Volume 5 No. 2
Summer 2018
Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation
Developing nicely!
Read cover story on page 3 for latest update
medical
CONTENTS
CONTENTS 4
EDITORS COMMENT
7
CLINICAL PAPER Management of upper gastrointestinal bleeding in emergency departments
21
CLINICAL PAPER Development of the major trauma case review tool
30
NEWS
Resuscitation Today This issue edited by: Paul Jones c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED: Spring, Summer and Autumn
COVER STORY Dear Friends and Colleagues, Developing nicely! Following our announcement earlier this year about the good news that Mrs. Brayden and I are expecting a new edition to the Brayden family, you can see from the cover image that our Brayden Baby is well on the way. As we advised, this is a very special ‘baby’ as it is being created by a highly talented, professional team using the latest technology. We are delighted that Brayden Baby is developing so well and that some of its unique features are already well defined. There has been tremendous interest and questions about when he or she will be ‘delivered’ and we look forward to announcing the arrival in early Autumn. For everyone who has trained with me and given invaluable feedback, we will offer you a first, special look at our new edition.
PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Autumn 2018 Subscription Information – Summer 2018 Resuscitation Today is a tri-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details.
Best wishes
Cheques should be made payable to MEDIA PUBLISHING.
Brayden
Designed in the UK by Hansell Design
P.S. We have lots of suggestions for names and will choose our favourite once Brayden Baby arrives – so watch this space!
RESUSCITATION TODAY - SUMMER 2018
We can be reached by email at home via our new website at www.innosonian.eu
COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ
3
EDITORS COMMENT
EDITORS COMMENT In a time where resuscitation can make such a difference in comparison to years gone by, we all need to begin focussing on wider and more challenging aspects of our roles in order to reduce the risk of patient deterioration and increase the chance of survivability from sudden cardiac arrest. This edition has been geared around exactly this, there are a number of key conditions that can lead to cardiac arrest, if we begin to focus more on researching and discussing these things then we will start to see people in a different light. We will see the potential for deterioration and, whilst it is difficult to measure, we will start to save lives before needing to resuscitate them.
“Those performing resuscitation have always given everything they can and will always continue to RESUSCITATION TODAY - SUMMER 2018
4
do so.”
Whatever our clinical environment, from first aider to intensivist, we are in a position to recognise deterioration by many methods. Whether it is the simple recognition of an altering level of consciousness, changes within a scientific scoring system which brings together baseline observations (such as NEWS) or the use of haematological testing and interpretation. We all have the opportunity to prevent cardiac arrest instead of needing to successfully perform resuscitation – and this has to be better for patient outcome! The UK Resus Council notably offer guidance on peri-arrest specifically for cardiac arrhythmias and anaphylaxis, and this sits very comfortably within the theme of cardiac arrest prevention. From simple to complex, they continue to promote an understanding of the Chain of Survival whilst offering support to those wanting to fully consider deficiencies in acute care, ‘at risk’ patients, clinical response and the role that education can play in improving outcomes for all (https://www.resus.org.uk/resuscitation-guidelines/prevention-of-cardiac-arrest-and-decisionsabout-cpr/#). Those performing resuscitation have always given everything they can and will always continue to do so. I’m not decrying this fact. The suggestion is that we develop our skill-set and prevent the patient needing this in the first place. If we continue to develop our skills of recognising the sickest of patients with the highest levels of risk of cardiac arrest, then we will successfully save lives – maybe without realising we did so and with minimal recognition or fuss. Training and education, continuing professional development opportunities and research, conferences and conversations have started to move in this direction. So, let us do the same, let’s continue to identify the killers and keep the dialogue going – resuscitation isn’t just about chest compressions, ventilations and drug therapy; it’s about the hours of peri-arrest, the contact leading to the point of crisis, the actions of those who treat the sickest of patients and the studies which inform them and keep them ready for unglorified action.
Paul Jones
when every breath counts Waveform Capnography 2015 ERC/UK ALS waveform capnography guidelines
All Patient use
EtC02 & Respiratory rate
Adult/Paediatric Infant/Neonate
End-tidal C02 Respiratory Rate + Waveform {+FiC02 CapnoTrue}
Configurable Alarms
Pulse Oximetry {CapnoTrue}
High & Low EtC02, Apnoea Blocked airway, Battery status
Oxygen Saturation, Pulse Rate values & Plethysmogram.
Tube Placement & ROSC
Data Transfer {CapnoTrue}
Ensures efficacy of intubation Early detection of ROSC
Data Transfer capability SW for patient ID, events & trends
Effectiveness of CPR
Optimised Battery Life
Feedback > effectiveness of chest compressions & CPR
8 hrs. continuous use {EMMA} 6 hrs + Charger unit {CapnoTrue}
EMMA Capnograph Mainstream Waveform EtC0 2 + Respiratory Rate + Alarms
CapnoTrue AMP Mainstream
Waveform EtC02 + Respiratory Rate + FiC02 + Sp02 + Alarms + Trends + Data store & Transfer
CapnoTrue ASP Sidestream
Waveform EtC02 + Respiratory Rate + FiC02 + Sp02 + Alarms + Trends + Data store & Transfer
MEDACX LIMITED | ALEXANDER HOUSE | 60-62 STATION ROAD | HAYLING ISLAND | HAMPSHIRE | PO11 0EL
02392 469737 info@medacx.co.uk www.medacx.co.uk
CLINICAL PAPER
Laerdal Suction Unit (LSU) Be prepared for emergency situations
Manual SphygMode
The Laerdal Suction Unit (LSU) is a portable, powerful and highly reliable suction unit designed for optimal preparation in emergency situations. The LSU is available as a REUSABLE or DISPOSABLE configuration STANDARD FEATURES:
5 year manufacturer’s warranty
• 5 year manufacturer’s warranty • Lightweight, powerful and effective • Built-in self-test • Rechargeable battery • Quiet when running • Shock & splash proof design • Vacuum of 500 + mmHg and flow rate of >25 LPM • A range of consumables and accessories are available
Also available is the smaller and compact LCSU4, designed for FIRST RESPONDERS LCSU4 (Laerdal Compact Suction Unit) The Laerdal LCSU4 suction unit combines rugged design with lightweight portability, an essential too for every first responder The LCSU4® comes with RESUSCITATION TODAY - SUMMER 2018
6
a 2 year warranty and can be easily and quickly be converted into either a 300ml or 800ml canister capacity by ordering additional parts.
Cardiac Services
For more information or to arrange a demonstration call 07789 817 060 or e-mail d-booth@cardiac-services.com
Europa House, Adlington Business Park, Adlington, Macclesfield, SK10 4NL. Tel: 01625 878 999 Fax: 01625 878 880 Contact: d-booth@cardiac-services.com Web: www.cardiac-services.com
CLINICAL PAPER
MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING IN EMERGENCY DEPARTMENTS, FROM BLEEDING SYMPTOMS TO DIAGNOSIS: A PROSPECTIVE, MULTICENTER, OBSERVATIONAL STUDY Pierre-Clément Thiebaud1,2, Youri Yordanov1,3,4, Jacques-Emmanuel Galimard5, Pierre-Alexis Raynal1,3, Sébastien Beaune2,6, Laurent Jacquin2,7, François-Xavier Ageron2,8, Dominique Pateron1,3* and the Initiatives de Recherche aux Urgences Group Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Abstract Background
Results
Upper gastrointestinal bleeding (UGB) is common in emergency
In total, 110 EDs participated, including 194 patients with suspected
departments (EDs) and can be caused by many eso-gastro-duodenal
UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%)
lesions. Most available epidemiological data and data on the
had hematemesis and 75 (39%) melena. Endoscopy revealed lesions
management of UGB comes from specialized departments (intensive
in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or
care units or gastroenterology departments), but little is known from the
bleeding lesions due to portal hypertension (20%). The final diagnosis
ED perspective.
of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died
We aimed to determine the distribution of symptoms revealing UGB
(11%); 40 (21%) were hospitalized in intensive care units and 126 (65%)
in EDs and the hemorrhagic lesions identified by endoscopy. We
in medicine departments; 28 (14%) were outpatients. Mortality was
also describe the characteristics of patients consulting for UGB, UGB
higher among patients with clinical and biological severity signs.
management in the ED and patients outcomes. Conclusion Method
Most of the UGB cases in EDs are revealed by hematemesis. The
This was a prospective, observational, multicenter study covering 4
emergency physician diagnosis of UGB is rarely challenged by the
consecutive days in November 2013. Participating EDs were part of
endoscopic findings.
the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected
Keywords: Gastrointestinal bleeding, Hematemesis, Melena,
UGB in these EDs were included.
Endoscopy, Emergency department
Background Upper gastrointestinal bleeding (UGB) is a common emergency, with
an endoscopy [10–13]. But these patients represent only a portion of
a variety of eso-gastro-duodenal symptoms as hematemesis, melena,
all those with UGB seen in emergency departments (EDs). Specifically
less often hematochezia or anemia. It can be caused by various
targeting UGB patients presenting in EDs could give us a more
potentially serious lesions, as peptic ulcers or varices [1]. UGB annual
comprehensive epidemiological description.
incidence tends to decrease, influenced by the latest therapeutical Therefore, we aimed at describing the distribution of symptoms
of portal hypertension complications [2]. But it remains relatively high
revealing UGB in EDs and the hemorrhagic lesions identified
because of the widespread use of non-steroidal anti-inflammatory
by endoscopy. Our secondary objectives were to describe the
drugs (NSAIDS) and anti-thrombotic agents [3, 4]. Current cases of
epidemiological characteristics and management of patients with UGB,
UGB occur in patients older than previously described [4–6]. Several
including outcomes.
recommendations regarding UGB management have been published, including therapeutic interventions initiated by the emergency physicians. The implementation of these recommendations could affect
Methods
patients’ prognosis [2, 7, 8]. This prospective, observational, multicenter study was conducted over Very few studies have been conducted in the emergency setting
4 consecutive days in November 2013. We included the 110 EDs, 17
(hospital and pre-hospital settings) to describe UGB epidemiology and
with a prehospital medical unit, that were part of a network of clinical
management [9]. Existing epidemiological data usually concern UGB
research (Initiatives de Recherche aux Urgences [IRU]) coordinated by
in patients hospitalized in gastroenterology, intensive care units or after
the French Society of Emergency Medicine [SFMU].
