Showing papers by "Steve Goodacre published in 2018"
TL;DR: Overall, the evidence supporting the interventions to improve patient flow is weak and failure to consider the correlation of the data in the primary studies could result in erroneous conclusions of effectiveness.
Abstract: Objectives Patient flow and crowding are two major issues in ED service improvement. A substantial amount of literature exists on the interventions to improve patient flow and crowding, making it difficult for policymakers, managers and clinicians to be familiar with all the available literature and identify which interventions are supported by the evidence. This umbrella review provides a comprehensive analysis of the evidence from existing quantitative systematic reviews on the interventions that improve patient flow in EDs. Methods An umbrella review of systematic reviews published between 2000 and 2017 was undertaken. Included studies were systematic reviews and meta-analyses of quantitative primary studies assessing an intervention that aimed to improve ED throughput. Results The search strategy yielded 623 articles of which 13 were included in the umbrella review. The publication dates of the systematic reviews ranged from 2006 to 2016. The 13 systematic reviews evaluated 26 interventions: full capacity protocols, computerised provider order entry, scribes, streaming, fast track and triage. Interventions with similar characteristics were grouped together to produce the following categories: diagnostic services, assessment/short stay units, nurse-directed interventions, physician-directed interventions, administrative/organisational and miscellaneous. The statistical evidence from 14 primary randomised controlled trials (RCTs) was evaluated to determine if correlation or clustering of observations was considered. Only the fast track intervention had moderate evidence to support its use but the RCTs that assessed the intervention did not use statistical tests that considered correlation. Conclusions Overall, the evidence supporting the interventions to improve patient flow is weak. Only the fast track intervention had moderate evidence to support its use but correlation/clustering was not taken into consideration in the RCTs examining the intervention. Failure to consider the correlation of the data in the primary studies could result in erroneous conclusions of effectiveness.
51 citations
TL;DR: In pregnancy and the puerperium, conventional and candidate biomarkers have no utility either for their negative or positive predictive value in the diagnosis of VTE.
Abstract: This study aimed to estimate the diagnostic utility of biomarkers for suspected venous thromboembolism (VTE) in pregnancy and the puerperium Research nurses/midwives collected blood samples from 310 pregnant/postpartum women with suspected pulmonary emboli (PE) and 18 with diagnosed deep vein thrombosis (DVT) VTE was diagnosed using imaging, treatment and adverse outcome data Primary analysis was limited to women with conclusive imaging (36 with VTE, 247 without) The area under the curve (AUC) for each biomarker was: activated partial thromboplastin time 0·669 (95% confidence interval 0·570-0·768), B-type natriuretic peptide 0·549 (0·453-0·645), C-reactive protein 0·542 (0·445-0·639), Clauss fibrinogen 0·589 (0·476-0·701), D-Dimer (by enzyme-linked immunosorbent assay) 0·668 (0·561-0·776), near-patient D-Dimer 0·651 (0·545-0·758), mid-regional pro-atrial natriuretic peptide 0·524 (0·418-0·630), prothrombin fragment 1 + 2 0·562 (0·462-0·661), plasmin-antiplasmin complexes 0·639 (0·536-0·742), prothombin time 0·613 (0·508-0·718), thrombin generation lag time 0·702 (0·598-0·806), thrombin generation endogenous potential 0·559 (0·437-0·681), thrombin generation peak 0·596 (0·478-0·715), thrombin generation time to peak 0·655 (0·541-0·769), soluble tissue factor 0·531 (0·424-0·638) and serum troponin 0·597 (0·499-0·695) No diagnostically useful threshold for diagnosing or ruling out VTE was identified In pregnancy and the puerperium, conventional and candidate biomarkers have no utility either for their negative or positive predictive value in the diagnosis of VTE
33 citations
TL;DR: The 4 ’A’s Test (4AT) is validated against a reference standard to determine if the 4AT is sensitive to general cognitive impairment and if 4AT scores predict outcomes, including a health economic analysis.
