The influence of undetected hemolysis on POCT potassium results in the emergency department.

OBJECTIVES: This study aimed to evaluate discrepancies in potassium measurements between point-of-care testing (POCT) and central laboratory (CL) methods, focusing on the impact of hemolysis on these measurements and its impact in the clinical practice in the emergency department (ED). METHODS: A retrospective analysis was conducted using data from three European university hospitals: Technische Universitat Munchen (Germany), Hospital Universitario La Paz (Spain), and Erasmus University Medical Center (The Netherlands). The study compared POCT potassium measurements in EDs with CL measurements. Data normalization was performed in categories for potassium levels (kalemia) and hemolysis. The severity of discrepancies between POCT and CL potassium measurements was assessed using the reference change value (RCV). RESULTS: The study identified significant discrepancies in potassium between POCT and CL methods. In comparing POCT normo- and mild hypokalemia against CL results, differences of -4.20 % and +4.88 % were noted respectively. The largest variance in the CL was a +4.14 % difference in the mild hyperkalemia category. Additionally, the RCV was calculated to quantify the severity of discrepancies between paired potassium measurements from POCT and CL methods. The overall hemolysis characteristics, as defined by the hemolysis gradient, showed considerable variation between the testing sites, significantly affecting the reliability of potassium measurements in POCT. CONCLUSIONS: The study highlighted the challenges in achieving consistent potassium measurement results between POCT and CL methods, particularly in the presence of hemolysis. It emphasised the need for integrated hemolysis detection systems in future blood gas analysis devices to minimise discrepancies and ensure accurate POCT results.

Intensive care following in-hospital cardiac arrest / periarrest calls-experience from one Scottish hospital.

BACKGROUND: In-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called. METHODS: Analysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards. RESULTS: Of the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low - 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being "too well" at the time of review (78/129 - 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient's resuscitation status. CONCLUSIONS: This study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis".

Background: Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window. Methods: ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours. Objectives: Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs. Discussion: This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.

Performance of bedside tools for predicting infection-related mortality and administrative data for sepsis surveillance: An observational cohort study.

BACKGROUND: Measuring sepsis incidence and associated mortality at scale using administrative data is hampered by variation in diagnostic coding. This study aimed first to compare how well bedside severity scores predict 30-day mortality in hospitalised patients with infection, then to assess the ability of combinations of administrative data items to identify patients with sepsis. METHODS: This retrospective case note review examined 958 adult hospital admissions between October 2015 and March 2016. Admissions with blood culture sampling were matched 1:1 to admissions without a blood culture. Case note review data were linked to discharge coding and mortality. For patients with infection the performance characteristics of Sequential Organ Failure Assessment (SOFA), National Early Warning System (NEWS), quick SOFA (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS) were calculated for predicting 30-day mortality. Next, the performance characteristics of administrative data (blood cultures and discharge codes) for identifying patients with sepsis, defined as SOFA ≥2 because of infection, were calculated. RESULTS: Infection was documented in 630 (65.8%) admissions and 347 (55.1%) patients with infection had sepsis. NEWS (Area Under the Receiver Operating Characteristic, AUROC 0.78 95%CI 0.72-0.83) and SOFA (AUROC 0.77, 95%CI 0.72-0.83), performed similarly well for prediction of 30-day mortality. Having an infection and/or sepsis International Classification of Diseases, Tenth Revision (ICD-10) code (AUROC 0.68, 95%CI 0.64-0.71) performed as well in identifying patients with sepsis as having at least one of: an infection code; sepsis code, or; blood culture (AUROC 0.68, 95%CI 0.65-0.71), Sepsis codes (AUROC 0.53, 95%CI 0.49-0.57) and positive blood cultures (AUROC 0.52, 95%CI 0.49-0.56) performed least well. CONCLUSIONS: SOFA and NEWS best predicted 30-day mortality in patients with infection. Sepsis ICD-10 codes lack sensitivity. For health systems without suitable electronic health records, blood culture sampling has potential utility as a clinical component of a proxy marker for sepsis surveillance.