* 1 3
Correspondence: Dominique.pateron@aphp.fr; dominique.pateron@sat.aphp.fr Service des Urgences - Hôpital Saint Antoine, Assistance Publique–Hôpitaux de Paris (APHP), Paris, France Sorbonne Universités, UPMC Paris Univ-06, Paris, France Full list of author information is available at the end of the article
RESUSCITATION TODAY - SUMMER 2018
developments in the management of peptic ulcers or the prevention
7
CLINICAL PAPER Table 1 General characteristics and treatments of patients presenting an upper gastrointestinal bleeding (UGB)
Age (median [Q1–Q3])a Sex (men; n, %)
Arrival at the ED n = 170
Pre-hospital management n = 24
Total n = 194
P value
66 [49–82]
71 [57.5–75.5]
66 [51–81]
0.71
88 (52)
17 (71)
105 (54)
0.085
Hematemesis
87 (51)
17 (71)
104 (54)
0.096
Melena
70 (41)
5 (21)
75 (39)
Hematochezia
6 (4)
2 (8)
8 (4)
Other
7 (4)
0 (0)
7 (4)
n = 143
n = 20
n = 163
Known cirrhosis
31 (22)
4 (20)
35 (21)
1.
Known ulcer
33 (23)
5 (25)
38 (23)
0.78
Initial symptoms suggesting UGB, n (%)
Medical history and medication, n (%)b
Non-steroid anti-inflammatory drugs
10 (7)
2 (10)
12 (7)
0.64
Antithrombotic agents
54 (38)
8 (40)
62 (38)
1.
Comorbidity
57 (40)
5 (25)
62 (38)
0.25
86 (51)
16 (67)
102 (53)
0.19
Exteriorized bleeding in the ED, n (%)c d
Clinical features of severity, n (%) Heart rate > 100 bpm
n = 166
n = 22
n = 188
36 (22)
12 (55)
48 (26)
0.003
Systolic arterial pressure < 90 mmHg
27 (16)
8 (36)
35 (19)
0.037
Marbling
5 (3)
3 (14)
8 (4)
0.053
Altered mental status Hemoglobin level, n (%)e
< 7 g/dL
Treatments in ED, n (%)
5 (3)
4 (18)
9 (5)
0.012
34 (20)
5 (24)
39 (21)
0.77
n = 170
n = 24
n = 194
Nasogastric tube
15 (9)
4 (17)
19 (10)
0.26
Fluid administration
55 (32)
12 (50)
67 (35)
0.11
Transfusion
71 (42)
1 (4)
72 (37)
0.0002
Proton pump inhibitors
132 (78)
8 (33)
140 (72)
< 0.0001
Vasopressors
33 (19)
3 (13)
36 (19)
0.58
Catecholamines
2 (1)
2 (8)
4 (2)
0.075
Antibioticsf (excluding erythromycin)
8 (5)
—
—
—
Vitamin K antagonist reversal
18 (11)
1 (4)
19 (10)
0.048
Erythromycin
16 (9)
1 (4)
17 (9)
0.70
a
for 193 of 194 patients for 163 of 194 patients for 192 of 194 patients d for 188 of 194 patients e for 189 of 194 patients f for 170 of 194 patients b c
RESUSCITATION TODAY - SUMMER 2018
8
The IRU correspondent for each ED was responsible for patients’
(hematemesis, melena, other), medical history (cirrhosis, ulcer and other
inclusion and data extraction. The STROBE recommendations for
comorbidities), and NSAIDS and/or antithrombotic treatment. In light
reporting of observational studies were followed [14].
of existing epidemiological data, showing an annual incidence of high digestive bleeding of 100 to 150/100,000 inhabitants [5], the number of
Patients
centres in the IRU network and the duration of the study of 4 days, we
All patients with suspected UGB, hematemesis with or without melena,
expected to include 150 to 300 cases of UGB. We estimated the prevalence
melena without hematemesis, hematochezia or other symptoms (acute
of UGB with 2013 data from the French Emergency Survey (FES) and the
anemia, hemorrhagic shock or syncope) suggestive of hemorrhage, who
National Institute of Statistics and Economic Studies (INSEE) data.
were seen in one of the participating pre-hospital or hospital EDs were included by the emergency physicians of the participating departments.
Assessment of disease severity
Exclusion criteria were patients aged less than 18 years old, refusal to
Data for the initial clinical items related to severity were collected,
participate or already included in the study once. For each patient, the
including signs related to blood loss (heart rate > 100 bpm, systolic
following data were collected: type of first contact with an emergency
blood pressure < 90 mmHg, marbling, altered mental status) and
medicine structure (hospital or pre-hospital), age, sex, first symptoms
haemoglobinemia (> 10, 7–10 and <7 g/dL hemoglobin level).
CLINICAL PAPER
Fig. 1 Flow of patients from the first symptoms of suspected upper gastrointestinal bleeding (UGB) to endoscopy diagnosis. N = total number of patients. n1 = patients arriving to the emergency department. n2 = patients initially assessed by a pre-hospital medical team
The following therapeutic measures, done in the ED, were collected:
Categorical variables are expressed as number and percentage. They
placement of a nasogastric tube; fluid administration; transfusion; and
were compared using Fisherâ&#x20AC;&#x2122;s exact test. Statistical analyses were
use of proton pump inhibitors, vasopressors (somatostatin, octreotide,
two-tailed, and a p value less than 0.05 was considered significant.
terlipressin), catecholamines (adrenaline, norepinephrine), anticoagulation
Analyses were performed using R statistical software, version 3.1.3
reversal and antibiotics. The use of erythromycin before endoscopy was
(www.r-project.org).
also noted. Endoscopy data concerning bleeding lesions and hemostasis procedures were noted, as were the performance of any imaging test
Ethics
(ultrasonography, CT). Patients outcome (hospitalised or outpatient), final
The study was approved by the institutional review board (IRB) (ComitĂŠ
diagnosis and hospital deaths were also collected.
de protection des personnes, Ile de France XI, Paris, France) and the Advisory Committee on Information Processing in Material Research in
Statistical analysis
the Field of Health (CCTIRS). Patients, or their next of kin, were informed
Continuous variables are presented as median, first and third quartile
that a study was being led and that their data might be used. They
(Q1-Q3) and were compared using the Wilcoxon rank sum test.
could refuse being included.
RESUSCITATION TODAY - SUMMER 2018
Management and treatment
9
CLINICAL PAPER Results
Table 2 Final diagnosis Final diagnosis
n (%)
Ulcers
44 (30)
Gastritis
16 (11)
not included in the study. The participating EDs received 46.190 visits
Variceal bleeding
30 (20)
during the study period and UGB was suspected in 0.42% of the
Esophagitis
12 (8)
situations. Thus, the estimated incidence of UGB in France, in 2013,
Mallory-Weiss tear
7 (5)
Cancer
12 (8)
Lower gastrointestinal bleeding
5 (3)
None
22 (15)a
Lower gastrointestinal bleeding
4 (9)
None
42 (91)b
During the study, we have included 194 patients with suspected UGB, No patients declined participation, no patients were excluded due to multiple inclusions, and two patients younger than 18 years old were
Endoscopy performed, n = 148 (76%)
was 122/100,000 inhabitants. Out of the 194 included patients, 24 received initial prehospital medical care (12%), median age was 66 years [Q1-Q3 51-81] and 105 (54%) were male. Overall, 104 (54%) had hematemesis and 75 melena (39%). For 15 patients (8%), the suspicion was based on other symptoms (Table 1). Bleeding externalization was observed during the ED stay of a 102 patients (53%). The flow from first
No endoscopy performed, n = 46 (24%)
symptoms to endoscopy diagnosis is reported in Fig. 1. In total, 148
a
patients (76%) underwent endoscopy during their hospital stay, out of
b
5 outpatients included 23 outpatients included
which 44 (23%) during the ED stay: 9/44 (20%) received erythromycin and 12/44 (27%) a hemostatic procedure. Endoscopy confirmed the diagnosis and revealed lesion explaining UGB in 121/148 patients (82%) (Table 2). Gastroduodenal ulcer (44/148 patients, 30%) was the most frequent lesion followed by variceal bleeding (30/148, 20%) and gastritis (16/148, 11%). In 22/148 patients (15%), no lesion was found. In 5/148 (3%) the diagnosis of UGB was overturned, with lower gastrointestinal
than one third of patients had at least one severity sign; about 20% had hypotension, < 7 g/dL hemoglobin level, and a known cirrhosis. In all, 11% of patients died; initial hypotension, marbling or altered mental status were significantly linked to mortality.
bleeding finally diagnosed.
Our proportion of patients presenting with hematemesis (54%) is close
Overall, 67/194 patients (35%) had at least one severity sign: 48 (26%)
departments, intensive care units or by emergency endoscopy [3, 9, 17,
tachycardia, 35 (19%) hypotension, some could present several severity sign (Table 1). Thirty-nine patients (21%) had a hemoglobin level < 7 g/
to literature data (42â&#x20AC;&#x201C;61%) for UGB managed in gastroenterology 18]. In a study of 1140 emergency and ambulatory care patients with UGB of ulcerative origin, the proportion of melena was higher than in
dL and 72 (37%) underwent transfusion. Data regarding type of UGB
our study (52 vs 39%), with 40% of patients having hematemesis and
management are presented in Table 1. Thirty-five patients (21%) had
8% anemia without exteriorized bleeding [19]. In our study, bleeding
a known cirrhosis. Clinical characteristics and outcomes depending
lesions were diagnosed by endoscopy in 80% of cases. One quarter
on presence or not of cirrhosis are presented in Table 3. Patients with
of patients had no endoscopy during hospitalization, often because of
a history of cirrhosis were more often younger and males than those
the low severity among outpatients and more rarely (4 cases) because
without cirrhosis. They presented with a significantly higher proportion
the patient died before endoscopy could be performed. This might
of severity signs, as heart rate > 100 bpm (p = 0.006), marbling (p =
have an impact on the distribution of the causes of UGB. In about 15%
0.031) or an altered mental status (p = 0.015). A total of 21 patients
of patients, endoscopic diagnosis was missing, which is comparable
(11%) died, of which 3 during the pre-hospital phase; 40 (21%) were
to previously published studies [5, 20, 21]. The prevalence of 41%
hospitalized in intensive care units, 126 (65%) in medicine departments
of lesions with an ulcerative origin (ulcer disease or complicated
and 28 (14%) were outpatients.
ulcerations) is close to data (28-67%) from studies including UGB cases from endoscopy examination [5, 21]. The 20% of bleeding lesions
RESUSCITATION TODAY - SUMMER 2018
10
Mortality was significantly higher for hypotensive patients (p = 0.004),
due to portal hypertension was associated to the high prevalence of
with marbling (p = 0.042) or altered mental status (p = 0.0008).
cirrhosis in our population [22]. More than a quarter of patients with
Exteriorized bleeding in the ED was also associated to a higher
cirrhosis presented bleeding from other causes than cirrhosis. This
mortality rate (p = 0.035). Deceased patients received more frequently
can be a strong argument in favor of the use of proton pump inhibitors
vasopressors (p = 0.0009) or catecholamines (p = 0.004). Although not
before endoscopy in this subset of patients, as itâ&#x20AC;&#x2122;s recommended [7],.
significant, there seem to be a trend between mortality and cirrhosis (p
In our study, the diagnosis of UGB in the ED was rarely challenged by
= 0.071) and transfusion (p = 0.057) (Table 4).
subsequent explorations (3% of cases).