Abstract: Introduction: Delirium is a severe neuropsychiatric syndrome of rapid onset, commonly precipitated by acute illness. It is common in older people in the emergency department and acute hospital, but greatly under-recognised in these and other settings. Delirium and other forms of cognitive impairment, particularly dementia, commonly co-exist. There is a need for a rapid delirium screening tool that can be administered by a range of professional level healthcare staff to patients with sensory or functional impairments in a busy clinical environment, which also incorporates general cognitive assessment. We developed the ‘4As Test’ (4AT) for this purpose. This study’s primary objective is to validate the 4AT against a reference standard. Secondary objectives include (a) comparing the 4AT with another widely used test (the Confusion Assessment Method (CAM)); b) determining if the 4AT is sensitive for general cognitive impairment; c) assessing if 4AT scores predict outcomes; including d) a health economic analysis. Methods and analysis: 900 patients aged 70 or over in Emergency Departments or acute general medical wards will be recruited in three sites (Edinburgh, Bradford, Sheffield) over 18 months. Each patient will undergo a reference standard delirium assessment and will be randomised to assessment with either the 4AT or the CAM. At 12 weeks outcomes (length of stay, institutionalisation, and mortality) and resource utilisation will be collected by a questionnaire, and via the electronic patient record. Ethics and dissemination: Ethical approval was granted in Scotland (Scotland A NHS Research Ethics Committee) and England (Yorkshire and the Humber NHS Research Ethics Committee). The study involves administering tests commonly used in clinical practice. The main ethical issues are the essential recruitment of people without capacity. Dissemination is planned via publication in high impact journals, presentation at conferences, social media and the website www.the4AT.com. Registration details: International standard randomised controlled trial number (ISRCTN) 53388093. UK Clinical Research Network ID: 19502
27 citations
TL;DR: This study demonstrates very strong overall interoperator reliability between the four groups of clinicians studied, suggesting that the HEART Score is reproducible when used by different professional groups and grade of clinician.
Abstract: Background Patients presenting with chest pain represent a significant proportion of attendances to the ED The History, ECG, Age, Risk Factors and Troponin (HEART) Score is validated for the risk stratification of suspected ischaemic chest pain within the ED The goal of this research was to establish the interoperator reliability of the HEART Score as performed in the ED by different grades of doctor and nurse Methodology Patients with suspected ischaemic chest pain presenting to the ED of an inner city, London Hospital, were recruited prospectively between January and May 2016 Patients that had been enrolled in the study were interviewed by clinicians from four different categories: senior doctor, junior doctor, senior nurse and junior nurse Clinicians, blinded to other raters’ results, calculated the HEART Scores for each patient with the assistance of a pocket-sized HEART Score card The intraclass correlation coefficient (ICC) was calculated as the primary measure of reliability 120 patients were required to achieve a desired power of 80% Results 88 complete comparisons were obtained There were no significant differences between the distributions of HEART Scores for each clinician group (p=095) The ICC for the overall HEART Score was 091 (95% CI 087 to 093) The ICC for troponin and age were ‘1’, for ‘history’ 041 (95% CI 030 to 052), ‘ECG’ 064 (95% CI 054 to073) and ‘risk factors’ 084 (95% CI 079 to 089) Conclusion This study demonstrates very strong overall interoperator reliability between the four groups of clinicians studied This suggests that the HEART Score is reproducible when used by different professional groups and grade of clinician
18 citations
TL;DR: The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and health-care costs.
Abstract: BACKGROUND: Pulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging. OBJECTIVE: To estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging. DESIGN: An expert consensus study to develop new clinical decision rules, a case-control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling. SETTING: Emergency departments and consultant-led maternity units. PARTICIPANTS: Pregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites. INTERVENTIONS: Clinical features, decision rules and biomarkers. MAIN OUTCOME MEASURES: Sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs. RESULTS: The primary analysis involved 181 women with PE and 259 women without PE in the case-control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells's PE criteria (permissive), 0.577; and Wells's PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time - 0.669, B-type natriuretic peptide - 0.549, C-reactive protein - 0.542, Clauss fibrinogen - 0.589, enzyme-linked immunosorbent assay D-dimer - 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) - 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) - 0.524, prothrombin fragment 1 + 2 - 0.562, plasmin-antiplasmin - 0.639, Prothombin time - 0.613, thrombin generation lag time - 0.702, thrombin generation endogenous potential - 0.559, thrombin generation peak - 0.596, thrombin generation time to peak - 0.655, tissue factor - 0.531 and troponin - 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy. LIMITATIONS: The findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care. CONCLUSIONS: Clinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging. FUTURE WORK: New diagnostic technologies need to be developed to detect PE in pregnancy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN21245595. FUNDING DETAILS: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.
16 citations
TL;DR: A brief history of diversionary services is outlined, the concept of Alcohol Intoxication Management Services (AIMS) is introduced and examples of AIMS in the UK are described, and Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment that involves an ethnographic study, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of A IMS.
