Recognition of sepsis in primary care: a survey among GPs

BackgroundEarly recognition and treatment of sepsis are important to reduce morbidity and mortality. Screening tools using vital signs are effective in emergency departments. It is not known how the decision to refer a patient to the hospital with a possible serious infection is made in primary care.AimTo gain insight into the clinical decision-making process of GPs in patients with possible sepsis infections.Design & settingSurvey among a random sample of 800 GPs in the Netherlands.MethodQuantitative questionnaire using Likert scales.ResultsOne hundred and sixty (20.3%) of questionnaires were eligible for analysis. Based on self-reported cases of possible serious infections, the factors most often indicated as important for the decision to refer patients to the hospital were: general appearance (94.1%), gut feeling (92.1%), history (92.0%), and physical examination (89.3%). Temperature (88.7%), heart rate (88.7%), and blood pressure (82.1%), were the most frequently measured vital signs. In general, GPs more likely referred patients in case of: altered mental status (98.7%), systolic blood pressure <100 mmHg (93.7%), unable to stand (89.3%), insufficient effect of previous antibiotic treatment (87.4%), and respiratory rate ≥22/minute (86.1%).ConclusionThe GPs' assessment of patients with possible serious infection is a complex process, in which besides checking vital signs, many other aspects of the consultation guide the decision to refer a patient to the hospital. To improve care for patients with sepsis, the diagnostic and prognostic value of assessing the vital signs and symptoms, GPs' gut feeling, and additional diagnostic tests, should be prospectively studied in the primary care setting.

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Can Alveolar-Arterial Difference and Lung Ultrasound Help the Clinical Decision Making in Patients with COVID-19?

Diagnostics ◽

10.3390/diagnostics11050761 ◽

2021 ◽

Vol 11 (5) ◽

pp. 761

Author(s):

Gianmarco Secco ◽

Francesco Salinaro ◽

Carlo Bellazzi ◽

Marco La Salvia ◽

Marzia Delorenzo ◽

...

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Lung Ultrasound ◽

Signs And Symptoms ◽

Clinical Decision ◽

Arterial Oxygen ◽

Arterial Blood Gas ◽

Arterial Blood ◽

Lung Dysfunction ◽

Close Relationship

Background: COVID-19 is an emerging infectious disease, that is heavily challenging health systems worldwide. Admission Arterial Blood Gas (ABG) and Lung Ultrasound (LUS) can be of great help in clinical decision making, especially during the current pandemic and the consequent overcrowding of the Emergency Department (ED). The aim of the study was to demonstrate the capability of alveolar-to-arterial oxygen difference (AaDO2) in predicting the need for subsequent oxygen support and survival in patients with COVID-19 infection, especially in the presence of baseline normal PaO2/FiO2 ratio (P/F) values. Methods: A cohort of 223 swab-confirmed COVID-19 patients underwent clinical evaluation, blood tests, ABG and LUS in the ED. LUS score was derived from 12 ultrasound lung windows. AaDO2 was derived as AaDO2 = ((FiO2) (Atmospheric pressure − H2O pressure) − (PaCO2/R)) − PaO2. Endpoints were subsequent oxygen support need and survival. Results: A close relationship between AaDO2 and P/F and between AaDO2 and LUS score was observed (R2 = 0.88 and R2 = 0.67, respectively; p < 0.001 for both). In the subgroup of patients with P/F between 300 and 400, 94.7% (n = 107) had high AaDO2 values, and 51.4% (n = 55) received oxygen support, with 2 ICU admissions and 10 deaths. According to ROC analysis, AaDO2 > 39.4 had 83.6% sensitivity and 90.5% specificity (AUC 0.936; p < 0.001) in predicting subsequent oxygen support, whereas a LUS score > 6 showed 89.7% sensitivity and 75.0% specificity (AUC 0.896; p < 0.001). Kaplan–Meier curves showed different mortality in the AaDO2 subgroups (p = 0.0025). Conclusions: LUS and AaDO2 are easy and effective tools, which allow bedside risk stratification in patients with COVID-19, especially when P/F values, signs, and symptoms are not indicative of severe lung dysfunction.