Discussion
The UGB incidence estimated from our study favours the completeness of data for our included patients. Epidemiological reviews show an annual incidence of UGB of 50 to 150/100,000 inhabitants [5] and
The distribution of symptoms for suspected UGB is poorly known,
the main French study showed an annual incidence of 146/100,000
especially in EDs, even though most cases of UGB (80â&#x20AC;&#x201C;90%) are
[1]. The median age of UGB and proportion of patients older than 80
managed in EDs [11, 15, 16]. Our multicentric, prospective study
years is similar to that observed in the most recent studies and seems
performed over a short period (4 days) in French EDs found that
higher than that observed 10 years ago, with a significant proportion
for more than half of the patients (54%), the UGB was revealed by
of patients on anti-thrombotic therapy [3, 4]. The proportion of patients
hematemesis. Endoscopy revealed a lesion in about 80% of patients.
with UGB who were older than 75 years was 27% in 1996 [23] but 37%
The final diagnosis of UGB was reversed for only 3% of patients. More
in our study.
CLINICAL PAPER “The Bluetooth link between the impressive Brayden Pro manikin and the App on the android tablet greatly enhances the training value of the system. It gives not only an immediate guide to the quality of compressions and ventilations, but also offers trends and a permanent record of what is being achieved. It would be hard to rival as a training system.” Professor Douglas Chamberlain, CBE, KSG ? PRO
S
RESULT DETAILED rescuer / Single
Learner
01 30
10
2
n rate Comp. release
84
No. of comp.
60
Total times
Ventilatio
n Ventilatio volume
Avg.
138
sion Compres depth CCF
cm
52
Hands-o
97
%
Avg.
4
times
e ion volum Ventilat
520
%
12
ml
ion speed Ventilat
ff time
tion Hand posi
P
/ min
5.3
avg. Comp. rate
accuracy
Total
times
sion rate Compres
CCF Score of
sition Hand po
ion Ventilat
sion Compres
rmance h CPR Perfo sion dept Compres
Overall
Y
ng Self traini
ining / Self tra
Cycle
d nt Perio CPR Eve
AR / SUMM
sec
3.5
sec
ies chart Time ser 120 100 700
400
5.0 6.0
Quality
“This manikin is a refreshing change from traditional basic life support manikins. I have found my class more eager to practice with this new CPR feedback technique. Demonstrating blood flow and the concept of CPR in this unique way engages every class I teach. Over the last year the manikin has proved to be robust and reliable after being transported to a variety of locations for basic CPR teaching sessions.”
of CPR
xls
Rob Morrison Resuscitation Officer, Dartford & Gravesham NHS Trust, Darent Valley Hospital
Brayden PRO is one of the Brayden range of manikins for CPR training. A new model, the Brayden Baby, is currently under development – see cover story.
RESUSCITATION TODAY - SUMMER 2018
The award winning Brayden with Lights is now used by The American Red Cross for its CPR training in the USA.
11
CLINICAL PAPER Table 3 Patients characteristics depending on their cirrhosis history
Age (median [Q1–Q3]) Sex (men; n, %) Initial symptoms suggesting UGB, n (%)
With cirrhosis n = 35
Without cirrhosis n = 128
P value
56 [50–67.5]
73 [56–83]
0.0006
26 (74%)
69 (54%)
0.034
Hematemesis
24 (69)
60 (47)
0.005
Melena
7 (20)
60 (47)
Hematochezia
1 (3)
6 (5)
Other
2 (2)
3 (9)
21 (62)
69 (54)
Exteriorized bleeding in the ED, n (%)a b
Clinical features of severity, n (%)
0.56
n = 32
n = 127
Heart rate > 100 bpm
17 (53)
26 (20)
0.0006
Systolic arterial pressure < 90 mmHg
9 (28)
22 (17)
0.21
Marbling
4 (13)
3 (2)
0.031
Altered mental status Hemoglobin level, n (%)b
< 7 g/dL c
Upper endoscopy in ED, n (%) Hemostatic procedured Treatments in ED, n (%)
4 (13)
2 (2)
0.015
10 (29)
26 (21)
0.35
29 (26)
9 (29)
0.82
5 (17)
5 (5)
0.036
n = 35
n = 128
Nasogastric tube
5 (14)
12 (9)
0.37
Fluid administration
20 (57)
38 (30)
0.005
Transfusion
16 (46)
50 (39)
0.56
Proton pump inhibitors
28 (80)
93 (73)
0.51
Vasopressors
23 (66)
10 (8)
<0.0001
Catecholamines
2 (6)
1 (1)
0.12
Antibioticsc (excluding erythromycin)
4 (13)
2 (2)
0.020
Vitamin K antagonist reversal
0
19 (15)
0.027
Erythromycin
6 (17)
9 (7)
0.09 <0.0001
e
Final diagnosis (hospitalized patients), n (%)
Ulcer
2 (6)
38 (37)
Gastritis
3 (9)
12 (12)
Variceal bleeding
25 (74)
1 (1)
Esophagitis
2 (6)
9 (9)
Mallory-Weiss tear
0
6 (6)
Cancer
0
12 (12)
Lower GI bleeding
0
6 (6)
None
2 (6)
19 (18)
a
for 161 of 163 patients for 159 of 163 patients for 143 of 163 patients d for 141 of 163 patients e for 137 of 163 patients b
RESUSCITATION TODAY - SUMMER 2018
12
c
Two studies [4, 6] confirmed an increase in the ageing of the population
bleeding, including those with a history of cirrhosis that appeared more
with UGB, with average age 57, 59, 63 and 66 years in 1986-1987, 1995,
severe, and critically ill patients that were initially managed in the pre-
2000-2001, and 2005, respectively. As in our study, the literature shows
hospital setting. The main factors associated with mortality found in the
a male predominance, with a sex ratio between 1.3 and 2 [1, 20, 23],
literature are ageing, co-morbidities (including cirrhosis), signs of severity,
but the proportion of women with UGB is increasing [24].
an initial low blood pressure, hematemesis and low hemoglobin level [4, 5, 20, 21]. We found a significant association between mortality and
The observed severity of disease in our patients was similar to
signs of severity (low blood pressure, marbling, altered mental status),
epidemiological studies, finding mortality between 3 and 14% [4, 5, 17,
exteriorized bleeding in the ED or therapeutical interventions as the use of
21]. Our level of mortality (11%) might seem relatively high for patients with
catecholamines or vasoactive agents. There appear to be a trend toward
UGB in EDs [5], possibly because we included all patients with suspected
an association with history of cirrhosis and need to transfusion, although
CLINICAL PAPER Table 4 Patients characteristics depending on their survival status Age (median [Q1–Q3])
b
Sex (men; n, %)
Survivors n = 172a
Dead n = 21a
P value
66.5 [49–81]
66 [57–83]
0.46
91 (53)
13 (62)
0.49
Hematemesis
90 (52)
13 (62)
0.87
Melena
67 (39)
8 (38)
Hematochezia
8 (5)
0 (0)
Other
7 (4)
0 (0)
n = 144
n = 18
Known cirrhosis
28 (19)
7 (39)
Known ulcer
35 (24)
3 (17)
0.57
Non-steroid anti-inflammatory drugs
54 (38)
8 (44)
0.61
Antithrombotic agents
58 (40)
4 (22)
0.20
Initial symptoms suggesting UGB, n (%)
Medical history and medication, n (%)c
Comorbidity
0.071
12 (8)
0 (0)
0.36
Exteriorized bleeding in the ED, n (%)d
85 (50)
16 (76)
0.035
Clinical features of severity, n (%)e
n = 167
n = 20
Heart rate > 100 bpm
39 (23)
8 (40)
0.11
Systolic arterial pressure < 90 mmHg
26 (16)
9 (45)
0.004
Marbling
5 (3)
3 (15)
0.042
Altered mental status
4 (2)
5 (25)
0.0008
34 (20)
5 (24)
0.55
39 (25)
5 (31)
0.57
11 (7)
1 (7)
1.00
n = 172
n = 21
18 (10)
1 (5)
0.70
Fluid administration
58 (34)
8 (38)
0.81
Transfusion
60 (35)
12 (57)
0.057
Proton pump inhibitors
125 (73)
14 (67)
0.61
Vasopressors
25 (15)
10 (48)
0.0009
Hemoglobin level n (%)f Upper endoscopy in ED, n (%)
< 7 g/dL g
Hemostatic procedureh Treatments in ED, n (%) Nasogastric tube
1 (1)
3 (14)
0.004
7 (5)
1 (6)
0.56
Vitamin K antagonist reversal
16 (9)
3 (14)
0.44
Erythromycin
15 (9)
2 (10)
1.00
Ulcer
41 (29)
3 (19)
0.31
Gastritis
15 (11)
1 (6)
Variceal bleeding
23 (17)
7 (44)
Esophagitis
12 (9)
0 (0)
Mallory-Weiss tear
7 (5)
0 (0)
Cancer
10 (7)
2 (13)
Lower GI bleeding
8 (6)
1 (6)
None
23 (17)
2 (13)
i
Final diagnosis, n (%) (hospitalized patients)
a
1 missing data b for 192 of 193 patients c for 162 of 193 patients d for 191 of 193 patients e for 187 of 193 patients f for 188 of 193 patients g for 169 of 193 patients h for 167 of 193 patients i for 155 of 193 patients
not significant, which could be due to a lack of statistical power of our
for these patients with a bleeding ulcer [21]. Use of anti-thrombotic agents,
study. When looking at published literature, mortality was higher in patient
a known risk factor of digestive hemorrhage [21], was frequent in our
with a history of cirrhosis [10, 23], with variceal bleeding [17, 20] but also
population but did not predict mortality.
