scholarly journals Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review

2020 ◽  
Vol 5 (1) ◽  
Author(s):  
Emma Bourke-Matas ◽  
Emma Bosley ◽  
Paul Gowens ◽  
Karen Smith ◽  
Kelly-Ann Bowles
Keyword(s):  
Scoping Review ◽  
Early Identification ◽  
Ad Hoc ◽  
Prehospital Care ◽  
Early Warning Systems ◽  
Operational Definition ◽  
Prehospital Setting ◽  
Clinical Deterioration ◽  
Future Care ◽  
Additional Reference

<p><strong>Introduction</strong></p><p>Early identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting.</p><p> </p><p><strong>Methods</strong></p><p>In December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken.</p><p> </p><p><strong>Results</strong></p><p>A total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS.</p><p> </p><p><strong>Conclusion</strong></p><p>This review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes. </p>

scholarly journals Machine Learning-based Early Warning Systems for Clinical Deterioration: A Systematic Scoping Review (Preprint)

10.2196/25187 ◽  
2020 ◽  
Author(s):  
Sankavi Muralitharan ◽  
Walter Nelson ◽  
Shuang Di ◽  
Michael McGillion ◽  
PJ Devereaux ◽  
...  
Keyword(s):  
Machine Learning ◽  
Scoping Review ◽  
Early Warning ◽  
Early Warning Systems ◽  
Clinical Deterioration ◽  
Warning Systems

Are paramedic graduates effectively prepared for death? A scoping review

2021 ◽  
Vol 13 (10) ◽  
pp. 408-413
Author(s):  
Anna Somers
Keyword(s):  
Mental Health ◽  
Literature Review ◽  
Scoping Review ◽  
Prehospital Setting ◽  
Death Education ◽  
Preparation Methods ◽  
Scoping Literature Review ◽  
Potential Impact ◽  
New Research

Paramedics often come across death because of the nature of their work. Attending an incident involving the death of a patient could affect a paramedic's mental health. A scoping literature review surrounding the readiness and education regarding death in the prehospital setting for paramedic students was carried out. Given the potential impact upon practitioner mental health, the review aimed to determine the quality and extent of new research regarding education in death for paramedics. Four themes arose from the review: inadequate preparation; methods of death education; improved confidence; and implications for more research.

scholarly journals Advance care planning evaluation: a scoping review of best research practice

2021 ◽  
pp. bmjspcare-2021-003193
Author(s):  
Sophie Gloeckler ◽  
Tanja Krones ◽  
Nikola Biller-Andorno
Keyword(s):  
Advance Care Planning ◽  
Scoping Review ◽  
Retrospective Chart Review ◽  
Evidence Base ◽  
Future Research ◽  
Care Planning ◽  
Completion Rates ◽  
Future Care ◽  
Actual Care ◽  
Advance Care

Various indicators have been used to evaluate advance care planning, including completion rates, type of care received, and satisfaction. Recent consensus suggests, though, that receiving care consistent with one’s goals is the primary outcome of advance care planning and assessment should capture this metric. Goal concordant care is challenging to measure, and there is little clarity about how best to do so. The aim of this scoping review is to explore what methods have been used to measure goal concordant care in the evaluation of advance care planning. PubMed, Embase, PsycINFO, CINAHL and Cochrane were searched in September 2020 to identify studies that aimed to track whether advance care planning affected the likelihood of patients receiving care that matched their preferred care. 135 original studies were included for review. Studies used retrospective chart review (36%, n=49), questionnaire (36%, n=48) and interview (31%, n=42), focusing on both patients and proxies. Studies considered both actual care received (55%, n=74) and hypothetical scenarios anticipating possible future care (49%, n=66); some studies did both. While the reviewed studies demonstrate the possibility of working towards a solid methodology, there were significant weaknesses. Notably, studies often lacked enough reporting clarity to be reproducible and, relatedly, key concepts, such as end-of-life or preferred care, were left undefined. The recommendations that follow from these findings inform future research approaches, supporting the development of a strong evidence base to guide advance care planning implementation in practice.

scholarly journals Algorithms for Prediction of Clinical Deterioration on the General Wards: A Scoping Review

2021 ◽  
Author(s):  
Roel V Peelen ◽  
Yassin Eddahchouri ◽  
Mats Koeneman ◽  
Tom H van de Belt ◽  
Harry van Goor ◽  
...  
Keyword(s):  
Scoping Review ◽  
Data Extraction ◽  
Vital Signs ◽  
Population Data ◽  
Primary Objective ◽  
General Ward ◽  
Clinical Deterioration ◽  
Predictive Algorithms ◽  
Study Characteristics ◽  
Input Variables