Failure Mode and Effects Analysis (FMEA) at the preanalytical phase for POCT blood gas analysis: proposal for a shared proactive risk analysis model.

OBJECTIVES: Proposal of a risk analysis model to diminish negative impact on patient care by preanalytical errors in blood gas analysis (BGA). METHODS: Here we designed a Failure Mode and Effects Analysis (FMEA) risk assessment template for BGA, based on literature references and expertise of an international team of laboratory and clinical health care professionals. RESULTS: The FMEA identifies pre-analytical process steps, errors that may occur whilst performing BGA (potential failure mode), possible consequences (potential failure effect) and preventive/corrective actions (current controls). Probability of failure occurrence (OCC), severity of failure (SEV) and probability of failure detection (DET) are scored per potential failure mode. OCC and DET depend on test setting and patient population e.g., they differ in primary community health centres as compared to secondary community hospitals and third line university or specialized hospitals. OCC and DET also differ between stand-alone and networked instruments, manual and automated patient identification, and whether results are automatically transmitted to the patient's electronic health record. The risk priority number (RPN = SEV × OCC × DET) can be applied to determine the sequence in which risks are addressed. RPN can be recalculated after implementing changes to decrease OCC and/or increase DET. Key performance indicators are also proposed to evaluate changes. CONCLUSIONS: This FMEA model will help health care professionals manage and minimize the risk of preanalytical errors in BGA.

Association of out of hospital paediatric early warning score with need for hospital admission in a Scottish emergency ambulance population.

OBJECTIVE: Physiological derangement, as measured by paediatric early warning score (PEWS) is used to identify children with critical illness at an early point to identify and intervene in children at risk. PEWS has shown some utility as a track and trigger system in hospital and also as a predictor of adverse outcome both in and out of hospital. This study examines the relationship between prehospital observations, aggregated into an eight-point PEWS (Scotland), and hospital admission. METHODS: A retrospective analysis of all patients aged less than 16 transported to hospital by the Scottish Ambulance Service between 2011 and 2015. Data were matched to outcome data regarding hospital admission or discharge and length of stay. RESULTS: Full data were available for 21 202 paediatric patients, of whom 6340 (29.9%) were admitted to hospital. Prehospital PEWS Scotland was associated with an odds ratio for admission of 1.189 [95% confidence interval (CI): 1.176-1.202; P < 0.001]. The area under receiver operating curve of 0.617 (95% CI: 0.608-0.625; P < 0.001) suggests poorly predictive ability for hospital admission. There was no association between prehospital PEWS Scotland and length of hospital stay. CONCLUSION: These data show that a single prehospital PEWS Scotland was a poor predictor of hospital admission for unselected patients in a prehospital population. The decision to admit a child to hospital is not solely based on the physiological derangement of vital signs, and hence physiological-based scoring systems such as PEWS Scotland cannot be used as the sole criteria for hospital admission, from an undifferentiated prehospital population.

Sexual health care provision in cancer nursing care: A systematic review on the state of evidence and deriving international competencies chart for cancer nurses.

