Responding to the deteriorating patient: The rationale for treatment escalation plans.

A Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. The aims are to reduce variation caused by discontinuity of care; avoid harms caused by inappropriate treatment and promote patients' priorities and preferences. The TEP is based on the goals of treatment - 'What are we trying to achieve?' The goals take account of the context of acute illness, the consequences of interventions and discussion with the patient. They should reflect a shift away from 'fix-it' medicine to what is realistic and pragmatic. A TEP has three escalation categories: full escalation, selected appropriate treatments and palliative/supportive care. Other appropriate/inappropriate treatments are also recorded. Treatment Escalation Plans are associated with significant reductions in intensive care unit (ICU) admissions, non-beneficial interventions, harms and complaints. Treatment Escalation Plans contribute to staff well-being by reducing uncertainty. Successful implementation requires training and education in medical decision-making and communication skills.

Randomised trial of intravenous thiamine and/or magnesium sulphate administration on erythrocyte transketolase activity, lactate concentrations and alcohol withdrawal scores.

Alcohol withdrawal syndrome (AWS) occurs in 2% of patients admitted to U.K. hospitals. Routine treatment includes thiamine and benzodiazepines. Laboratory studies indicate that thiamine requires magnesium for optimal activity, however this has not translated into clinical practice. Patients experiencing AWS were randomized to three groups: (group 1) thiamine, (group 2) thiamine plus MgSO4 or (group 3) MgSO4. Pre- and 2-h post-treatment blood samples were taken. AWS severity was recorded using the Glasgow Modified Alcohol Withdrawal Score (GMAWS). The primary outcome measure was 15% change in erythrocyte transketolase activity (ETKA) in group 3. Secondary outcome measures were change in plasma lactate concentrations and time to GMAWS = 0. 127 patients were recruited, 115 patients were included in the intention-to-treat analysis. Pre-treatment, the majority of patients had normal or high erythrocyte thiamine diphosphate (TDP) concentrations (≥ 275-675/> 675 ng/gHb respectively) (99%), low serum magnesium concentrations (< 0.75 mmol/L) (59%), and high plasma lactate concentrations (> 2 mmol/L) (67%). Basal ETKA did not change significantly in groups 1, 2 or 3. Magnesium deficient patients (< 0.75 mmol/L) demonstrated less correlation between pre-treatment basal ETKA and TDP concentrations than normomagnesemic patients (R2 = 0.053 and R2 = 0.236). Median plasma lactate concentrations normalized (≤ 2.0 mmol/L) across all three groups (p < 0.001 for all groups), but not among magnesium deficient patients in group 1 (n = 22). The median time to achieve GMAWS = 0 for groups 1, 2 and 3 was 10, 5.5 and 6 h respectively (p < 0.001). No significant difference was found between groups for the primary endpoint of change in ETKA. Co-administration of thiamine and magnesium resulted in more consistent normalization of plasma lactate concentrations and reduced duration to achieve initial resolution of AWS symptoms.ClinicalTrials.gov: NCT03466528.

A prospective evaluation of thiamine and magnesium status in relation to clinicopathological characteristics and 1-year mortality in patients with alcohol withdrawal syndrome.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is routinely treated with B-vitamins. However, the relationship between thiamine status and outcome is rarely examined. The aim of the present study was to examine the relationship between thiamine and magnesium status in patients with AWS. METHODS: Patients (n = 127) presenting to the Emergency Department with AWS were recruited to a prospective observational study. Blood samples were drawn to measure whole blood thiamine diphosphate (TDP) and serum magnesium concentrations. Routine biochemistry and haematology assays were also conducted. The Glasgow Modified Alcohol Withdrawal Score (GMAWS) measured severity of AWS. Seizure history and current medications were also recorded. RESULTS: The majority of patients (99%) had whole blood TDP concentration within/above the reference interval (275-675 ng/gHb) and had been prescribed thiamine (70%). In contrast, the majority of patients (60%) had low serum magnesium concentrations (< 0.75 mmol/L) and had not been prescribed magnesium (93%). The majority of patients (66%) had plasma lactate concentrations above 2.0 mmol/L. At 1 year, 13 patients with AWS had died giving a mortality rate of 11%. Male gender (p < 0.05), BMI < 20 kg/m2 (p < 0.01), GMAWS max ≥ 4 (p < 0.05), elevated plasma lactate (p < 0.01), low albumin (p < 0.05) and elevated serum CRP (p < 0.05) were associated with greater 1-year mortality. Also, low serum magnesium at time of recruitment to study and low serum magnesium at next admission were associated with higher 1-year mortality rates, (84% and 100% respectively; both p < 0.05). CONCLUSION: The prevalence of low circulating thiamine concentrations were rare and it was regularly prescribed in patients with AWS. In contrast, low serum magnesium concentrations were common and not prescribed. Low serum magnesium was associated more severe AWS and increased 1-year mortality.

SODAS: Surveillance of Drugs of Abuse Study.