RESUSCITATION TODAY - SUMMER 2018
Catecholamines Antibioticsg (excluding erythromycin)
13
CLINICAL PAPER Management of UGB in our cohort of patients shows an evolution of
Acknowledgments
practices, possibly influenced by recommendations [2, 7, 8]. Proton
The authors thank Laura Smales (BioMedEditing) for editing and all
pump inhibitors were used for three-quarters of our patients, and their
the members of the Initiatives de Recherche aux Urgences network
administration is now recommended as soon as possible without
(Additional file 1).
waiting for endoscopy [7]. Most patients with cirrhosis received vasopressor treatment in the first 24 h [2]. The number of transfusions
Funding
suggests that the policy of restricting transfusion is not yet followed [25].
This study did not receive any specific funding.
Only a few patients received nasogastric tubes (10%). Several studies indicated that nasogastric tube placement does not confirm the upper
Availability of data and materials
origin of a gastrointestinal bleeding [26, 27] and recommendations
Datasets are available upon request to the corresponding author.
remain unclear on this topic. Erythromycin perfusion before endoscopy is rarely used [28]. This practice, although validated by several
Authors’ contributions
studies, is not shared by some international recommendations [21].
PCT and DP designed the study. PCT acquired the data. PCT, DP, PAR,
The use of antibiotics in patients with cirrhosis remains low despite
YY drafted the paper. JEG performed the statistical analysis. All authors
recommendations on this topic [29]. Outpatient care concerned only
revised and reviewed the final paper. All authors read and approved the
14% of our patients, which is less than in studies using a severity score
final manuscript.
[30]. The use of these scores would probably increase the proportion of outpatients.
Ethics approval and consent to participate The study was approved by the institutional review board (IRB) (Comité de protection des personnes, Ile de France XI, Paris, France) and the
Limitations One main limitation of our study is the risk of selection. The departments participating in the study are a subset of the 600 French EDs, that are particularly interested in clinical research. Patients presenting at these EDs might not be representative of the general population. The IRU includes community and university hospitals, so this risk was deemed acceptable. Another limitation can be due to the short inclusion period of 4 days that might not perfectly reflect the distribution of the causes of upper GI bleeding. There’s also a possibility of under or overestimation
Advisory Committee on Information Processing in Material Research in the Field of Health (CCTIRS). Patients, or their next of kin, were informed that a study was being led and that their data might be used. They could refuse being included. Consent for publication Not applicable. Competing interests The authors declare no conflict of interest.
of UGB incidence, due possible natural variations in the number of patients presenting with UGB in EDs. The third limitation is the absence of precise quantitative data. Each local investigator, when including patients, had to choose between various categories (e.g., tachycardia >100 bpm, hemoglobin level > 10, 7–10 and <7 g/dL) to simplify data extraction sheets and ensure data quality and comprehensiveness, at the expense of severity score precision. The number of inclusions (194 patients) limits the statistical power of the study, especially for prognostic factors. Moreover, the number of deceased patients did not allow us to perform a robust multivariate analysis.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1
Service des Urgences - Hôpital Saint Antoine, Assistance Publique–
Hôpitaux de Paris (APHP), Paris, France. 2Initiatives de Recherche aux Urgences, SFMU, French Society of of Emergency Medicine, Paris, France. 3Sorbonne Universités, UPMC Paris Univ-06, Paris,
RESUSCITATION TODAY - SUMMER 2018
14
Conclusions
France. 4INSERM, U1153, Paris, France. 5INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRA Team, Saint-Louis Hospital, Paris, France. 6Emergency
Most of the UGB cases in EDs are revealed by hematemesis. The
department, CHU Ambroise Paré, Assistance Publique Hôpitaux de
emergency physician diagnosis of UGB is rarely challenged by the
Paris, Boulogne-Billancourt, France. 7Emergency department, Hôpital
endoscopic findings. Epidemiological data for patients with UGB
Edouard Herriot, Hospices Civils de Lyon, Lyon, France. 8Emergency
managed in the emergency departments are similar to the patients
department, Centre Hospitalier Annecy Genevois, Pringy Cedex,
treated in gastroenterology departments and/or in intensive care units.
Metz-Tessy, France.
More than one third of UGB patients are more than 75 years old.
References Additional file
1. Czernichow P, Hochain P, Nousbaum JB, Raymond JM, Rudelli A, Dupas JL, et al. Epidemiology and course of acute upper gastro-
Additional file 1: Appendix 1. Members of the Initiatives de Recherche
intestinal haemorrhage in four French geographical areas. Eur J
aux Urgences network. (DOCX 16 kb)
Gastroenterol Hepatol. 2000;12:175–181.
CLINICAL PAPER 2. de Franchis R, Faculty BVI. Expanding consensus in portal
16. Paspatis GA, Matrella E, Kapsoritakis A, Leontithis C, Papanikolaou
hypertension: report of the Baveno VI consensus workshop:
N, Chlouverakis GJ, et al. An epidemiological study of acute upper
stratifying risk and individualizing care for portal hypertension. J
gastrointestinal bleeding in Crete, Greece. Eur J Gastroenterol
Hepatol. 2015;63:743–752.
Hepatol. 2000;12:1215–1220.
3. Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper
17. Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding
gastrointestinal bleeding: incidence, etiology and outcomes in a
and outcomes in patients hospitalized with upper gastrointestinal
population-based setting. Scand J Gastroenterol. 2013;48:439–447.
bleeding. J Clin Gastroenterol. 2014;48:113–118.
4. Thomopoulos KC, Vagenas KA, Vagianos CE, Margaritis VG, Blikas
18. Lanas A, Aabakken L, Fonseca J, Mungan ZA, Papatheodoridis GV,
AP, Katsakoulis EC, et al. Changes in aetiology and clinical outcome
Piessevaux H, et al. Clinical predictors of poor outcomes among
of acute upper gastrointestinal bleeding during the last 15 years.
patients with nonvariceal upper gastrointestinal bleeding in Europe.
Eur J Gastroenterol Hepatol. 2004;16:177–182. 5. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22:209–224. 6. Theocharis GJ, Thomopoulos KC, Sakellaropoulos G, Katsakoulis E, Nikolopoulou V. Changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in Greece. J Clin Gastroenterol. 2008;42:128– 133. 7. Osman D, Djibré M, Da Silva D, Goulenok C, group of experts Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care. 2012;2:46. 8. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–113. 9. Chassaignon C, Letoumelin P, Pateron D, Group HD 2000 Upper gastrointestinal haemorrhage in emergency Departments in France: causes and management. Eur J Emerg Med Off J Eur Soc Emerg Med. 2003;10:290–295. 10. van Leerdam ME, Vreeburg EM, Rauws E a J, Geraedts A a M, Tijssen JGP, Reitsma JB, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98:1494–1499. 11. Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol. 1997;92:236–243. 12. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J 13. Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ. 1997;315:510–514. 14. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,
19. Zeitoun J-D, Rosa-Hézode I, Chryssostalis A, Nalet B, Bour B, Arpurt J-P, et al. Epidemiology and adherence to guidelines on the management of bleeding peptic ulcer: a prospective multicenter observational study in 1140 patients. Clin Res Hepatol Gastroenterol. 2012;36:227–234. 20. Nahon S, Hagège H, Latrive JP, Rosa I, Nalet B, Bour B, et al. Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: results of a French prospective multicenter study. Endoscopy. 2012;44:998–1008. 21. Rotondano G. Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin N Am. 2014;43:643–663. 22. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823–832. 23. Di Fiore F, Lecleire S, Merle V, Hervé S, Duhamel C, Dupas J-L, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol. 2005;17:641–647. 24. Loperfido S, Baldo V, Piovesana E, Bellina L, Rossi K, Groppo M, et al. Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc. 2009;70:212–224. 25. Villanueva C, Colomo A, Bosch A, Concepción M, HernandezGea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21. 26. Cuellar RE, Gavaler JS, Alexander JA, Brouillette DE, Chien MC, Yoo YK, et al. Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate. Arch Intern Med. 1990;150:1381–1384. 27. Kessel B, Olsha O, Younis A, Daskal Y, Granovsky E, Alfici R. Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena. Eur J Emerg Med Off J Eur Soc Emerg Med. 2016;23:71–73. 28. Pateron D, Vicaut E, Debuc E, Sahraoui K, Carbonell N, Bobbia X, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal
Vandenbroucke JP, et al. The strengthening the reporting of
bleeding: a multicenter randomized controlled trial. Ann Emerg
observational studies in epidemiology (STROBE) statement:
Med. 2011;57:582–589.
guidelines for reporting observational studies. Lancet Lond Engl. 2007;370:1453–1457. 15. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the
29. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, SoaresWeiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;(9):CD002907. 30. Longstreth GF, Feitelberg SP. Outpatient care of selected patients with
National Audit of acute upper gastrointestinal haemorrhage. BMJ.
acute non-variceal upper gastrointestinal haemorrhage. Lancet Lond
1995;311:222–226.
Engl. 1995;345:108–111.
RESUSCITATION TODAY - SUMMER 2018
Gastroenterol. 1995;90:206–210.
Aliment Pharmacol Ther. 2011;33:1225–1233.
15
CLINICAL PAPER
The new corpuls cpr has redefined the standard for the next gerneation of chest compression devices used by the emergency services and hospitals. PROTECT YOUR AMBULANCE CREW
USER FRIENDLY
The corpuls cpr has the capability of being able to
The corpuls cpr comes with clearly visible colour
supply fully automated chest compressions, ensuring less
display and easy to access control panel buttons.
strain on rescue workers, particularly when performed in
The compression depth and/or rate, can be manually
a moving vehicle. The corpuls cpr is able to check its
adjusted when required.
position of the compression pad after each ventilation break or 100 compressions (in continuous mode) to compensate for any impact cpr has on the patient’s thorax.
RESUSCITATION TODAY - SUMMER 2018
16
TS S O C G N I N ESSION PADS N U R W O L ABLE COMPR
REUS
The compression pads come in two sizes and can be disinfected with all common agents, keeping running costs to a minimum. This ensures that the corpuls cpr can be deployed on every CPR job without financial impact.
CLINICAL PAPER
The Tireless Arm that saves lives BLE A L I A V A ES I D U T S E NEW CAS
sales@theortusgroup.com www.theortusgroup.com T: +44 0845 4594705
RESUSCITATION TODAY - SUMMER 2018
corpuls cpr compliant to current ERC/AHA guidelines.