BACKGROUND: Sexual health care should be an integral part of holistic, person-centred care for patients with cancer. Nurses can have a pivotal role, but nurse-led care in this context has been historically challenging. OBJECTIVES: To update the state of scientific knowledge pertinent to nurses' competencies in delivering sexual health care to patients with cancer; better understand moderating factors; and evaluate interventions developed/tested to enhance nurses' competencies. DESIGN: Systematic literature review in line with published PRISMA Statement guidelines. DATA SOURCES: Electronic bibliographic databases; journal content lists; reference lists of included studies; author/expert contact REVIEW METHODS: Nine electronic databases were searched (June 2008-October 2018) to identify studies employing diverse research methods. We applied pre-specified eligibility criteria to all retrieved records and integrated findings in a narrative synthesis. RESULTS: Of 2,614 returned articles, we included 31 unique studies. Five articles reported on two randomised controlled trials and three single-arm, before-and-after trials. Current evidence suggests that nurses' knowledge and skill in providing sexual health care still varies widely across different settings, phases and cancers. A plethora of intra-personal, inter-personal, societal and organisational factors may hinder nurse-led care in this context. Nurses' perceived professional confidence was repeatedly examined as influencing provision of care in this context; unfortunately, it was found lacking and complicated by unhelpful views and beliefs about SHC. Despite the magnitude of the problem, the few trials that tested, sexual health-targeted continuing professional development programmes for nurses, were of low-to-moderate methodological quality, while the associated high risk of methodological bias downgraded the evidence on the interventions' effectiveness. CONCLUSION: Our systematic review replicates previous findings and highlights a continuing problem: nurse-led provision of sexual health care in cancer care remains sub-optimal and challenging, due mainly to nurses' assumptions and prejudices towards sexuality, lack of professional confidence in dealing with sensitive issues, and a complex health care system environment. To realistically deal with this problem, we propose a flexible, two-level chart to promote development of basic competence among all nurses caring for patients with cancer (entry-level), and facilitate subsequent transition to a more specialised, self-pursued role for a subset of nurses (champion-level). The chart itself can be relevant to an international audience, while it might be transferable to other long-term conditions. Accordingly, we propose additional rigorous research to test multi-component educational programmes, customised to meet entry-level and champion-level requirements to realise continuous nursing provision of sexual health care in cancer care.

Improving the waiting times within a hospice breathlessness service.

Background: Breathlessness, a common symptom in advanced disease, is a distressing, complex symptom that can profoundly affect the quality of one's life. Evidence suggests that specialist palliative care breathlessness intervention services can improve physical well-being, personal coping strategies and quality of life. In the UK, the use of quality improvement methods is well documented in the National Health Service. However, within the independent hospice sector there is a lack of published evidence of using such methods to improve service provision. Aim: The aim of this project was to reduce the waiting time from referral to service commencement for a hospice breathlessness service by 40%-from a median of 19.5 to 11.5 working days. Methods: Using a quality planning and systems thinking approach staff identified barriers and blockages in the current system and undertook plan-do-study-act cycles to test change ideas. The ideas tested included offering home visits to patients on long-term oxygen, using weekly team 'huddles', streamlining the internal referral process and reallocating staff resources. Results: Using quality improvement methods enabled staff to proactively engage in positive changes to improve the service provided to people living with chronic breathlessness. Offering alternatives to morning appointments; using staff time more efficiently and introducing accurate data collection enabled staff to monitor waiting times in real time. The reduction achieved in the median waiting time from referral to service commencement exceeded the project aim. Conclusions: This project demonstrates that quality improvement methodologies can be successfully used in a hospice setting to improve waiting times and meet the specific needs of people receiving specialist palliative care.

Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting.

BACKGROUND: Early intervention and response to deranged physiological parameters in the critically ill patient improve outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service in the UK. The quick Sepsis-related Organ Failure Assessment Score (qSOFA) was developed as a simple bedside criterion to identify adult patients outwith the ICU with suspected infection who are likely to have a prolonged ICU stay or die in hospital. We aim to compare the ability of NEWS and qSOFA to predict adverse outcomes in a prehospital population. PATIENTS AND METHODS: All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to mortality over a 2-month period. The performance of the NEWS and qSOFA in identifying the endpoints of 30-day mortality, ICU admission and a combined endpoint of 48 h. ICU admission or 30-day mortality was analysed. RESULTS: Complete data were available for 1713 patients. For the primary outcome of ICU admission within 48 h or 30-day mortality, the odds ratio for a qSOFA score of 3 compared with 0 was 124.1 [95% confidence interval (CI): 13.5-1137.7] and the odds ratio for a high NEWS category, compared with the low NEWS category was 9.82 (95% CI: 5.74-16.81). Comparison of qSOFA and NEWS performance was assessed using receiver operating characteristic curves. The area under the receiver operating characteristic curve for the primary outcome for qSOFA was 0.679 (95% CI: 0.624-0.733), for NEWS category was 0.707 (95% CI: 0.654-0.761) and for NEWS total score was 0.740 (95% CI: 0.685-0.795). Comparison of the receiver operating characteristic curves between NEWS total score and qSOFA using DeLong's test showed NEWS total score to be superior to qSOFA at predicting combined ICU admission within 48 h of presentation or 30-day mortality (P = 0.011). CONCLUSION: Our study shows qSOFA can identify patients at risk of adverse outcomes in the prehospital setting. However, NEWS is superior to qSOFA in a prehospital environment at identifying patients at risk of adverse outcomes.