Abstract: Acute alcohol intoxication (AAI) has a long history of burdening emergency care services. Healthcare systems around the world have explored a variety of different services that divert AAI away from EDs to better manage their condition. Little formal evaluation has been undertaken, particularly in the UK where alcohol misuse is one of the highest in the world. In this article, we outline a brief history of diversionary services, introduce the concept of Alcohol Intoxication Management Services (AIMS) and describe examples of AIMS in the UK. We then describe Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment including six cities with AIMS compared with six cities without, that involves an ethnographic study, records patient experiences in both AIMS and EDs, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of AIMS.
14 citations
TL;DR: Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately.
Abstract: Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately
11 citations
TL;DR: A prognostic model for identifying people at increased risk of poor outcome after an acute ankle sprain and updated models with the additional pain variable at 4 weeks had improved discriminatory ability over the baseline models but not better calibration.
Abstract: BACKGROUND: Ankle sprains are very common injuries. Although recovery can occur within weeks, around one-third of patients have longer-term problems. OBJECTIVES: To develop and externally validate a prognostic model for identifying people at increased risk of poor outcome after an acute ankle sprain. DESIGN: Development of a prognostic model in a clinical trial cohort data set and external validation in a prospective cohort study. SETTING: Emergency departments (EDs) in the UK. PARTICIPANTS: Adults with an acute ankle sprain (within 7 days of injury). SAMPLE SIZE: There were 584 clinical trial participants in the development data set and 682 recruited for the external validation study. PREDICTORS: Candidate predictor variables were chosen based on availability in the clinical data set, clinical consensus, face validity, a systematic review of the literature, data quality and plausibility of predictiveness of the outcomes. MAIN OUTCOME MEASURES: Models were developed to predict two composite outcomes representing poor outcome. Outcome 1 was the presence of at least one of the following symptoms at 9 months after injury: persistent pain, functional difficulty or lack of confidence. Outcome 2 included the same symptoms as outcome 1, with the addition of recurrence of injury. Rates of poor outcome in the external data set were lower than in the development data set, 7% versus 20% for outcome 1 and 16% versus 24% for outcome 2. ANALYSIS: Multiple imputation was used to handle missing data. Logistic regression models, together with multivariable fractional polynomials, were used to select variables and identify transformations of continuous predictors that best predicted the outcome based on a nominal alpha of 0.157, chosen to minimise overfitting. Predictive accuracy was evaluated by assessing model discrimination (c-statistic) and calibration (flexible calibration plot). RESULTS: (1) Performance of the prognostic models in development data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.74 [95% confidence interval (CI) 0.70 to 0.79], with good model calibration across the imputed data sets. The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.70 (95% CI 0.65 to 0.74), with good model calibration across the imputed data sets. Updating these models, which used baseline data collected at the ED, with an additional variable at 4 weeks post injury (pain when bearing weight on the ankle) improved the discriminatory ability (c-statistic 0.77, 95% CI 0.73 to 0.82, for outcome 1 and 0.75, 95% CI 0.71 to 0.80, for outcome 2) and calibration of both models. (2) Performance of the models in the external data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.73 (95% CI 0.66 to 0.79), with a calibration plot intercept of -0.91 (95% CI -0.98 to 0.44) and slope of 1.13 (95% CI 0.76 to 1.50). The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.63 (95% CI 0.58 to 0.69), with a calibration plot intercept of -0.25 (95% CI -0.27 to 0.11) and slope of 1.03 (95% CI 0.65 to 1.42). The updated models with the additional pain variable at 4 weeks had improved discriminatory ability over the baseline models but not better calibration. CONCLUSIONS: The SPRAINED (Synthesising a clinical Prognostic Rule for Ankle Injuries in the Emergency Department) prognostic models performed reasonably well, and showed benefit compared with not using any model; therefore, the models may assist clinical decision-making when managing and advising ankle sprain patients in the ED setting. The models use predictors that are simple to obtain. LIMITATIONS: The data used were from a randomised controlled trial and so were not originally intended to fulfil the aim of developing prognostic models. However, the data set was the best available, including data on the symptoms and clinical events of interest. FUTURE WORK: Further model refinement, including recalibration or identifying additional predictors, may be required. The effect of implementing and using either model in clinical practice, in terms of acceptability and uptake by clinicians and on patient outcomes, should be investigated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12726986. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 64. See the NIHR Journals Library website for further project information. Funding was also recieved from the NIHR Collaboration for Leadership in Applied Health Research, Care Oxford at Oxford Health NHS Foundation Trust, NIHR Biomedical Research Centre, Oxford, and the NIHR Fellowship programme.