17
Life Connec
Aylesbury Event - Thu 6th September 2018 The G Paramedic Conference Programme
Around 200 delegates registered to attend each of our Harrogate and Bristol multi-conference/workshop events and we are hoping for a similar turnout in Aylesbury. In addition to our Paramedic & Resuscitation conferences, separate conferences will also be taking place for First Responders and First Aid Trainers, both have excellent presentations in place that include:
Time
Presentation
Speaker
Position
Why Trauma Patients Die (Professor Sir Keith Porter), The Alternative Role of the CFR (James Crawley), The Changing Face of First Aid (Dr Mark Forrest), First Aid...The Need for Effective Teaching & Learning
9.00 - 9.30
Registration
(Rob Shaloe) and First Class First Aid...Enhancing Care at the Point of
9.30 - 10.00
Tea / Coffee
For full events details, please visit: www.lifeconnections.uk.com
Integrating Service Users & Carers 10.00 - 10.30 Into Undergraduate Paramedic Education 10.30 - 11.00
Impact Brain Apnoea & Head Injuries
11.00 - 11.30
Advanced Airway Management
11.30 - 12.00
Tea / Coffee Exhibition
Using Simulation as 12.00 - 12.30 a Learning, Teaching & Assessment Tool 12.30 - 13.00
Burns - Timing is Everything
Immediate Need (Paul Jones).
In addition, Pre-Hospital Care Consultancy are running a morning Miriam Perry
Senior Lecturer
Trauma Workshop that includes Trauma Patient Assessment, Catastrophic Bleeding and Splintage Skills followed by an afternoon Airway Management Workshop that includes Direct and Video Laryngoscopy and Emergency Surgical Airways.
Amy Kyle
Amy Chan-Dominy
Paediatric Consultant
Dr Natasha Taylor
Principal Lecturer
Kristina Stiles
Clinical Nurse Specialist
13.00 - 14.00 Lunch, Exhibition
Topics & Speakers correct at the time of press but may be subject to change.
To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434
Only 50 Places are available on each of our Paramedic and Resuscitation Conferences at a cost of ÂŁ30pp to include VAT, lunch/tea/cof combined rate of just ÂŁ42 to include VAT, lunch, etc. To view all programmes and to secure your delegate place please visit: www.lifec
A further Conference is planned later in th
www.lifeconnections.uk.com
ctions 2018
Gateway Conference Centre, Aylesbury HP19 8FF Delegate feedback received from our Harrogate and Bristol events has been very positive, a typical example being as follows: ‘We had 6 x personnel attend your workshops / conference last week in Harrogate. The feedback from this has been very positive. Everyone felt they benefited from attending for the day’ Thanks to the generosity of WEL Medical, delegate rates at our Aylesbury event start from just £18 per person to include lunch,
Resuscitation Conference Programme Time
Presentation
Speaker
Position
Amy Chan-Dominy
Paediatric Consultant
Jonathan Leung
HEMS Pre-Hospital Registrar
Mike Davis
Keele University
Joanne Mildenhall
Paramedic Team Leader
Ken Spearpoint
Principal Lecturer
tea/coffee, free parking, etc. Combined rates are also available for those wishing to attend both a morning and afternoon conference or, alternatively, a conference plus a workshop or,
12.00 - 12.30 Registration
two workshops. As delegate places are limited, particularly on the workshops, early registration is recommended to avoid disappointment. Our Life Connections road show will then move on to Stoke-onTrent (October 25th). We look forward to welcoming you to Life Connections 2018.
12.30 - 14.00 Lunch/Exhibition
What Does Adult 14.00 - 14.30 Congenital Heart Disease Mean? Ultrasound Application 14.30 - 15.00 for Traumatic Cardiac Arrest 15.00 - 15.30
Simulation Challenging Reality
15.30 - 16.00 Tea/Coffee/Exhibition
16.00 - 16.30
Dealing with Distressing Incidents
16.30 - 17.00
Application of Educational Theory
Topics & Speakers correct at the time of press but may be subject to change.
To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434
ffee and free parking. Delegates can attend both our morning Paramedic Conference and afternoon Resuscitation Conference for a connections.uk.com or call the organisers on: 01322 660434
he year for Stoke-on-Trent (October 25th)
www.lifeconnections.uk.com
CLINICAL PAPER Four things in one pack,
one less thing to think about
RESUSCITATION TODAY - SUMMER 2018
www.i-gel.com
Quality, innovation and choice
20
CLINICAL PAPER
DEVELOPMENT OF THE MAJOR TRAUMA CASE REVIEW TOOL Kate Curtis1,2, Rebecca Mitchell3, Amy McCarthy1, Kellie Wilson4, Connie Van1*, Belinda Kennedy1, Gary Tall5, Andrew Holland6, Kim Foster1,7, Stuart Dickinson8 and Henry T. Stelfox9 Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Abstract Background
Results
As many as half of all patients with major traumatic injuries do
The final trauma case review tool contained ten sections, including patient
not receive the recommended care, with variance in preventable
factors (such as pre-existing conditions), presenting problem, a timeline
mortality reported across the globe. This variance highlights the
of events, factors contributing to the care delivery problem (including
need for a comprehensive process for monitoring and reviewing
equipment, work environment, staff action, organizational factors), positive
patient care, central to which is a consistent peer-review process
aspects of care and the outcome of panel discussion. After refinement,
that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure. Methods
the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters. Discussion This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care. Conclusions This tool can be used to identify opportunities for improvement in
Development of the trauma case review tool was multi-faceted,
trauma care and guide quality assurance activities. Validation is required
beginning with a review of the trauma audit tool literature.
in the adult population.
Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement
Keywords: Injury, Quality, Safety, Peer review, Adverse event, Mortality,
was assessed for both the pilot and finalised versions of the tool.
Morbidity, Human factors, Organizational factors, Emergency
Background ought not to be hospital-centric and silo driven and should include
ideal care, with between 2.5% and 14% of medical errors in trauma deaths
elements of trauma system safety and human factors [9]. A process
determined as potentially clinically preventable [1]. The 2014 Australian
with standardized criteria (definitions) and measures of trauma care
Trauma Registry report demonstrated a variance in mortality rates
quality, along with consistent approaches to measurement, monitoring
between states and hospitals [2], such variance is reported across clinical
and reporting between hospitals is required to ascertain areas for
specialties and the globe [3, 4]. The literature also suggests that there is
improvements in care and identify corrective strategies. Further,
great variability in the quality of care for injured youth [5, 6], that deficiencies
the impacts of the trauma system should include all phases of care
exist in the quality of care for 8% to 45% of severely injured children, and
including prehospital, trauma triage criteria, hospital type and interfacility
that 6% to 32% of in-hospital deaths are preventable [7]. This variance in
transfer, focusing on timeliness and appropriateness of care [10].
in-hospital mortality between hospitals highlights the need for a systematic, comprehensive system for monitoring and reviewing patient care to inform
Within hospitals, there have been a range of classification frameworks
processes for change to ultimately improve patient outcomes.
and taxonomic tools developed to attempt to identify the causal factors of adverse events from a human factors perspective [11]. Many of the
Trauma centres have a wide and varying range of trauma quality
frameworks developed have been based on Reasonâ&#x20AC;&#x2122;s Organisational
improvement projects, and initiatives, including morbidity and mortality
Accident Causation Model [12], such as the London Protocol [13].
meetings. Such meetings are longstanding throughout healthcare
Several of these do not consider the underlying causes of adverse
for review of patient deaths and complications, however, there
incidents, however, nor do they consider all human factors, including
remains a need to standardise the approach taken to review cases
human behavior (ie. human error), that may contribute towards an
across hospitals and other trauma care providers [8]. This approach
adverse event or a potential adverse event occurring.
* 1
Correspondence: connie.van@sydney.edu.au Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia Full list of author information is available at the end of the article
RESUSCITATION TODAY - SUMMER 2018
As many as half of all patients with major traumatic injuries do not receive
21
CLINICAL PAPER Currently, there is no published, evidence-informed standardised tool
issues. Error was classified using Rasmussen’s [19] skill, rule or
that considers both system safety and human factors for use in adult or
knowledge-based error classifications, or a violation classification
paediatric trauma case peer review. To address this evidence-practice
[20]. Skill-based errors referred to unintentional failures in the
gap, the aim of this research was to develop and validate a trauma
execution of a well-rehearsed action or routine task that required
case review tool to facilitate clinical review of trauma patient care that
little conscious attention. Rule-based errors referred to unintentional
addresses the recommendations of the World Health Organization
failures during activities conducted in familiar situations that
(WHO) [8] and Australasian Trauma Quality Improvement Program
were controlled by stored rules. Knowledge-based errors referred
Guidelines [2].
to unintentional failures during a novel situation that required conscious analytic processing and stored knowledge. A violation
Aim
was considered to be an intentional failure to follow accepted work
To describe the development and validation of a trauma case review tool
practices, guidelines or procedures during the execution of a task.
to facilitate peer-review of adverse events in paediatric major trauma
It is noted that within this classification system a violation does not
designed to extract information to facilitate monitoring, inform change
indicate the intent to cause harm.
and facilitate loop closure. Data collection
Methods
Each of the clinical reviewers was provided verbal instruction on how to use the tool and a data dictionary and each signed a confidentiality agreement. Clarification on definitions and aspects
This trauma case review tool is intended for use to facilitate peer-
of the tool was provided as required, and modifications made
review of major paediatric trauma cases flagged for analysis as a
accordingly following the testing.
result of an adverse event and was developed during a state-wide, prospective paediatric trauma system evaluation in Australia’s most
For the pilot, the reviewers were emailed links to the de-identified
populous State, New South Wales [14]. Development was multi-
files using the secure Cloudstor platform (Australia Academic and
faceted, beginning with a review of the literature on trauma audit
Research Network). A second round of testing following refinement
tools. Data were extracted from the literature to inform iterative
of the tool was conducted by eight trauma clinicians who used the
tool development using a consensus approach, which was then
tool to classify eight de-identified paediatric trauma cases. This
followed by pilot and inter-rater reliability testing. Each step is
group included the same clinicians who reviewed the pilot tool, as
described below.
well as interstate and international clinicians from nursing, surgical, emergency and retrieval backgrounds. For the second round of
Review of literature
testing, a day long face-to-face meeting was held, orientation to
A review of key principles from the WHO Trauma Quality Improvement
the tool conducted, and hard copies of de-identified trauma cases
Program Guidelines [8], National Safety and Quality Framework [15], the
provided for peer-review. Each reviewer completed the case review
Institute of Medicine [16] and the London Trauma Protocol [17] along
independently using the tool. Cases used for testing had been
with the international literature on Trauma audit tools was conducted.
identified as having adverse events by the site trauma service and the
Electronic database search was conducted using the terms “injury”,
age range of the injured children was 8 weeks to 15 years.