Developing a framework for evaluating the impact of Healthcare Improvement Science Education across Europe: a qualitative study.

PURPOSE: Frontline healthcare professionals are well positioned to improve the systems in which they work. Educational curricula, however, have not always equipped healthcare professionals with the skills or knowledge to implement and evaluate improvements. It is important to have a robust and standardized framework in order to evaluate the impact of such education in terms of improvement, both within and across European countries. The results of such evaluations will enhance the further development and delivery of healthcare improvement science (HIS) education. We aimed to describe the development and piloting of a framework for prospectively evaluating the impact of HIS education and learning. METHODS: The evaluation framework was designed collaboratively and piloted in 7 European countries following a qualitative methodology. The present study used mixed methods to gather data from students and educators. The framework took the Kirkpatrick model of evaluation as a theoretical reference. RESULTS: The framework was found to be feasible and acceptable for use across differing European higher education contexts according to the pilot study and the participants' consensus. It can be used effectively to evaluate and develop HIS education across European higher education institutions. CONCLUSION: We offer a new evaluation framework to capture the impact of HIS education. The implementation of this tool has the potential to facilitate the continuous development of HIS education.

Focal and Ambient Processing of Built Environments: Intellectual and Atmospheric Experiences of Architecture.

Neuroscience has well established that human vision divides into the central and peripheral fields of view. Central vision extends from the point of gaze (where we are looking) out to about 5° of visual angle (the width of one's fist at arm's length), while peripheral vision is the vast remainder of the visual field. These visual fields project to the parvo and magno ganglion cells, which process distinctly different types of information from the world around us and project that information to the ventral and dorsal visual streams, respectively. Building on the dorsal/ventral stream dichotomy, we can further distinguish between focal processing of central vision, and ambient processing of peripheral vision. Thus, our visual processing of and attention to objects and scenes depends on how and where these stimuli fall on the retina. The built environment is no exception to these dependencies, specifically in terms of how focal object perception and ambient spatial perception create different types of experiences we have with built environments. We argue that these foundational mechanisms of the eye and the visual stream are limiting parameters of architectural experience. We hypothesize that people experience architecture in two basic ways based on these visual limitations; by intellectually assessing architecture consciously through focal object processing and assessing architecture in terms of atmosphere through pre-conscious ambient spatial processing. Furthermore, these separate ways of processing architectural stimuli operate in parallel throughout the visual perceptual system. Thus, a more comprehensive understanding of architecture must take into account that built environments are stimuli that are treated differently by focal and ambient vision, which enable intellectual analysis of architectural experience versus the experience of architectural atmosphere, respectively. We offer this theoretical model to help advance a more precise understanding of the experience of architecture, which can be tested through future experimentation. (298 words).

The development of a consensus definition for healthcare improvement science (HIS) in seven European countries: A consensus methods approach.