OBJECTIVE: Novel psychoactive substance (NPS) as a form of recreational drug use has become increasingly popular. There is a paucity of information with regard to the prevalence and clinical sequelae of these drugs. The aim of this study was to detect NPS in patients presenting to the emergency department with suspected toxicological ingestion. PATIENTS AND METHODS: The prospective study was performed in a large emergency department in the UK. During a 3-month period 80 patients were identified by clinicians as having potentially ingested a toxicological agent. Urine samples were analysed using liquid chromatography high-resolution mass spectrometry, and basic clinical data was gathered. RESULTS: Eighty patients with a history of illicit or recreational drug consumption had urine screenings performed. Forty-nine per cent (39) of the patients undergoing a screen had more than one illicit substance detected. Twenty per cent (16) of the patients tested positive for at least one NPS. CONCLUSION: Almost half of the presented patients revealed ingestion of multiple substances, which correlated poorly with self-reporting of patients. Developing enhanced strategies to monitor evolving drug trends is crucial to the ability of clinicians to deliver care to this challenging group of patients.

Predicting admission at triage: are nurses better than a simple objective score?

AIM: We compared two methods of predicting hospital admission from ED triage: probabilities estimated by triage nurses and probabilities calculated by the Glasgow Admission Prediction Score (GAPS). METHODS: In this single-centre prospective study, triage nurses estimated the probability of admission using a 100 mm visual analogue scale (VAS), and GAPS was generated automatically from triage data. We compared calibration using rank sum tests, discrimination using area under receiver operating characteristic curves (AUC) and accuracy with McNemar's test. RESULTS: Of 1829 attendances, 745 (40.7%) were admitted, not significantly different from GAPS' prediction of 750 (41.0%, p=0.678). In contrast, the nurses' mean VAS predicted 865 admissions (47.3%), overestimating by 6.6% (p<0.0001). GAPS discriminated between admission and discharge as well as nurses, its AUC 0.876 compared with 0.875 for VAS (p=0.93). As a binary predictor, its accuracy was 80.6%, again comparable with VAS (79.0%), p=0.18. In the minority of attendances, when nurses felt at least 95% certain of the outcome, VAS' accuracy was excellent, at 92.4%. However, in the remaining majority, GAPS significantly outperformed VAS on calibration (+1.2% vs +9.2%, p<0.0001), discrimination (AUC 0.810 vs 0.759, p=0.001) and accuracy (75.1% vs 68.9%, p=0.0009). When we used GAPS, but 'over-ruled' it when clinical certainty was ≥95%, this significantly outperformed either method, with AUC 0.891 (0.877-0.907) and accuracy 82.5% (80.7%-84.2%). CONCLUSIONS: GAPS, a simple clinical score, is a better predictor of admission than triage nurses, unless the nurse is sure about the outcome, in which case their clinical judgement should be respected.

Exploring situational awareness in emergency medicine: developing a shared mental model to enhance training and assessment.

Non-technical skills (NTS) are gaining increasing prominence within the field of emergency medicine. Situational awareness (SA), one key component of NTS, is a key skill for emergency physicians (EPs) during initial training and throughout their career. Furthermore, the majority of frameworks used to evaluate clinical performance incorporate SA as one key component. This review seeks to define and explore the concept of SA within the context of emergency medicine. We describe SA at an individual, team and departmental level. Development of this ability enables EPs to function effectively within the challenging environment of the emergency department (ED). Enhancing our understanding of SA may develop the cognitive process that underpins our clinical performance. We propose a model for consideration to support evaluation and training of SA within the ED, linking the model to the novice expert continuum.

A simple tool to predict admission at the time of triage.

AIM: To create and validate a simple clinical score to estimate the probability of admission at the time of triage. METHODS: This was a multicentre, retrospective, cross-sectional study of triage records for all unscheduled adult attendances in North Glasgow over 2 years. Clinical variables that had significant associations with admission on logistic regression were entered into a mixed-effects multiple logistic model. This provided weightings for the score, which was then simplified and tested on a separate validation group by receiving operator characteristic (ROC) analysis and goodness-of-fit tests. RESULTS: 215 231 presentations were used for model derivation and 107 615 for validation. Variables in the final model showing clinically and statistically significant associations with admission were: triage category, age, National Early Warning Score (NEWS), arrival by ambulance, referral source and admission within the last year. The resulting 6-variable score showed excellent admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752 to 0.8796). Higher scores also predicted early returns for those who were discharged: the odds of subsequent admission within 28 days doubled for every 7-point increase (log odds=+0.0933 per point, p<0.0001). CONCLUSIONS: This simple, 6-variable score accurately estimates the probability of admission purely from triage information. Most patients could accurately be assigned to 'admission likely', 'admission unlikely', 'admission very unlikely' etc., by setting appropriate cut-offs. This could have uses in patient streaming, bed management and decision support. It also has the potential to control for demographics when comparing performance over time or between departments.