“audit”, “tool”, “peer review”. Data management and analysis Development of the trauma case review tool
Data from both rounds of testing were entered in ExcelTM. Double data
Extraction of data from the literature identifying categories of factors
entry was conducted to ensure accuracy. Inter-rater reliability of the
found to be causally related to adverse events was conducted and a
adverse event causal factors and outcomes components sections of
draft tool containing seven components that considered the trauma
the tool was assessed using percent agreement [18, 21]. Entries had to
system, and human factors was developed. A pre-existing, validated,
agree exactly to be considered the same, and only those answered as
hierarchical human factors framework was included in the tool [18],
‘yes/no/not applicable’ were assessed.
RESUSCITATION TODAY - SUMMER 2018
consisting of three levels to categorise the human factors contributing to any care delivery problems (Section 6). The draft tool was reviewed by the NSW Institute of Trauma and Injury Management’s Clinical review committee and then trialed by five experienced trauma clinicians (including a trauma nurse, emergency physicians, and surgeons) using medical records from three deidentified paediatric trauma cases from different hospitals. Following feedback from the reviewers, refinements and retesting of the tool with additional de-identified cases was conducted. Classification of terms
-Addition of a timeline displaying key events in chronological order to provide a snapshot of what happened -Addition of Section 8 which allows for the recording of positive aspects of care -Addition of Section 9 to identify whether reviewers have had prior knowledge of the case which may impact on their review -Addition of answer options in cases where not all options are covered -Minor modification to the wording of some questions to avoid ambiguity
Information on the role of error in any adverse events was identified
-Minor modification to the layout and structure to improve usability
for the staff action-related classifications involving medical task
-Prompts to interview relevant staff to gather further information
failures, monitoring tasks, delays, misdiagnoses, or medication
22
Table 1 Modifications made to the case peer review tool
CLINICAL PAPER
Carts f
rom
£75
0
exc V AT
RESUSCITATION TODAY - SUMMER 2018
23
CLINICAL PAPER Table 2 Components of the major trauma case peer review tool Basic information Record ID
This is the unique record used by the study team to identify each record
Reviewer ID
Each reviewer has a unique identification number
Date of review
For recording when the review was conducted
Date and time of injury
Key time variables allow for the development of a chronology
Age and gender
Age and gender to allow comparative analysis across groupings and determination of specific areas for education/change within the trauma system that considers age related physiology, age specific injury patterns [36, 37]
Date and time of incident(s)
Key time variables allow for the development of a chronology
Section 1: Patient factors Background
Such as whether the child is Aboriginal or Torres Strait Islander, culturally and linguistically diverse or a refugee to assist with the identification of potentially vulnerable groups and engagement with appropriate stakeholders when required
Previous location and source of referral
Primary presentation, secondary presentation (e.g. inter-hospital transfer) and source of referral (e.g. self, road ambulance) to assist with mapping of patient flow and identification of potential areas of deficits
Other patient factors
This component attempts to capture the unique characteristics of the patient in the context of their presentation including: complexity and acuity of presentation; behavioural and social factors
Table 2 Components of the major trauma case peer review tool (Continued) Was a toxicology screen/post mortem conducted? If yes, what type was completed and is the report available?
Category of the problem (either To assist with the determination of clinical, systems or communication) how the clinical deficit occurred and to allow comparative analysis across groupings and determination of specific areas for education/ change within the trauma system [27] Section 5: Specific services involved in the care delivery problem Specific department and staff involved in the care delivery problem
These sections capture the cause and nature of the injury
Equipment
Including: lack of medical equipment, medical equipment breakage or failure, equipment failure (design), medical equipment not elsewhere classified, non-medical equipment and medical supplies
Work environment
Including: light, temperature, noise, physical layout, security and work environment not elsewhere classified
Staff action
Including: verbal communication and written documentation issues, medical task failure, monitoring, delay, misdiagnosis, medication issue and human factors not elsewhere classified
Patient
Including: physical health, health state, communication issues, medication, toxicology, clothing, and patient characteristics not elsewhere classified
Organisational factors
Including: work practices, policies or guidelines, supervision, organisational resources, work pressure and organisational factors not elsewhere classified
Individual factors
Including: training, experience, fatigue, stress and individual factors not elsewhere classified
Other factors
This is a free text response for factors the reviewer feels are not addressed in the previous categories
Section 3: Timeline of events Timeline of events
RESUSCITATION TODAY - SUMMER 2018
24
Timeline of events in chronological order
Section 4: General incident information Did the patient die?
Phase of care the patient died in (pre-hospital/during transport/ in-hospital/which ward?)
To determine whether the child died as a result of their injuries and to assist with further questioning To provide a construct on where the incident occurred, allowing monitoring of one point of care or service
This multiple choice and free text response section allows for determination of services involved in the care delivery problem
Section 6: Factors contributing to the care delivery problem
Section 2: Presenting problem/diagnosis Injury mechanism, injuries, and signs and symptoms on presentation
Autopsy reports are a valuable source of information and provide an important adjunct to any investigation of factors potentially contributing to patient mortality [8]
Section 7: Outcome Best description of the incident
How the incident can be best described ranging from clinically preventable to clinically nonpreventable death, near miss of death, near miss of incident that did not result in death, preventable error causing lasting disability or no problems identified
The percentage agreement was calculated as the ratio of the total
concordance in the human factors framework section that consists
number of â&#x20AC;&#x2DC;sameâ&#x20AC;&#x2122; responses for each data element divided by
of three levels to categorise the human factors contributing to any
the total number of data elements assessed. For measurement of
care delivery problems, agreement pertained to raters recording the
CLINICAL PAPER Table 2 Components of the major trauma case peer review tool (Continued) Section 8: Positives of care
Section 9: Prior knowledge Section 10:prior Panelknowledge discussion of Reviewer the case Summary of review and recommendations Section 10: Panel discussion Interview involved? Summaryofofstaff review and recommendations
Interview of staff involved?
Review of literature Several papers reported that they conducted a peer-review process and
Positive of care theofpatient Thistrauma free textcase response allow fortool Table aspects 2 Components the major peer review received the recording of positives of care (Continued) the patient received Section9:8:Prior Positives of care Section knowledge Positive aspects of care the Reviewer prior knowledge of patient received the case
Results
This freetotext response allowthe for Included identify whether the recording of positives of care reviewer had prior knowledge received ofthe thepatient case which may affect their review of the case Included to identify whether the reviewer had priortoknowledge Free text response allow for a of the case which mayand summary of the review affect their review of the case recommendation for corrective strategies after panel discussion ToFree allow details to recorded textstaff response to be allow for a ifsummary staff are recommended of the review for and interview to obtain further recommendation for corrective information for completing strategies after panel discussion the assessment To allow staff details to be recorded if staff are recommended for interview to obtain further information for completing the assessment
‘same’ response for up to three levels for each factor, for example, a Level 1 factor was ‘Work Environment - Did the work environment contribute to difficulties in delivering the required care?”. Level 2 of ‘Work Environment’ is the subsection within Level 1, with a possible response being ‘Light’ and a Level 3 response could have been ‘No or too little light’.
No original research studies of a validated peer-review tool for use in trauma care were identified. Iterative refinement The usability testing and pilot of the trauma case review tool by the clinical reviewers identified that several modifications of the tool needed to be made. Modifications made are presented in Table 1. Inter-rater reliability For the pilot, the interrater reliability of the human factors and outcome components of the tool had an average 81% agreement between raters at level 1, 69% at level 2 and 69% at level 3. After refinement of the tool, the interrater reliability of the human factors and outcome components of the tool improved and had an average 86% agreement between raters at Level 1. There was a moderate decrease in reliability with 67% at level 2 and 63% at level 3. Final trauma case review tool The final tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, specific services involved in the care delivery, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), patient outcome, positive aspects of care and the outcome of panel discussion (Additional files 1 and 2).
RESUSCITATION TODAY - SUMMER 2018
Fig. 1 Factors contributing to the care delivery problem
classified outcomes as either preventable or non-preventable [22–24].
Fig. 1 Factors contributing to the care delivery problem
25
CLINICAL PAPER Each component of the tool was informed by the aforementioned
organisational and environmental factors that may have contributed to
literature search and is outlined in Table 2.
the occurrence of the event which is in line with WHO recommendations that the review process should identify clinical errors, consider work
Trauma system components
system factors that contributed to the occurrence of the errors, and
The first sections (Sections 1–3) of the case review tool include
facilitate corrective action plans [8].
demographic and injury information to allow for the development of a chronology and consideration of age- and any patient- specific
Adverse events are directly linked to actual harm resulting from (or
physiology [25]. The following sections (Sections 4–5) collect clinical
omission of) health care and are generally independent of the patient’s
management and service delivery information in the standardised
disease. An adverse event may occur despite the correct care being
Airway, Breathing, Circulation format known to improve trauma
given under correct circumstances but ultimately associated with a
patient outcomes when followed [26]. This clinical categorisation of
poor outcome [30]. Errors are one aspect of failure in the processes
treatment in common trauma language facilitates case-specific areas
of care. While historically there has been a focus on the individuals
of improvement and longer term monitoring of areas of care that may
that perpetrated the error we know that human performance and the
require widespread education or intervention for change [1, 23, 27,
occurrence of errors is influenced by a range of factors in the environment
28]. It also enables identification of compliance with specific local
and organisational systems. It is through understanding these influences
or statewide trauma management guidelines or protocols. Detailed
that we can identify potential improvements in the system and thereby
information on the locations and services involved in a particular
reduce the re-occurrence of similar incidents in the future. The approach
incident or near miss will also allow specific intervention if required, and
of applying a structured framework of these influencing/causal factors
ongoing monitoring to provide evidence for change.
is particularly suited to the case review methodology where the detailed data around individual action may not be available but environmental and
Consideration of causal factors
organisational factors can be identified by experienced reviewers. This
Section six records information on human factors that may have
tool records adverse events, but also informs understanding of the areas
influenced clinical practice including: equipment, work environment,
of the system that require further investigation, and monitoring for trends
staff action, patient, organizational, individual and other factors. The
to highlight where change is needed.