INTRODUCTION: There is a limited body of research in the field of healthcare improvement science (HIS). Quality improvement and 'change making' should become an intrinsic part of everyone's job, every day in all parts of the healthcare system. The lack of theoretical grounding may partly explain the minimal transfer of health research into health policy. METHODS: This article seeks to present the development of the definition for healthcare improvement science. A consensus method approach was adopted with a two-stage Delphi process, expert panel and consensus group techniques. A total of 18 participants were involved in the expert panel and consensus group, and 153 answers were analysed as a part of the Delphi survey. Participants were researchers, educators and healthcare professionals from Scotland, Slovenia, Spain, Italy, England, Poland, and Romania. RESULTS: A high level of consensus was achieved for the broad definition in the 2nd Delphi iteration (86%). The final definition was agreed on by the consensus group: 'Healthcare improvement science is the generation of knowledge to cultivate change and deliver person-centred care that is safe, effective, efficient, equitable and timely. It improves patient outcomes, health system performance and population health.' CONCLUSIONS: The process of developing a consensus definition revealed different understandings of healthcare improvement science between the participants. Having a shared consensus definition of healthcare improvement science is an important step forward, bringing about a common understanding in order to advance the professional education and practice of healthcare improvement science.

A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle.

BACKGROUND: Implementation of the 'Sepsis Six' clinical care bundle within an hour of recognition of sepsis is recommended as an approach to reduce mortality in patients with sepsis, but achieving reliable delivery of the bundle has proved challenging. There remains little understanding of the barriers to reliable implementation of bundle components. We examined frontline clinical practice in implementing the Sepsis Six. METHODS: We conducted an ethnographic study in six hospitals participating in the Scottish Patient Safety Programme Sepsis collaborative. We conducted around 300 h of non-participant observation in emergency departments, acute medical receiving units and medical and surgical wards. We interviewed a purposive sample of 43 members of hospital staff. Data were analysed using a constant comparative approach. RESULTS: Implementation strategies to promote reliable use of the Sepsis Six primarily focused on education, engaging and motivating staff, and providing prompts for behaviour, along with efforts to ensure that equipment required was readily available. Although these strategies were successful in raising staff awareness of sepsis and engagement with implementation, our study identified that completing the bundle within an hour was not straightforward. Our emergent theory suggested that rather than being an apparently simple sequence of six steps, the Sepsis Six actually involved a complex trajectory comprising multiple interdependent tasks that required prioritisation and scheduling, and which was prone to problems of coordination and operational failures. Interventions that involved allocating specific roles and responsibilities for completing the Sepsis Six in ways that reduced the need for coordination and task switching, and the use of process mapping to identify system failures along the trajectory, could help mitigate against some of these problems. CONCLUSIONS: Implementation efforts that focus on individual behaviour change to improve uptake of the Sepsis Six should be supplemented by an understanding of the bundle as a complex trajectory of work in which improving reliability requires attention to coordination of workflow, as well as addressing the mundane problems of interruptions and operational failures that obstruct task completion.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field.

BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Making it easy to do the right thing in healthcare: Advancing improvement science education through accredited pan European higher education modules.

BACKGROUND: Numerous international policy drivers espouse the need to improve healthcare. The application of Improvement Science has the potential to restore the balance of healthcare and transform it to a more person-centred and quality improvement focussed system. However there is currently no accredited Improvement Science education offered routinely to healthcare students. This means that there are a huge number of healthcare professionals who do not have the conceptual or experiential skills to apply Improvement Science in everyday practise. METHODS: This article describes how seven European Higher Education Institutions (HEIs) worked together to develop four evidence informed accredited inter-professional Improvement Science modules for under and postgraduate healthcare students. It outlines the way in which a Policy Delphi, a narrative literature review, a review of the competency and capability requirements for healthcare professionals to practise Improvement Science, and a mapping of current Improvement Science education informed the content of the modules. RESULTS: A contemporary consensus definition of Healthcare Improvement Science was developed. The four Improvement Science modules that have been designed are outlined. A framework to evaluate the impact modules have in practise has been developed and piloted. CONCLUSION: The authors argue that there is a clear need to advance healthcare Improvement Science education through incorporating evidence based accredited modules into healthcare professional education. They suggest that if Improvement Science education, that incorporates work based learning, becomes a staple part of the curricula in inter-professional education then it has real promise to improve the delivery, quality and design of healthcare.