Escalation Of Care Research Articles

Prognostic Role of Lung-Ultrasound Score in Acute Bronchiolitis Patients Treated With High Flow Nasal Cannula: A Prospective Study.

Lung ultrasound (LUS) has emerged as a reliable, noninvasive tool for bedside assessment of acute bronchiolitis (AB) in infants. Its role in guiding therapeutic decisions is increasingly recognized. This study aimed to determine the predictive value of LUS in identifying infants with AB at risk of HFNC therapy failure. This prospective, single-center study was conducted in the pediatric department of Fattouma Bourguiba Hospital in Monastir from January 2022 to March 2024. Infants under 12 months hospitalized with moderate to severe AB and requiring HFNC therapy were enrolled. LUS was performed within 3-6 h of HFNC initiation and repeated 24 h later. Clinical and laboratory data, including the Wang score and LUS findings, were analyzed to predict HFNC failure. Among 124 enrolled infants, 98 (79%) responded successfully to HFNC therapy, while 26 (21%) failed. Baseline characteristics, including age, weight, and clinical symptomes, were comparable between groups, except for a higher Wang score in the failure group (p = 0.008). LUS scores were significantly higher in the failure group on both day 1 and day 2 (p < 0.001), with a more pronounced score progression (p < 0.001). ROC analysis identified a LUS score > 7 on day 1 and > 9 on day 2 as predictive thresholds for HFNC failure. Multivariate analysis confirmed the day 2 LUS score as an independent predictor of HFNC failure (p = 0.022). LUS is a valuable prognostic tool in infants with AB undergoing HFNC therapy. Incorporating LUS into routine clinical assessments may help predict therapy failure early, allowing timely escalation of care.

Guideline concordance of electronic health record order sets for hospital-based treatment of alcohol withdrawal syndrome.

Treatment of alcohol withdrawal syndrome (AWS) in hospitals is inconsistent. Electronic health record (EHR) order sets protocolize care. We examined variation in AWS order sets across hospital organizations and their concordance with AWS guidelines. We conducted a cross-sectional study of hospital organization user-created EHR order sets for AWS extracted from the December 2021 Epic® userweb community library. Hospital organizations with an acute care hospital and 1 AWS order set were included. We measured the proportion of guideline-concordant care practices within four categories: (1) laboratory assessment, (2) risk assessment for severe AWS and associated management changes, (3) symptom assessment and treatment of AWS, and identification and management of complications and (4) screening, diagnosis, and treatment of unhealthy alcohol use and AUD including medications for alcohol use disorder (MAUD). Ninety-five organizations with 289 order sets were included. The proportion of organizations with guideline-concordant laboratory assessments included testing of electrolytes (83%), hepatic function (75%), substance use (83%), and screening for infections (33%). Guidance for assessing risk of severe AWS (34%) and indications for care escalation (63%) used inconsistent definitions. Use of guideline-concordant medications for AWS (99%) and AWS symptom scores (91%) were nearly universal. MAUD was included by two organizations (2%). A common templated order set was used by 26% of organizations in EHR order sets. We observed frequent organizational inclusion of guideline-concordant medications and symptom scores but rare and/or poorly defined guidance for evaluating risk of severe AWS, escalation of care, and MAUD.

Harnessing delegation and technology to identify and manage malnutrition in a digital hospital: An implementation study

AbstractAimsDelegation of nutrition care activities to Dietetic Assistants in hospitals has been identified as one innovative malnutrition model of care, but there has been limited evaluation of their roles. This study aimed to develop, implement and evaluate a new Malnutrition Model of Care embracing automated delegation and digital systems.MethodsThe Malnutrition Model of Care was created to detect patients at risk of malnutrition (using the Malnutrition Screening Tool) and nutritional decline (via routine intake tracking at all meals and snacks). Digital systems generated automated referrals to dietetics, with protocols to support Dietetic Assistants to action these to direct care escalation to the ward dietitian. Dietetic Assistant training included simulations and clinical task instructions. Implementation evaluation was guided by the Donabedian model of quality and included a review of inpatient dietetics occasions of service, survey of Dietetic Assistant role satisfaction and task confidence, and hospital‐wide cross‐sectional malnutrition audit. Data was descriptively analysed.ResultsDuring the first year of implementation, 60% of Dietetics inpatient occasions of service were completed by Dietetic Assistants, with 26% of Dietetic Assistant inpatient tasks initiated from nursing malnutrition risk screening. Most Dietetic Assistants reported adequate training and confidence in completing delegated tasks. Malnutrition prevalence was 14% with no hospital‐acquired malnutrition identified. No clinical incidents were reported.ConclusionsThe Dietetic Assistant workforce and technology were harnessed to implement an innovative delegated Malnutrition Model of Care that appears to be safe and effective at managing malnutrition from preliminary evaluation. Work continues to formally assess service efficiencies, cost and patient experience.