human factors component was adapted from the Human Factors Classification Framework for patient safety [18]. This framework
Adverse patient events require monitoring, and, for system-wide
was adopted as previous inter-rater reliability for human factors
change, active monitoring and investigation of local, state-based
classifications has been demonstrated to be high [29] and the approach
and a national registry(s) is optimal as they are designed to provide
was based on James Reason’s model of organisational incidents [20].
information that can be used to improve the efficiency and quality of trauma care. However, trauma registries require more rigour to
The human factors component was used to identify influencing or
be reliable in the quality of the reproducible data [31, 32], and they
causal factors that were thought to play a role in leading to the adverse
lack the detail afforded by a human factors enhanced peer-review
event. Each causal factor was classified into one of seven categories
process. There are growing efforts to improve patient safety in trauma
(Fig. 1) then a number of subcategories.
and quantification of the burden of iatrogenic harm could catalyse awareness and stimulate changes in trauma practice and healthcare
Discussion
RESUSCITATION TODAY - SUMMER 2018
26
policy [33]. Future work should include integration of the two. There are some limitations to the development of the tool. Evaluation of
This manuscript describes the development, refinement and reliability of
the trauma case review tool in this study was restricted to the paediatric
a trauma case review tool to facilitate peer-review of adverse events in
trauma population whose anatomical, physiological and psychological
pre- and in-hospital care provision for major trauma patients. The major
management varies significantly compared to adults [34, 35]. There was
trauma case review tool, informed by evidence, is designed to extract
a wide range of ages of children examined using the development of
trauma system safety and human factor causal information to facilitate
the tool, and recognition of these differences in a review tool, including
monitoring, inform change and facilitate loop closure in the provision of
age-specific injury patterns and appropriate care of children’s families
care of major trauma patients.
should be included [36, 37]. Future clinical care review tools should also include the patient experience where possible, although challenges
This tool incorporates human factors with the intent of enhancing current
remain in how best to obtain this information. Doyle et al. [38] found a
Morbidity and Mortality review practices. Following an adverse event it
positive association between patient experience and measures of the
is common across industries for the focus to be understanding what
technical quality of care and adverse events and support the inclusion
happened. The focus in a human factors approach is to understand
of patient experience as one of the central pillars of quality in healthcare.
why an adverse event occurred. Identifying the underlying systemic factors that contributed to the occurrence of an adverse event and the
This tool was tested using a retrospective review of medical records.
event outcomes will assist in understanding why particular decisions
This method provided informative timelines and information about
and actions occurred. It can also provide insight as to what can be
procedures and immediate patient outcomes. However it was more
done to prevent these events from occurring in the future, by addressing
difficult to extract human factors information. The tool is recommended
the underlying causal factors. Incorporating a human factors review
to be used in conjunction with staff who were part of the treating team,
component within this case review tool seeks to place greater focus on
so they can be involved in the review process to ensure accurate and
why the event occurred. This involves investigating human, equipment,
informed classification of human factors.
CLINICAL PAPER It is anticipated that more intimate knowledge of situation and
Authors’ contributions
organizational factors will allow even more useful information to be
KC and RM designed the study, AM and BK collected the data, all
captured in the human factors section of the tool. To attempt to link the
authors analysed the data and contributed to the development of the
adverse event to longer term patient outcomes would require linkage
Major Trauma Case Review Tool. All authors drafted/critically revised the
with a trauma registry that collects such information or a follow-up study
article for important intellectual content. All authors read and approved
with adversely affected patients.
the submitted version.
The next stages of evaluation of the trauma case review tool could include
Competing interests
a trial of the tool with an adult population and heuristic evaluation (that is,
The authors declare that they have no competing interests.
usability evaluation by a human factors expert against a set of usability rules/principles) and could entail observing clinicians using the tool.
Consent for publication
This would include consideration of the clinicians’ ability to understand
Not applicable.
and apply the human factors component of the tool, which requires a degree of understanding of human factors principles. Also, although
Ethics approval and consent to participate
the case review tool is evidence-informed, and has been piloted by
Ethics approval was obtained from NSW Population and Health Services
trauma clinicians it requires validation for sensitivity and specificity in
Research Ethics Committee (HREC/15/CIPHS/6).
identifying causes of adverse events. A retrospective cohort study to measure operating characteristics and prospective implementation of
Author details Sydney Nursing School, The University of Sydney, 88 Mallet Street,
the tool into quality assurance activities to gauge how it is received, how
1
well it identifies adverse events, and what type of quality improvement
Camperdown, NSW, Australia. 2St George Clinical School, Faculty of
activities it spurs, would be valuable. Such evaluation could also lead to
Medicine, University of New South Wales, Gray St, Kogarah, NSW,
the development of trauma specific trigger tools, to be used in real time
Australia. 3Australian Institute of Health Innovation, Faculty of Medicine
as a predictor for adverse events and provide the basis of a measurable
and Health Sciences, Macquarie University, Sydney, Australia. 4NSW
trauma quality improvement program [33, 39].
Institute of Trauma and Injury Management, Level 4, Sage Building, 67 Albert Avenue, Chatswood, NSW, Australia. 5NSW Ambulance, Level 2, Sydney Ambulance Centre, Garden St Eveleigh, NSW 2015, Australia.
Conclusions As many as half of all patients with major traumatic injuries do not receive the recommended care and up to 14% of medical errors in trauma deaths are potentially preventable. This research has developed an evidence-informed tool for use in trauma case review that considers system safety and human factors to facilitate clinical review of trauma patient care. This tool can be used to identify opportunities for
Sydney Medical School, The University of Sydney and The Children’s
6
Hospital at Westmead, Sydney, NSW, Australia. 7NorthWestern Mental Health & School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Level 1 North, City Campus, The Royal Melbourne Hospital Grattan Street, Parkville, VIC 3050, Australia. 8Human Risk Solutions, Victoria, Australia. 9Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada.
improvement in trauma care and guide quality assurance activities.
Additional files Additional file 1: Major trauma case peer review tool. (PDF 422 kb) Additional file 2: Data dictionary. (PDF 236 kb)
References 1. Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Quality indicators for evaluating trauma care: a scoping review. Arch Surg. 2010;145(3):286–295. 2. Alfred Health. Caring for the Severely Injured in Australia: Inaugural Report of the Australian Trauma Registry 2010 to 2012. Melbourne:
WHO: World Health Organization.
Alfred Health; 2014. 3. Moore L, Evans D, Hameed SM, et al. Mortality in Canadian Trauma
Acknowledgements Not applicable. Funding The development of this tool was funded by an NHMRC Partnership Grant GNT1092499. Partners include NSW Ambulance, NSW Institute of Trauma and Injury Management, NSW Agency for Clinical Innovation, Thyne Reid Foundation, The Day of Difference Foundation and The NSW Office of Kids and Families. Availability of data and materials
Systems: A Multicenter Cohort Study. Ann Surg. 2017;265(1):212–7. 4. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139. 5. Cooper CG, Santana MJ, Stelfox HT. A comparison of quality improvement practices at adult and pediatric trauma centers. Pediatr Crit Care Med. 2013;14(8):e365–e371. 6. Mitchell RJ, Curtis K, Chong S, et al. Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia. Injury. 2013;44:97–103. 7. Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. A
The data that support the findings of this study are available from the
systematic review of quality indicators for evaluating pediatric
corresponding author upon reasonable request.
trauma care. Crit Care Med. 2010;38(4):1187–1196.
RESUSCITATION TODAY - SUMMER 2018
Abbreviations
27
CLINICAL PAPER 8. World Health Organization. Guidelines for trauma quality improvement programmes. Geneva: World Health Organization; 2009. 9. Amalberti R, Benhamou D, Auroy Y, Degos L. Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. J Biomed Inform. 2011;44(3):390–394. 10. McCarthy A, Curtis K, Holland AJA. Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review. Injury. 2016;47(3):574–585. 11. Mitchell R, Williamson A, Molesworth B, Chung AZ. A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting. Ergonomics. 2014;57(10):1443–1472. 12. Reason J. Managing the risks of organisational accidents. Aldershot: Ashgate Publishing Ltd; 1997. 13. Vincent C, Taylor-Adams S, Chapman E, et al. How to investigate
K, Ramsden C, editors. Emergency and Trauma Care. 2. Sydney: Elsevier; 2015. 26. Williams MJ, Lockey AS, Culshaw MC. Improved trauma management with advanced trauma life support (ATLS) training. J Accid Emerg Med. 1997;14:81–83. 27. Curtis K, Chong S, Mitchell R, Newcombe M, Black D, Langcake M. Outcomes of Severely Injured Adult Trauma Patients in an Australian Health Service: Does Trauma Center Level Make a Difference? World J Surg. 2011;35(10):2332–2340. 28. Palmer CS, Davey TM, Mok MT, et al. Standardising trauma monitoring: The development of a minimum dataset for trauma registries in Australia and New Zealand. Injury. 2012;44(6):834–841. 29. Mitchell R, Williamson A, Molesworth B. Identifying causal patterns and errors in adverse clinical incidents. Paper presented at:
and analyse clinical incidents: Clinical Risk Unit and Association
Contemporary Ergonomics and Human Factors 2013: Proceedings
of Litigation and Risk Management Protocol. Br Manage J.
of the international conference on Ergonomics & Human Factors
2000;320:777–781.
2013, Taylor & Francis: Cambridge; 2013.
14. Curtis K, McCarthy A, Mitchell R, et al. Paediatric trauma systems and their impact on the health outcomes of severely injured children: protocol for a mixed methods cohort study. Scand J Trauma Resusc Emerg Med. 2016;24(1):69. 15. Australian Commission on Safety and Quality in Health Care. Developing a safety and quality framework for Australia. 2009. 16. Committee on Quality of Health Care in America Institute of Medicine . Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academies Press; 2001. 17. Cole E, Lecky F, West A, et al. The impact of a pan-regional inclusive trauma system on quality of care. Ann Surg. 2016;264(1):188–94. 18. Mitchell RJ, Williamson A, Molesworth B. Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital. Appl Ergon. 2016;52:185–195. 19. Rasmussen J. Human errors. A taxonomy for describing human malfunction in industrial installations. J Occup Accid. 1982;4(2):311– 333. 20. Reason J. Human error: models and management. Br Med J. 2000;320(7237):768–770. RESUSCITATION TODAY - SUMMER 2018
21. Shiloach M, Frencher SK, Jr, Steeger JE, et al. Toward Robust Information: Data Quality and Inter-Rater Reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6–16. 22. Shackford SR, Hollingsworth-Fridlund P, McArdle M, Eastman AB. Assuring quality in a trauma system—the medical audit committee: Composition, cost, and results. J Trauma Inj Infect Crit Care. 1987;27(8):866–875. 23. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: Lessons learned from 2594 deaths. Ann Surg. 2006;244(3):371–380. 24. Jat AA, Khan MR, Zafar H, et al. Peer Review Audit of Trauma Deaths in a Developing Country. Asian J Surg. 2004;27(1):58–64.
