepts in diagnosing and managing osteoporosis.

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An unexpectedly high occurrence of aciclovir-induced neuropsychiatric symptoms in patients treated for herpesvirus CNS infection: a prospective observational study

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkz357 ◽

2019 ◽

Vol 74 (12) ◽

pp. 3565-3572 ◽

Cited By ~ 1

Author(s):

Johan Lindström ◽

Anders Helldén ◽

Jan Lycke ◽

Anna Grahn ◽

Marie Studahl

Keyword(s):

Risk Factors ◽

Renal Function ◽

Medical Records ◽

Regression Models ◽

Prospective Observational Study ◽

Neuropsychiatric Symptoms ◽

Cns Infection ◽

Albumin Ratio ◽

Number Of Patients ◽

The Impact

Abstract Background Aciclovir is effective in herpesvirus infections of the CNS. Aciclovir-induced neuropsychiatric symptoms (AINS) have been reported and are associated with high CSF concentrations of aciclovir metabolite 9-carboxymethoxymethylguanine (CMMG). Risk factors except for renal failure have not been explored, and disruption of the blood–brain barrier (BBB) in acute CNS infection may be of interest. Objectives To investigate the impact of risk factors on aciclovir and CMMG concentrations, and to relate the results to AINS. Methods We investigated 21 consecutively included, consenting patients treated with aciclovir or valaciclovir for herpesvirus CNS infection. Regression models were constructed to study the impact of risk factors including BBB disruption, as measured with CSF:serum albumin ratio, on CSF aciclovir and CMMG concentrations. Medical records were assessed retrospectively to identify patients with AINS. Results Increased CSF:serum albumin ratio, as well as decreased renal function and high aciclovir doses, was associated with increased aciclovir and CMMG concentrations in the CSF. We identified five patients with new neuropsychiatric symptoms; four of those were considered to have AINS and had increased CSF CMMG concentrations. Only one patient without suspicion of AINS had an increased CSF CMMG concentration. Conclusions In patients with herpesvirus CNS infections, BBB disruption is associated with increasing aciclovir and CMMG CSF concentrations. We also found an unexpectedly high number of patients with AINS. Evaluation of CSF:serum albumin ratios, renal function and CSF concentrations of aciclovir and CMMG may all contribute to the optimization of aciclovir dosing and avoidance of AINS.

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Impact of the COVID-19 pandemic on emergent pacemaker implantation during lockdown and its aftermath

European Heart Journal ◽

10.1093/eurheartj/ehab724.0404 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

D De Almeida Fernandes ◽

R Cadete ◽

J Guimaraes ◽

E Monteiro ◽

G Costa ◽

...

Keyword(s):

Pacemaker Implantation ◽

Implantation Rate ◽

Tertiary Hospital ◽

World Health ◽

Loop Recorder ◽

Patient Profile ◽

Number Of Patients ◽

The World ◽

Temporary Pacemaker ◽

The Impact

Abstract Background COVID-19 was first considered a pandemic on the 11th of March of 2020 by the World Health Organization. Its impact comprised not only the direct consequences of the disease but a decrease in the follow-up and interventions of patients with cardiovascular (CV) disease. In Portugal and the World, the consequences of this complex paradigm shift on emergent pacemaker implantation rates during and after this pandemic is largely unknown. Purpose We sought to analyse the impact of COVID-19 pandemic on emergent pacemaker implantation rate and patient profile in a tertiary hospital during the first Portuguese lockdown and subsequent post-lockdown period. Methods We retrospectively reviewed the clinical profile of patients who had pacemakers implanted in our hospital in an urgent/emergent setting from March 18, 2020 to May 17, 2020 (lockdown) and May 19 to July 17, 2020 (post-lockdown). This data was then directly compared to the homologous periods from the year before (H1 and H2, respectively). Results A total of 180 patients submitted to emergent pacemaker implantation were included. The cohort was comprised of 29 patients who had a pacemaker implanted during lockdown, 60 post-lockdown, 38 in H1 (+31% vs lockdown) and 53 in H2. Average age and gender proportion were similar for all groups. When comparing lockdown and post-lockdown periods, the number of cases significantly increased in the second period (+106.9%) and there was a tendency for a higher number of temporary pacemaker use (3.4% vs 16.7%; p=0.076). Patients admitted during lockdown were 7.57 times more likely to present with hypotension/shock (odds ratio (OR) 7.57; p=0.013). Regarding lockdown and its homologous 2019 period, there was a decrease in the number of patients admitted (−23.7%). Again, there was a higher tendency for hypotension on presentation during lockdown (p=0.054). In comparison to its homologous 2019 period, post-lockdown saw a slight increase in the number of patients (+13.2%) and more patients presented with bradycardia (16.7% vs 3.8%; p=0.026). Also of note, no patients were admitted to the emergency department during lockdown for anomalies detected on ambulatory tests (Holter, electrocardiogram or implanted loop recorder). Conclusion During lockdown, clinical presentation was generally more severe, with a greater number of patients presenting with hypotension/shock. In addition, there appears to be a lockdown effect on emergent bradyarrhtmias admissions in the post-lockdown period with a profound impact: higher admission rates and more severe presentations including a higher need of temporary pacemaker. Patients with symptoms suggestive of bradyarrhythmias should be advised to present promptly regardless of the pandemic. FUNDunding Acknowledgement Type of funding sources: None. Pacemakers during lockdown/post-lockdown Pacemakers implanted by diagnosis