OBJECTIVE: The primary objective of this scoping review was to identify and describe state-of-the-art models that use vital sign monitoring to predict clinical deterioration on the general ward. The secondary objective was to identify facilitators, barriers, and effects of implementing these models. DATA SOURCES: PubMed, Embase, and CINAHL databases until November 2020. STUDY SELECTION: We selected studies that compared vital signs–based automated real-time predictive algorithms to current track-and-trace protocols in regard to the outcome of clinical deterioration in a general ward population. DATA EXTRACTION: Study characteristics, predictive characteristics and barriers, facilitators, and effects. RESULTS: We identified 1,741 publications, 21 of which were included in our review. Two of the these were clinical trials, 2 were prospective observational studies, and the remaining 17 were retrospective studies. All of the studies focused on hospitalized adult patients. The reported area under the receiver operating characteristic curves ranged between 0.65 and 0.95 for the outcome of clinical deterioration. Positive predictive value and sensitivity ranged between 0.223 and 0.773 and 7.2% to 84.0%, respectively. Input variables differed widely, and predicted endpoints were inconsistently defined. We identified 57 facilitators and 48 barriers to the implementation of these models. We found 68 reported effects, 57 of which were positive. CONCLUSION: Predictive algorithms can detect clinical deterioration on the general ward earlier and more accurately than conventional protocols, which in one recent study led to lower mortality. Consensus is needed on input variables, predictive time horizons, and definitions of endpoints to better facilitate comparative research.

Utility of M-Mode Echocardiography for Early Identification of Infants with Persistent Pulmonary Hypertension of the Newborn

PEDIATRICS ◽  
1981 ◽  
Vol 68 (4) ◽  
pp. 515-525 ◽  
Author(s):  
Lilliam M. Valdes-Cruz ◽  
Golde C. Dudell ◽  
Angelo Ferrara ◽  
Barbara J. Nickles
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Disease ◽  
Early Identification ◽  
Clinical Deterioration ◽  
Persistent Pulmonary Hypertension ◽  
Time Interval ◽  
Ejection Time ◽  
Systolic Time Interval ◽  
Systolic Time ◽  
Ventricular Ejection Time

The clinical syndrome of persistent pulmonary hypertension of the newborn (PPHN) still carries high mortality in spite of improved neonatal care. The purpose of this prospective study was to assess the utility of M-mode echocardiography for the early identification of infants with PPHN prior to clinical deterioration. Echocardiograms of 51 infants who needed fractional inspiratory oxygen (FIO2) ≥0.25 to maintain adequate Pao2 within 36 hours of life were compared to those of 115 healthy full-term and preterm newborns. Of the 51 infants, ten had elevated systolic time interval ratios of both ventricles simultaneously (ventricular pre-ejection period to ventricular ejection time [RPEP/RVET ≤0.50, LPEP/LVET ≤0.38J]). All of these newbrns had PPHN that was manifest clinically by 11 to 30 hours of age. The echocardiographic findings preceded clinical deterioration by at least one to five hours in all cases. The other 41 infants had clinical courses consistent with uncomplicated pulmonary disease. These data indicate that systolic time interval ratios, although not accurate measures of pulmonary arterial pressure and/or pulmonary vascular resistance, permit early identification of infants with PPHN and separation from others with uncomplicated pulmonary disease.

Management of limb and pelvic injuries

2016 ◽  
Author(s):  
Omar Sabri ◽  
Martin Bircher
Keyword(s):  
Early Identification ◽  
Bone Fractures ◽  
Pelvic Ring ◽  
Prehospital Care ◽  
Physiological State ◽  
Long Bone ◽  
Mechanism Of Injury ◽  
Early Management ◽  
Pelvic Ring Injuries ◽  
Lethal Triad

Pelvic ring injuries can be life and limb threatening. The mechanism of injury can often be a good indicator of the type of injury; the Young & Burgess classification deploys that concept to full effect. Early identification based on mechanism of injury and improved prehospital care can play a major role in the outcome following such injuries. Pelvic ring injuries can lead to significant haemorrhage. Mechanical measures to stabilize the pelvis, in addition to modern concepts of damage control resuscitation (DCR), have been shown to be effective in early management of potentially life-threatening haemorrhage. Emphasis is now entirely on protecting the primary clot following a pelvic ring injury. Mechanical disturbance by log rolling the patient or springing of the pelvis are strongly discouraged. Early radiological clearance of the pelvis is encouraged. The lethal triad of coagulopathy, acidosis, and hypothermia should be corrected simultaneously to improve outcome. A traffic light system for monitoring venous lactate as an indicator of the patients’ physiological state can help the intensive care practitioner and the surgeon identify optimum timing for surgery. Pelvic ring injuries are associated with significant concomitant injuries. Limb trauma can also be life or limb threatening. Early identification, splinting, and resuscitation follow the same guidelines as pelvic ring injuries. Open long bone fractures should be managed by senior orthopaedic and plastic surgeons.