28
25. Caldwell E, Delprado A, Curtis K. An Overview of Trauma. In: Curtis
30. Resar R, Rozich J, Classen J. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003. 2003;12(Suppl II):7. 31. Porgo TV, Moore L, Tardif PA. Evidence of data quality in trauma registries: A systematic review. J Trauma Acute Care Surg. 2016;80(4):648–658. 32. Moore L, Clark DE. The value of trauma registries. Injury. 2008;39(6):686–695. 33. Matlow AG, Cronin CMG, Flintoft V, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ Qual Safety. 2011;20(5):416–423. 34. Wyen H, Jakob H, Wutzler S, et al. Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort: Analysis of 2,961 Children in Comparison to 21,435 Adult Patients from the Trauma Registry of DGU in a 15-Year Period. Eur J Trauma Emerg Surg. 2010;36:300–307. 35. Zwingmann J, Schmal H, Südkamp NP, Strohm PC. Injury severity and localisations seen in polytraumatised children compared to adults and the relevance for emergency room management. Zentralbl Chir. 2008;133:68. 36. Andruszkow H, Deniz E, Urner J, et al. Physical and psychological long-term outcome after traumatic brain injury in children and adult patients. Health Qual Life Outcomes. 2014;12:26. 37. Bulger EM, Kaufman R, Mock C. Childhood crash injury patterns associated with restraint misuse: implications for field triage. Prehosp Disaster Med. 2008;23:9–15. 38. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). 39. Landrigan CP, Stockwell D, Toomey SL, et al. Performance of the global Assessment of Pediatric Patient Safety (GAPPS) Tool. Pediatrics. 2016;137(6):e20154076
Life Connections 2018 CLINICAL PAPER
Aylesbury/Stoke-on-Trent Resuscitation Conference Harrogate - March 15 Resuscitation Conference Programme
Bristol - June 21 Resuscitation Conference Programme
Thursday 6th September 2018
Thursday 25th October 2018
The Gateway Conference Centre, Gatehouse
The North Staffordshire Medical Institute,
Road, Aylesbury, Bucks, HP19 8FF
Hartshill Road, Stoke-on-Trent, ST4 7NY
Time
Presentation
Speaker
Position
Time
Presentation
12.00 - 12.30
Registration
12.00 - 12.30
Registration
12.30 - 14.00
Lunch/Exhibition
12.30 - 14.00
Lunch/Exhibition
14.00 - 14.30
What Does Adult Congenital Heart Disease Mean?
14.30 - 15.00
Ultrasound Application for Traumatic Cardiac Arrest
15.00 - 15.30
Simulation Challenging Reality
15.30 - 16.00
Tea/Coffee/Exhibition
16.00 - 16.30
Dealing with Distressing Incidents
16.30 - 17.00
Application of Educational Theory
Speaker
Position
Amy Chan-Dominy
Paediatric Consultant
14.00 - 14.30
Communication within Resus Team
Himanshu Kataria
Specialty Lead for Injuries
Jonathan Leung
HEMS Pre-Hospital Registrar
14.30 - 15.00
What Does Adult Congenital Heart Disease Mean?
Amy Chan-Dominy
Paediatric Consultant
Mike Davis
Keele University
15.00 - 15.30
Using Simulation as a Learning, Teaching & Assessment Tool
Dr Natasha Taylor
Principal Lecturer
15.30 - 16.00
Tea/Coffee/Exhibition
Joanne Mildenhall
Paramedic Team Leader
16.00 - 16.30
Leadership and Management During Crisis
Adam Layland
Senior Lecturer
Ken Spearpoint
Principal Lecturer
16.30 - 17.00
Simulation Challenging Reality
Mike Davis
Keele University
Topics & Speakers correct at the time of press but may be subject to change.
To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434
To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434
Only 50 Places are available on each Conference at a cost of ÂŁ30pp to include VAT, lunch/tea/coffee and free parking. Delegates can also attend our morning Paramedic Conference for a combined rate of just ÂŁ42 to include VAT, lunch, etc. To view all programmes and to secure your delegate place please visit: www.lifeconnections.uk.com or call the organisers on: 01322 660434
Further Conferences are planned later in the year for Aylesbury and Stoke-on-Trent
www.lifeconnections.uk.com
RESUSCITATION TODAY - SUMMER 2018
Topics & Speakers correct at the time of press but may be subject to change.
29
NEWS Study finds only half of infants with deadly meningitis display classic signs of the disease • Only around half of babies under three months of age who have bacterial meningitis present with fever which has for decades been the trigger for further medical investigation • Other features associated with meningitis in infants like a bulging fontanelle - the gap on the top of skull where the bones have not yet come together, coma, seizures and neck stiffness were found to be uncommon • Clinical presentation in young babies is often non-specific and hard to distinguish from mild illnesses common features were found to be poor feeding, lethargy and irritability
Experts are warning that doctors may miss
“Guidelines focusing on serious infections in
correctly diagnosing babies with deadly
children - including meningitis - have been
bacterial meningitis as they may assume
introduced in the UK and the USA but all
infants without a fever (a classic sign of the
specify fever as a key feature of infection.
disease) do not have the illness. “Unfortunately, neither the rates of bacterial Researchers at St George’s, University of London, say their new study shows the classic symptoms associated with bacterial meningitis are uncommon in young infants less than three months of age – the group at highest risk of the disease. Only around half of babies under three months of age who have bacterial meningitis display fever, which has for decades been the trigger for further medical investigations. Professor Paul Heath, one of the study investigators at St George’s, University
meningitis in babies, nor the numbers of deaths, has changed since the 1980s. “Clinicians must, therefore, still consider bacterial meningitis in the diagnosis of an unwell infant that doesn’t present with fever.” The study, Clinical Characteristics and Risk Factors for Poor Outcome in Infants Less Than 90 Days of Age with Bacterial Meningitis in the United Kingdom and Ireland, is published in the Paediatric Infectious Diseases journal. The study led by experts at St George’s University of London, funded by charity
of London, said: “The classic features of
Meningitis Research Foundation (MRF),
meningitis were uncommon in many cases.
involved 263 infants across the UK and Ireland
The symptoms displayed by young infants
and found that fever (temperature above 38°C)
when they are seen by doctors at first in
was reported in only 54% of cases, seizures
hospital are often non-specific and only half of
in 28%, bulging fontanelle in 22%, coma in 6%
cases showed signs of a fever.
and neck stiffness in only 3%.
WHY NOT WRITE FOR US? Resuscitation Today welcomes the submission of clinical papers, case reports and articles that you feel will be of interest to your colleagues. RESUSCITATION TODAY - SUMMER 2018
30
The publication is mailed to all resuscitation, A&E and anaesthetic departments plus all intensive care, critical care, coronary care and cardiology units. All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via: info@mediapublishingcompany.com
NEWS In the UK, babies under three months of age are 70 times more likely to get bacterial meningitis than adults. Newborn babies are at the highest risk of all. The study found that infants who did present with fever tended to be older than infants without fever. The median age for this symptom was around 21 days old. Common features were found to be poor feeding, lethargy and irritability, all of which can be difficult to distinguish from mild illness. The study suggests that there should be a low threshold for performing investigations on young infants when they arrive at hospital.
Vinny Smith, Chief Executive at MRF, said: “Young babies are particularly vulnerable to bacterial meningitis. Meningitis and septicaemia are deadly diseases
Four things in one pack, one less thing to think about
that strike without warning. Rapid diagnosis and treatment provides the best chance of survival. “Based on this research, we have collaborated with the study investigators to create a teaching package aimed at doctors and health professionals to aid rapid diagnosis and treatment. “The package includes an eTool to help clinicians recognise bacterial meningitis in young infants; a lumbar puncture information sheet to help explain
Of note, 52% of the infants without fever did have other features suggestive of bacterial meningitis, such as apnea (33%), seizures (32%), bulging fontanelle (16%), coma (7%) and neck stiffness (3%). Earlier research from the same experts, in collaboration with the British Paediatric Surveillance Unit, found there to be in the region of 350 cases of bacterial meningitis in infants under three months of age per year in the UK and Ireland. Group B streptococci (GBS) and Escherichia coli remain the main causes of bacterial meningitis in this age group.
this procedure to parents; and an algorithm to aid management of bacterial meningitis. We hope that this can ultimately improve outcomes for this vulnerable age group. We have also updated our symptoms information for parents so that they know not to rely on fever alone as the main symptom to look out for in babies.” MRF’s teaching package including the eTool and Babywatch card for parents can be accessed at www.meningitis.org/ HCPresources.
www.i-gel.com RESUSCITATION TODAY - SUMMER 2018
Quality, innovation and choice
31
when every breath counts EVE Critical Care Ventilator
Designed for hospital Intensive care & Emergency transfer/transport use FAST ‘Safe-start’ Neonate > Child > Adult modes ready to ventilate in ‘< 70 seconds’ Invasive & Non-Invasive ventilation modes: CPAP, nCPAP, DUOPAP, nDUOPAP, PRVC, VC-CMV VC-SIMV, PSV, PC-CMV, PC-SIMV, PC-ACV, PC-ACV+, PC-APRV, nPC-ACV, nPC-ACV+, nPC-CMV, nPC-SIMV
All Patient use
Capnography & Sp02
Battery Optimisation
Fully Adjustable Oxygen
Adult, Paediatric, Neonate 0.5kg > >200+ kg {Vt 2 > 2000ml}
Waveform EtC02 Options: Sp02 ,SpCO, SpHB
6 hours continuous use + ‘hot swap’ battery pack
Adjustable 02 mixing 21 to 100%
Robust & Lightweight
8.4 inch Touch Screen
Independent Air Supply
Patient Data Transfer
Rugged design, compact & portable ~5 kg
Configurable display, loops alarms, curves & trends
Integrated air turbine
Transfer capability for patient data, events
Ventilation Innovation since 1974
MEDACX LIMITED | ALEXANDER HOUSE | 60-62 STATION ROAD | HAYLING ISLAND | HAMPSHIRE | PO11 0EL
02392 469737 info@medacx.co.uk www.medacx.co.uk