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Recognition and management of neonatal sepsis

British Journal of Nursing ◽

10.12968/bjon.2021.30.7.410 ◽

2021 ◽

Vol 30 (7) ◽

pp. 410-415

Author(s):

Luke William Crocker ◽

Ayesha White ◽

Paul Anthony Heaton ◽

Débora Pascoal Horta ◽

Siba Prosad Paul

Keyword(s):

Neonatal Sepsis ◽

Early Recognition ◽

Signs And Symptoms ◽

Evidence Based ◽

Suspected Sepsis ◽

Serious Illness ◽

Prompt Treatment ◽

Serious Infection ◽

Common Causes ◽

Red Flag

Neonatal sepsis results from acute bacterial or viral infection occurring in the first 28 days of life. It causes significant morbidity and mortality, although the outcome can be improved by early recognition and prompt treatment by health professionals. This article describes the most common causes of sepsis, and explains why neonates are particularly vulnerable to infection. It highlights the non-specific way in which an infant with a serious infection may present, indicating the crucial features to elicit during history taking and examination, and emphasising the ‘red-flag’ signs and symptoms that should increase suspicion of a serious illness. The authors have adapted National Institute for Health and Care Excellence guidelines to produce an evidence-based approach to the management of an infant with suspected sepsis, and describe the roles of nurses in ensuring effective treatment and best outcomes for these babies.

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Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury

World Journal of Surgery ◽

10.1007/s00268-017-4121-5 ◽

2017 ◽

Vol 41 (12) ◽

pp. 3066-3073 ◽

Cited By ~ 6

Author(s):

Bryce E. Haac ◽

Jared R. Gallaher ◽

Charles Mabedi ◽

Andrew J. Geyer ◽

Anthony G. Charles

Keyword(s):

Decision Making ◽

Emergency Room ◽

Clinical Decision Making ◽

Traumatic Injury ◽

Vital Signs ◽

Clinical Decision ◽

Task Shifting

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Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: a quantitative study of decision thresholds in primary care

British Journal of General Practice ◽

10.3399/bjgp18x699545 ◽

2018 ◽

Vol 68 (676) ◽

pp. e765-e774 ◽

Cited By ~ 3

Author(s):

Mark H Ebell ◽

Isabella Locatelli ◽

Yolanda Mueller ◽

Nicolas Senn ◽

Kathryn Morgan

Keyword(s):

Primary Care ◽

Primary Care Physicians ◽

Signs And Symptoms ◽

Clinical Decision ◽

Community Acquired Pneumonia ◽

Multivariate Model ◽

Clinical Decisions ◽

Acute Cough ◽

Treatment Thresholds ◽

Rule Out

BackgroundTest and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough.AimTo determine decision thresholds in the management of patients with acute cough.Design and settingSet among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients.MethodClinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of community-acquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds.ResultsIn total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from ‘treat’ to ‘test’ or ‘test’ to ‘rule out’, whereas only 3.5% (26/749) changed their decision from ‘rule out’ to ‘test’ or ‘test’ to ‘treat’. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for non-primary care physicians.ConclusionTest and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

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The value of a consultant physiotherapist within a primary care musculoskeletal interface service: part of the spinal multidisciplinary team

International Journal of Therapy and Rehabilitation ◽

10.12968/ijtr.2019.0057 ◽

2021 ◽

Vol 28 (1) ◽

pp. 1-10

Author(s):

Michelle L Angus ◽

Victoria Dickens ◽

Naveed Yasin ◽

James Greenwood ◽

Irfan Siddique

Keyword(s):

Primary Care ◽

Clinical Decision Making ◽

Clinical Decision ◽

Tertiary Referral Centre ◽

Allied Health Professionals ◽

Convenience Sample ◽

Surgical Services ◽

Pain Pathway ◽

The Uk ◽

Case Based

Background/aims The national low back pain pathway in the UK suggests practitioners managing patients with spinal pathology should be specifically trained to do so and have the ability to link with tertiary spinal services when required. The aim of this study was to ensure referrals through to a tertiary spinal surgical centre are appropriate and patients get the correct advice early in their management pathway. Methods A retrospective review of 700 cases were discussed at a spinal case-based discussion meeting in a primary care interface service, compared to services without this model. A convenience sample of cases were analysed with the consultant physiotherapist and those referred from other allied health professionals into the tertiary spinal surgical centre. Case-based team discussion took place before every referral into the tertiary spinal service, with spinal surgical discussion where required. Results Patients referred from other interface services were more likely to require further work-up such as investigations, or be discharged from clinic on their first attendance than those who had been through the case-based discussion. Conclusions A consultant physiotherapist working as part of the spinal team of a tertiary referral centre can help advanced practitioners with their clinical decision making to help prevent unnecessary referrals to spinal surgical services.