10 citations
TL;DR: This study will determine if it is feasible, acceptable and cost-effective to undertake a full-scale trial comparing CPAP and standard oxygen treatment, delivered by ambulance service clinicians for ARF.
Abstract: Acute respiratory failure (ARF) is a common and life-threatening medical emergency. Standard prehospital management involves controlled oxygen therapy and disease-specific ancillary treatments. Continuous positive airway pressure (CPAP) is a potentially beneficial alternative treatment that could be delivered by emergency medical services. However, it is uncertain whether this treatment could work effectively in United Kingdom National Health Service (NHS) ambulance services and if it represents value for money. An individual patient randomised controlled external pilot trial will be conducted comparing prehospital CPAP to standard oxygen therapy for ARF. Adults presenting to ambulance service clinicians will be eligible if they have respiratory distress with peripheral oxygen saturation below British Thoracic Society (BTS) target levels, despite titrated supplemental oxygen. Enrolled patients will be allocated (1:1 simple randomisation) to prehospital CPAP (O_two system) or standard oxygen therapy using identical sealed boxes. Feasibility outcomes will include incidence of recruited eligible patients, number of erroneously recruited patients and proportion of cases adhering to allocation schedule and treatment, followed up at 30 days and with complete data collection. Effectiveness outcomes will comprise survival at 30 days (definitive trial primary end point), endotracheal intubation, admission to critical care, length of hospital stay, visual analogue scale (VAS) dyspnoea score, EQ-5D-5L and health care resource use at 30 days. The cost-effectiveness of CPAP, and of conducting a definitive trial, will be evaluated by updating an existing economic model. The trial aims to recruit 120 patients over 12 months from four regional ambulance hubs within the West Midlands Ambulance Service (WMAS). This sample size will allow estimation of feasibility outcomes with a precision of < 5%. Feasibility and effectiveness outcomes will be reported descriptively for the whole trial population, and each trial arm, together with their 95% confidence intervals. This study will determine if it is feasible, acceptable and cost-effective to undertake a full-scale trial comparing CPAP and standard oxygen treatment, delivered by ambulance service clinicians for ARF. This will inform NHS practice and prevent inappropriate prehospital CPAP adoption on the basis of limited evidence and at a potentially substantial cost. ISRCTN12048261. Registered on 30 August 2017. http://www.isrctn.com/ISRCTN12048261
7 citations
TL;DR: A prognostic model for poor recovery after ankle sprain developed and externally validate include predictors easy to assess clinically and show benefit when compared with not using any model.
Abstract: Objectives To develop and externally validate a prognostic model for poor recovery after ankle sprain. Setting and participants Model development used secondary data analysis of 584 participants from a UK multicentre randomised clinical trial. External validation used data from 682 participants recruited in 10 UK emergency departments for a prospective observational cohort. Outcome and analysis Poor recovery was defined as presence of pain, functional difficulty or lack of confidence in the ankle at 9 months after injury. Twenty-three baseline candidate predictors were included together in a multivariable logistic regression model to identify the best predictors of poor recovery. Relationships between continuous variables and the outcome were modelled using fractional polynomials. Regression parameters were combined over 50 imputed data sets using Rubin’s rule. To minimise overfitting, regression coefficients were multiplied by a heuristic shrinkage factor and the intercept re-estimated. Incremental value of candidate predictors assessed at 4 weeks after injury was explored using decision curve analysis and the baseline model updated. The final models included predictors selected based on the Akaike information criterion (p Results Outcome rate was lower in the development (6.7%) than in the external validation data set (19.9%). Mean age (29.9 and 33.6 years), body mass index (BMI; 26.3 and 27.1 kg/m2), pain when resting (37.8 and 38.5 points) or bearing weight on the ankle (75.4 and 71.3 points) were similar in both data sets. Age, BMI, pain when resting, pain bearing weight, ability to bear weight, days from injury until assessment and injury recurrence were the selected predictors. The baseline model had fair discriminatory ability (C-statistic 0.72; 95% CI 0.66 to 0.79) but poor calibration. The updated model presented better discrimination (C-statistic 0.78; 95% CI 0.72 to 0.84), but equivalent calibration. Conclusions The models include predictors easy to assess clinically and show benefit when compared with not using any model. Trial registration number ISRCTN12726986; Results.
5 citations
01 Nov 2018
TL;DR: It is suggested that children under the age of five should be supervised by an adult or preferably two adults to ensure that they do not fall victim to the harmful effects of infectious disease.
Abstract: ..................................................................................................................................... 3 Table of