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Abstract 16144: The Impact of Ventricular Pacing for Elderly Patients With Pacemaker Implantation: Over One Decade and Large Cohort Analysis

Circulation ◽

10.1161/circ.130.suppl_2.16144 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Ayako Kamijima ◽

Kohei Ishibashi ◽

Mitsuru Wada ◽

Ikutaro Nakajima ◽

Koji Miyamoto ◽

...

Keyword(s):

Adverse Events ◽

Elderly Patients ◽

Cohort Analysis ◽

Pacemaker Implantation ◽

The Elderly ◽

Ventricular Pacing ◽

Kaplan Meier ◽

Long Term Effect ◽

Significant Difference ◽

The Impact

Introduction: Previous studies showed that ventricular pacing (VP) increased the cardiac event of patients with pacemaker (PM). However, these studies consisted of patients under 75 years old and the influence of VP for elderly patients (over 75 years old) is still unclear. We sought to evaluate long-term effect of VP for elderly patients. Methods: A total of 782 patients (mean 57.2 years old) underwent PM implantation for brady-arrhythmia were enrolled from 1978 to 2005. The elderly patients (199 patients, over 75 years old, mean 80.7 years old) and all patients were divided into VP and non-VP group, and evaluated adverse events (death or readmission for heart failure). Results: The mean follow-up period was 10.1 years and 84 elderly patients (42%) developed adverse events. Kaplan-Meier analysis revealed that (1) VP increased the adverse event in all patients. (2) There was no significant difference in the adverse events of elderly patients between VP and non-VP group (Fig). Conclusion: VP may be tolerated for elderly patients with PM, whereas VP has no effect for the prognosis.

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P1096Cardioneuroablation changes the type of vaso-vagal response in patients with asystolic reflex syncope

EP Europace ◽

10.1093/europace/euaa162.303 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

R Piotrowski ◽

A Zuk ◽

J Baran ◽

A Sikorska ◽

T Krynski ◽

...

Keyword(s):

Heart Rate ◽

Heart Rate Variability ◽

Postgraduate Medical Education ◽

Sinus Node ◽

Pacemaker Implantation ◽

Heart Rate Variability Parameter ◽

History Of ◽

The Right ◽

The Impact

Abstract Funding Acknowledgements Centre of Postgraduate Medical Education No. 501-1-10-14-19 Background. Cardioneuroablation (CNA) - ablation of ganglionated plexi (GP) to eliminate or reduce parasympathetic overactivity, has been recently proposed as a new therapeutic method in patients with vaso-vagal syncope (VVS) due to cardioinhibitory or mixed mechanism. Purpose. To assess the impact of CNA on the type of VV response during tilt testing (TT). Methods. The study group consisted of the first 20 patients (7 males, mean age 38 ± 9 – year – old) enrolled in the ongoing prospective Roman study (NCT 03903744). All patients had a history of ECG documented syncope due to asystole and confirmed asystolic form of VVS at baseline TT. CNA was performed using electroanatomical system Carto 3 and radiofrequency applications delivered in the right and left atrium at the right anterior GP and right inferior GP sites. The second TT was performed three months later. Resting heart rate (HR) and heart rate variability parameter (SDDN) were also assessed. Results. At baseline TT, nineteen patients had cardioinhibitory syncope (asystole ranging from 3 to 60 s) (sinus node arrest – 17 patients, A-V block – 2 patients) and 1 had mixed form of VVS (asystole lasting 3 s preceded by hypotension). During three-month follow-up no syncopal episodes were noted. At the 3-month TT, 6 (30 %) patients had no syncope whereas the remaining 13 (65 %) had syncope – twelve (60 %) due to vasodepressor mechanism and only one (5 %) due to asystole - as before CNA. One patient did not have TT because of pregnancy. Mean resting HR after CNA was significantly faster and SDNN significantly lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0004 and 74 ± 22 vs 143 ± 40 ms, p = 0.00003, respectively) and these changes were was similar in those who fainted during second TT and those who did not (82 ± 11 vs 81 ± 4 beats/min, p = NS and (75 ± 2 vs 77 ± 18 ms, p = NS, respectively). Conclusions. CNA profoundly affects the type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. These effects are also depicted by changes in HR and heart rate variability. Elimination of TT-induced reflex asystole may prevent clinical recurrences of syncope during short-term follow-up. These findings encourage to conduct further studies involving CNA since this method appears to be effective and obviates the need for pacemaker implantation in young people with reflex asystolic syncope.