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Vital signs assessed in initial clinical encounters predict COVID-19 mortality in an NYC hospital system

Scientific Reports ◽

10.1038/s41598-020-78392-1 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Elza Rechtman ◽

Paul Curtin ◽

Esmeralda Navarro ◽

Sharon Nirenberg ◽

Megan K. Horton

Keyword(s):

Machine Learning ◽

New York ◽

Clinical Decision Making ◽

Care Delivery ◽

Vital Signs ◽

Clinical Decision ◽

Rapid Identification ◽

Gradient Boosting ◽

Hospital System ◽

Response Strategies

AbstractTimely and effective clinical decision-making for COVID-19 requires rapid identification of risk factors for disease outcomes. Our objective was to identify characteristics available immediately upon first clinical evaluation related COVID-19 mortality. We conducted a retrospective study of 8770 laboratory-confirmed cases of SARS-CoV-2 from a network of 53 facilities in New-York City. We analysed 3 classes of variables; demographic, clinical, and comorbid factors, in a two-tiered analysis that included traditional regression strategies and machine learning. COVID-19 mortality was 12.7%. Logistic regression identified older age (OR, 1.69 [95% CI 1.66–1.92]), male sex (OR, 1.57 [95% CI 1.30–1.90]), higher BMI (OR, 1.03 [95% CI 1.102–1.05]), higher heart rate (OR, 1.01 [95% CI 1.00–1.01]), higher respiratory rate (OR, 1.05 [95% CI 1.03–1.07]), lower oxygen saturation (OR, 0.94 [95% CI 0.93–0.96]), and chronic kidney disease (OR, 1.53 [95% CI 1.20–1.95]) were associated with COVID-19 mortality. Using gradient-boosting machine learning, these factors predicted COVID-19 related mortality (AUC = 0.86) following cross-validation in a training set. Immediate, objective and culturally generalizable measures accessible upon clinical presentation are effective predictors of COVID-19 outcome. These findings may inform rapid response strategies to optimize health care delivery in parts of the world who have not yet confronted this epidemic, as well as in those forecasting a possible second outbreak.

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Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs

BMJ Open ◽

10.1136/bmjopen-2020-039674 ◽

2020 ◽

Vol 10 (6) ◽

pp. e039674 ◽

Cited By ~ 11

Author(s):

Veronique Verhoeven ◽

Giannoula Tsakitzidis ◽

Hilde Philips ◽

Paul Van Royen

Keyword(s):

Primary Care ◽

General Practice ◽

Clinical Decision Making ◽

Core Competencies ◽

Well Being ◽

Clinical Decision ◽

Framework Analysis ◽

Profound Impact ◽

The Core ◽

Qualitative Interview Study

ObjectivesThe current COVID-19 pandemic, as well as the measures taken to control it, have a profound impact on healthcare. This study was set up to gain insights into the consequences of the COVID-19 outbreak on the core competencies of general practice, as they are experienced by general practitioners (GPs) on the frontline.Design, setting, participantsWe performed a descriptive study using semistructured interviews with 132 GPs in Flanders, using a topic list based on the WONCA definition of core competencies in general practice. Data were analysed qualitatively using framework analysis.ResultsChanges in practice management and in consultation strategies were quickly adopted. There was a major switch towards telephone triage and consults, for covid-related as well as for non-covid related problems. Patient-centred care is still a major objective. Clinical decision-making is largely focused on respiratory assessment and triage, and GPs feel that acute care is compromised, both by their own changed focus and by the fact that patients consult less frequently for non-covid problems. Chronic care is mostly postponed, and this will have consequences that will extend and become visible after the corona crisis. Through the holistic eyes of primary care, the current outbreak—as well as the measures taken to control it—will have a profound impact on psychological and socioeconomic well-being. This impact is already visible in vulnerable people and will continue to become clear in the medium and long terms. GPs think that they are at high risk of getting infected. Dropping out and being unable to contribute their part or becoming virus transmitters are reported to be greater concerns than getting ill themselves.ConclusionsThe current times have a profound impact on the core competences of primary care. Although the vast increase in patients soliciting medical help and the necessary separate covid and non-covid flows have been dealt with, GPs are worried about the continuity of regular care and the consequences of the anticovid measures. These may become a threat for the general health of the population and for the provision of primary healthcare in the near and distant future.