The early identification of people with personality disorder in the criminal justice system

2020 ◽  
Vol 60 (4) ◽  
pp. 294-300
Author(s):  
Laura Craster ◽  
Andrew Forrester
Keyword(s):  
Criminal Justice ◽  
Personality Disorder ◽  
Early Identification ◽  
Justice System ◽  
Substance Misuse ◽  
Screening Tool ◽  
Police Custody ◽  
Future Care ◽  
Time Limitations ◽  
Very High

The prevalence of personality disorder is very high among criminal justice (correctional) populations, yet our understanding of this condition as it arises in police custody is presently limited. Although healthcare screening has a well-described role within criminal justice settings, including police custody, specific screening for personality disorders has hardly been considered. Yet such screening is broadly in keeping with the aims of liaison and diversion services and the general healthcare principle of early identification, has the potential to inform future care pathways and ameliorate risk and could in some cases inform future sentencing arrangements including community alternatives. Therefore, there is a need for research to consider the design and implementation of a suitable screening tool for application as early as possible in the criminal justice pathway, either as a stand-alone instrument, or as part of a wider package of healthcare screens. It will be important to consider the feasibility of any such design, given environmental and time limitations within police custody and the high levels of substance misuse, with issues relating to intoxication and withdrawal.

scholarly journals Use of scratchcards for allocation concealment in a prehospital randomised controlled trial

2018 ◽  
pp. emermed-2018-207881 ◽  
Author(s):  
Leigh Keen ◽  
Jenna Katherine Bulger ◽  
Nigel Rees ◽  
Helen Snooks ◽  
Greg Fegan ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Randomised Controlled Trial ◽  
Prehospital Care ◽  
Controlled Trial ◽  
Allocation Concealment ◽  
Prehospital Setting ◽  
Random Allocation ◽  
Registration Number ◽  
Randomised Controlled ◽  
Fascia Iliaca Compartment Block

BackgroundRapid Analgesia for Prehospital Hip Disruption was a small study designed to determine the feasibility of undertaking a randomised controlled trial (RCT) to test the clinical and cost-effectiveness of paramedics administering Fascia Iliaca Compartment Block as early prehospital pain relief to patients with a fractured hip. The objective was to devise a simple and effective method of random allocation concealment suitable for use by paramedics while in the emergency prehospital setting.MethodsScratchcards were produced using scratch-off silver stickers which concealed the trial arm allocation. Paramedics were each allocated a unique range of consecutive numbers, used as both the scratchcard number and the patient’s study ID. The cards were designed to allow the paramedic to write on the incident number, date and signature. A small envelope holding the cards was prepared for each paramedic. The study took place between 28 June 2016 and 31 July 2017 in the Swansea area.ResultsNineteen trial paramedics used 71 scratchcards throughout the study and reported no problems randomly allocating patients using the scratchcards. Five protocol deviations were reported in relation to scratchcard use. On auditing the scratchcards, all unused cards were located, and no evidence of tampering with the silver panel was found.ConclusionParamedics can use scratchcards as a method of randomly allocating patients in trials in prehospital care. In the future, a method that allows only the top card to be selected and a more protective method of storing the cards should be used. Scratchcards can be considered for wider use in RCTs in the emergency prehospital setting.Trial registration numberISRCTN60065373; Post-results.

scholarly journals Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration

2021 ◽  
Vol 11 ◽  
Author(s):  
Dylan E. Graetz ◽  
Emily Giannars ◽  
Erica C. Kaye ◽  
Marcela Garza ◽  
Gia Ferrara ◽  
...  
Keyword(s):  
Pediatric Oncology ◽  
Early Warning Systems ◽  
Clinical Deterioration ◽  
High Rate ◽  
Structured Interviews ◽  
Oncology Patient ◽  
Research Hospital ◽  
Pediatric Oncology Patient ◽  
Patient Deterioration ◽  
The Impact

BackgroundPediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians’ emotional responses to deterioration events.MethodsSemi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children’s Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants’ native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content.ResultsEmotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children’s Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study.ConclusionClinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.

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