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Specifying ICD9, ICPC and ATC codes for the STOPP/START criteria: a multidisciplinary consensus panel

Age and Ageing ◽

10.1093/ageing/afu075 ◽

2014 ◽

Vol 43 (6) ◽

pp. 773-778 ◽

Cited By ~ 14

Author(s):

Dominique A. de Groot ◽

Marloes de Vries ◽

Karlijn J. Joling ◽

Jos P. C. M. van Campen ◽

Jacqueline G. Hugtenburg ◽

...

Keyword(s):

Medical Records ◽

Expert Panel ◽

The Elderly ◽

Adverse Outcomes ◽

Start Criteria ◽

Stopp Criteria ◽

Appropriate Prescribing ◽

Consensus Procedure ◽

The Impact ◽

Full Consensus

Abstract Background: the STOPP/START criteria are a promising framework to increase appropriate prescribing in the elderly in clinical practice. However, the current definitions of the STOPP/START criteria are rather non-specific, allowing undesirable variations in interpretation and thus application. The aim of this study was to design specifications of the STOPP/START criteria into international disease and medication codes to facilitate computerised extraction from medical records and databases. Methods: a three round consensus procedure with a multidisciplinary expert panel was organised to prepare, judge and agree on the design of the STOPP/START criteria specifications in corresponding international disease codes (ICD9 and ICPC) and medication codes (ATC). Results: after two rounds consensus was reached for 74% of the STOPP criteria and for 73% of the START criteria. After three rounds full consensus was reached resulting in a specification of 61 out of 62 STOPP criteria and 26 START criteria with their corresponding codes. One criterion could not be specified and for some criteria corresponding disease codes were lacking or imperfect. Conclusion: this study showed the necessity of a consensus procedure as even experts frequently differed on how to specify the STOPP/START criteria. This specification enables next steps such as prognostic validation of these criteria on adverse outcomes and studying the impact of improving appropriate prescribing in the elderly.

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Digital transformation of the emergency department-inpatient interface (EDii): integration for future innovation

Australian Health Review ◽

10.1071/ah18176 ◽

2020 ◽

Vol 44 (5) ◽

pp. 666

Author(s):

Andrew Staib ◽

Clair Sullivan ◽

Cara Joyce Cabilan ◽

Rohan Cattell ◽

Rob Eley

Keyword(s):

Electronic Medical Records ◽

Patient Outcomes ◽

Medical Records ◽

Emergency Admission ◽

Tertiary Hospital ◽

Digital Transformation ◽

Relative Reduction ◽

Process Measures ◽

The Impact

As the focus of clinicians and government shifts from speciality-based care to system-based key performance indicators such as the National Emergency Access Target (NEAT) or the 4-h rule, integration between emergency department (ED) and inpatient clinical workflows and information systems is becoming increasingly necessary. Such system measures drive the implementation of integrated electronic medical records (ieMR) to digitally integrate these workflows. The objective of this case study was to describe the impact of digital transformation of the ED–in-patient interface (EDii) of a large tertiary hospital on process measures and clinical outcomes for patients requiring emergency admission to hospital. Data were collected from routine clinical and administrative information systems to measure process and clinical outcome measures, including ED length of stay, compliance with the 4-h rule and in-patient mortality between 28 November 2014 and 28 February 2017. The 4-h rule compliance for all patients, as well as for the EDii group (admitted to hospital excluding short stay ward), declined after digitisation. There were 55 fewer deaths in the postintervention group (15% relative reduction; P = 0.02) and a 10% relative reduction in adjusted mortality as measured by the Hospital Standardised Mortality Ratio for emergency patients (eHSMR), which did not reach statistical significance. Digital deceleration in ED performance did occur with an ieMR rollout, but worsening of key patient outcomes was not observed. What is known about this topic? Much has been written about the introduction of electronic medical records (EMRs) in emergency departments. This work sits alongside a substantial body of evidence outlining the relationship between process measures of ED performance and important patient outcomes. However, much less is known about the impact of digital transformation on the complex adaptive system that is the EDii and the impact of digitisation on the vulnerable group of patients who require emergency admission to hospital. What does this paper add? The objective of this case study was to describe the effect of a rapid rollout of an integrated EMR. This EMR simultaneously transformed care delivery both in the ED and the inpatient space and impacted on the politically and clinically sensitive performance and outcome measures of the EDii in a large tertiary hospital. The present study is the first that specifically examined the effect of digitisation at the EDii. What are the implications for practitioners? The understanding that digital deceleration will occur, but that with good patient outcome monitoring worsening of key patient outcomes is not likely to occur, now holds a key place in digital transformation planning. The measures of the EDii examined in this case study provide a foundation for this montoring.

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