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Management of Cardiac Toxicity Induced by Chemotherapy

Journal of Clinical Medicine ◽

10.3390/jcm9092885 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2885 ◽

Cited By ~ 1

Author(s):

Dario Trapani ◽

Paola Zagami ◽

Eleonora Nicolò ◽

Gabriella Pravettoni ◽

Giuseppe Curigliano

Keyword(s):

Clinical Decision Making ◽

Current Knowledge ◽

Early Recognition ◽

Clinical Decision ◽

Cancer Treatments ◽

Drug Induced ◽

Medical Interventions ◽

Clinical Scenarios ◽

New Biomarkers ◽

Chemotherapy Agents

Cardiotoxicity encompasses a spectrum of adverse cardiological effects experienced by cancer patients during and after receiving antineoplastic treatments. The intersection of cancer care with the management of the multiple comorbid non-communicable diseases carried by patients or related to cancer treatments motivates the need for an integrated and multidisciplinary approach to therapeutic clinical decision-making. This present review aimed to provide a perspective and an update of the current pharmacotherapy approaches for the prevention and management of cardiotoxicity from antiblastic chemotherapy; as such, it addresses myocardial, vascular, and arrhythmic disorders associated to chemotherapy, by navigating the current knowledge and clinical indications in support of the medical interventions. Clinical scenarios of pharmacological interventions take place with patients receiving anthracycline and, by extrapolation, other agents with cardiotoxic potentials and non-chemotherapy agents, including various small molecules and immunotherapy agents. Analysis of these scenarios aims to provide practical evidence-based guidance for the management of drug-induced cardiac dysfunctions. The possible role of new biomarkers for the early recognition of cardiotoxicity is mentioned across the clinical studies, with reference to the pharmacological biomarker-driven interventions delivered. To best inform survivorship care, the management and context of cardio-oncology services are discussed within the broader network of providers and settings of care.

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Heterogeneity among hypertensive subjects: a tool for clinical decision-making

Clinical Chemistry ◽

10.1093/clinchem/37.10.1885 ◽

1991 ◽

Vol 37 (10) ◽

pp. 1885-1890 ◽

Cited By ~ 1

Author(s):

M H Alderman

Keyword(s):

Blood Pressure ◽

Blood Pressure Control ◽

Management Strategy ◽

Clinical Decision Making ◽

Adverse Outcome ◽

Blood Pressure Measurement ◽

Clinical Decision ◽

Pressure Control ◽

Treatment Progress ◽

The Status

Abstract Current antihypertensive treatment strategy tends to approach all patients similarly, with decision to treat, the goal of treatment, and medication use based largely on blood pressure measurement. Clearly, it would make far more sense if a management strategy could be developed that was not solely dependent on measurement of blood pressure, but rather reflected a clearer understanding of individual likelihood of adverse outcome, the nature of blood pressure control, and the importance of associated clinical and biological characteristics. New tools make it possible to accurately assess the status of the heart, kidney, and blood vessels, both as a guide to the need for therapy and as a measure of treatment progress when the treatment is used. New understanding of the vasoconstrictor and volume contributions to blood pressure control coupled with a rich armamentarium of therapeutic agents make it possible to tailor therapy more appropriately. Finally, growing awareness of the contribution of concomitant risk factors has made it clear that overall success depends on attention to the whole patient.

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OVERVIEW: THE VA GERIATRIC SCHOLARS PROGRAM FOR PRIMARY CARE WORKFORCE DEVELOPMENT

Innovation in Aging ◽

10.1093/geroni/igz038.2814 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S765-S766

Author(s):

Josea Kramer ◽

Joe Douglas ◽

Shawn Clarke ◽

Luis Melendez

Keyword(s):

Primary Care ◽

Workforce Development ◽

Clinical Decision Making ◽

Clinical Decision ◽

Potentially Inappropriate Medications ◽

Primary Care Workforce ◽

Core Components ◽

Intensive Course ◽

The Impact ◽

Inappropriate Medications

Abstract The VA has invested in developing the skills of its primary care workforce through the longitudinal Geriatric Scholars Program. The program consists of core components --- intensive course in geriatrics, intensive workshop in quality improvement (QI) and initiation of a micro QI projects in the Scholar’s clinic; electives allow learners to tailor the program to self-identified gaps in knowledge, skills and competencies. The program has demonstrated direct impacts of continuing education through a workforce development process that enhances skills and competencies at a pace and selection that meets clinicians’ self-identified gaps in training. Now in its 11th year, the program has been shown to increase career satisfaction and job retention, standardize provider behaviors, improve clinical decision-making and reduce dispensing of potentially inappropriate medications. This symposium further explores the impact of the program on individual clinicians and on clinical teams.

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