Point-of-care lung ultrasound in the assessment of COVID-19: results of a UK multicentre service evaluation.

BACKGROUND: Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application. METHODS: A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models. RESULTS: Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.

Impact of the Diabetes Inpatient Care and Education (DICE) project on length of stay and mortality.

AIM: To determine whether the Diabetes Inpatient Care and Education (DICE) programme, a whole-systems approach to managing inpatient diabetes, reduces length of stay, in-hospital mortality and readmissions. RESEARCH DESIGN AND METHODS: Diabetes Inpatient Care and Education initiatives included identification of all diabetes admissions, a novel DICE care-pathway, an online system for prioritizing referrals, use of web-linked glucose meters, an enhanced diabetes team, and novel diabetes training for doctors. Patient administration system data were extracted for people admitted to Ipswich Hospital from January 2008 to June 2016. Logistic regression was used to compare binary outcomes (mortality, 30-day readmissions) 6 months before and after the intervention; generalized estimating equations were used to compare lengths of stay. Interrupted time series analysis was performed over the full 7.5-year period to account for secular trends. RESULTS: Before-and-after analysis revealed a significant reduction in lengths of stay for people with and without diabetes: relative ratios 0.89 (95% CI 0.83, 0.97) and 0.93 (95% CI 0.90, 0.96), respectively; however, in interrupted time series analysis the change in long-term trend for length of stay following the intervention was significant only for people with diabetes (P=0.017 vs P=0.48). Odds ratios for mortality were 0.63 (0.48, 0.82) and 0.81 (0.70, 0.93) in people with and without diabetes, respectively; however, the change in trend was not significant in people with diabetes, while there was an apparent increase in those without diabetes. There was no significant change in 30-day readmissions, but interrupted time series analysis showed a rising trend in both groups. CONCLUSION: The DICE programme was associated with a shorter length of stay in inpatients with diabetes beyond that observed in people without diabetes.

Environmental Public Health Tracking: a cost-effective system for characterizing the sources, distribution and public health impacts of environmental hazards.

Background: The contemporary environment is a complex of interactions between physical, biological, socio-economic systems with major impacts on public health. However, gaps in our understanding of the causes, extent and distribution of these effects remain. The public health community in Sandwell West Midlands has collaborated to successfully develop, pilot and establish the first Environmental Public Health Tracking (EPHT) programme in Europe to address this 'environmental health gap' through systematically linking data on environmental hazards, exposures and diseases. Methods: Existing networks of environmental, health and regulatory agencies developed a suite of innovative methods to routinely share, integrate and analyse data on hazards, exposures and health outcomes to inform interventions. Results: Effective data sharing and horizon scanning systems have been established, novel statistical methods piloted, plausible associations framed and tested, and targeted interventions informed by local concerns applied. These have influenced changes in public health practice. Conclusion: EPHT is a powerful tool for identifying and addressing the key environmental public health impacts at a local level. Sandwell's experience demonstrates that it can be established and operated at virtually no cost. The transfer of National Health Service epidemiological skills to local authorities in 2013 provides an opportunity to expand the programme to fully exploit its potential.

The findings of the Mid-Staffordshire Inquiry do not uphold the use of hospital standardized mortality ratios as a screening test for 'bad' hospitals.

The Mid-Staffordshire Public Inquiry has published its findings. The initial investigations were triggered by an elevated hospital standardized mortality ratio (HSMR). This shows that the HSMR is being used as a screening test for substandard care; whereby hospitals that fail the test are scrutinized, whilst those that pass the test are not. But screening tests are often misunderstood and misused and so it is prudent to critically examine the HSMR before casting it in the role of a screening test for 'bad' hospitals. A screening test should be valid, have adequate performance characteristics and a clear post-test action plan. The HSMR is not a valid screening test (because the empirical relationship between clinically avoidable mortality and the HSMR is unknown). The HSMR has a poor performance profile (10 of 11 elevated HSMRs would be false alarms and 10 of 11 poorly performing hospitals would escape attention). Crucially, the aim of a post-test investigation into an elevated HSMR is unclear. The use of the HSMR as a screening test for clinically avoidable mortality and thereby substandard care, although well intentioned, is seriously flawed. The findings of the Mid-Staffordshire Public Inquiry have no bearing on this conclusion because a 'bad' hospital cannot uphold a bad screening test. Nonetheless, HSMRs continue to pose a grave public challenge to hospitals, whilst the unsatisfactory nature of the HSMR remains a largely unacknowledged and unchallenged private affair. This asymmetric relationship is inappropriate, unhelpful, costly and potentially harmful. The use of process measures remains a valid way to measure quality of care.

A study of childhood attendance at emergency departments in the West Midlands region.

INTRODUCTION: Research into childhood attendance at EDs in the UK has focused mainly on injury rather than medical conditions and studies have been relatively small. This study looks at all types of ED attendance by children across a large population. DATA AND METHODS: Routine data on all new attendances by children under 16 years were available for 12 EDs in the West Midlands (period: 1 April 2002 to 31 March 2004, 365 695 records). The data were split into four age groups (<1, 1-4, 5-9, and 10-15 years). RESULTS: Injury related conditions increased with age (with the exception of head injury). Respiratory and gastrointestinal were the most common medical conditions decreased with age. 11.5% of children were admitted to hospital and this varied from 8.2% (10-15 years) to 24.2% (<1 year). CONCLUSIONS: This study has shown substantial variations in ED attendance by age and has given an insight into the variation among hospitals. This is the largest study of childhood ED attendance undertaken in the UK, and it is hoped that the questions raised will prompt more research in this field.