Early prediction of acute-on-chronic liver failure development in patients with diverse chronic liver diseases

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by the acute decompensation of chronic liver disease, resulting in organ failure and high short-term mortality. The progression of ACLF is dynamic and reversible in a considerable proportion of patients during hospitalization. Early detection and accurate assessment of ACLF are essential; however, ideal methods for this purpose are still lacking. Therefore, this study aimed to develop a new score for predicting the onset of ACLF in patients with various chronic liver diseases.A total of 6,188 patients with various chronic liver diseases were included in the study. Clinical and laboratory data were collected, and the occurrence of ACLF within 28 days was recorded. The Lasso-Cox regression method was employed to develop prediction models for the onset of ACLF at 7, 14, and 28 days. Among 5,221 patients without ACLF, 477 progressed to ACLF within 28 days. Seven predictors were identified as significantly associated with the occurrence of ACLF at 7, 14, and 28 days. A new scoring system was developed as follows: [NEUT ≥ 7, 109/L; 1 or 0] × 0.49 + [PLT < 100, 109/L; 1 or 0] × 0.44 + [TBIL ≥ 35, µmol/L; 1 or 0] × 0.05 + [HDL-C < 0.5, mmol/L; 1 or 0] × 1.04 – Ln[Hb, g/L] × 0.89 + [BUN > 7, mmol/L; 1 or 0] × 0.51 + Ln[INR] × 0.87 + 3.40. This new score demonstrated superior discrimination, with the C-indexes of 0.958, 0.944, and 0.938 at 7, 14, and 28 days, respectively, outperforming those of four other scores (CLIF-C-ACLF-Ds, MELD, MELD-Na, and CLIF-C-ADs score; all P < 0.001). Additionally, the new score improved in predictive accuracy, time-dependent receiver operating characteristics, probability density function evaluations, and calibration curves, making it highly predictive for the onset of ACLF at all time points. The optimal cut-off value of 9.6 effectively distinguished between high- and low-risk patients for ACLF onset. These findings were further validated in a separate cohort of patients. A new progressive score, based on seven predictors, has been developed to accurately forecast the occurrence of ACLF within 7, 14, and 28 days in patients with various chronic liver diseases. This tool may be utilized to identify high-risk patients, tailor follow-up management, and guide the escalation of care, prognostication, and transplant evaluation.

Pediatric Early Warning Scores Before Rapid Response Poorly Predict Intensive Care Unit Transfers.

The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation. A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds. Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613). PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

Clinician and Visitor Activity Patterns in an Intensive Care Unit Room: A Study to Examine How Ambient Monitoring Can Inform the Measurement of Delirium Severity and Escalation of Care.

The early detection of the acute deterioration of escalating illness severity is crucial for effective patient management and can significantly impact patient outcomes. Ambient sensing technology, such as computer vision, may provide real-time information that could impact early recognition and response. This study aimed to develop a computer vision model to quantify the number and type (clinician vs. visitor) of people in an intensive care unit (ICU) room, study the trajectory of their movement, and preliminarily explore its relationship with delirium as a marker of illness severity. To quantify the number of people present, we implemented a counting-by-detection supervised strategy using images from ICU rooms. This was accomplished through developing three methods: single-frame, multi-frame, and tracking-to-count. We then explored how the type of person and distribution in the room corresponded to the presence of delirium. Our designed pipeline was tested with a different set of detection models. We report model performance statistics and preliminary insights into the relationship between the number and type of persons in the ICU room and delirium. We evaluated our method and compared it with other approaches, including density estimation, counting by detection, regression methods, and their adaptability to ICU environments.

Association between initial antibiotic route and outcomes for children hospitalized with pneumonia.

Initial oral antibiotics may be as effective as intravenous (IV) antibiotics for children hospitalized with community-acquired pneumonia (CAP), but further data are needed. We evaluated for associations of initial antibiotic route (IV vs. oral) with length of stay (LOS) and secondary outcomes for children hospitalized with CAP. This multicenter, retrospective cohort study included children with CAP who were hospitalized for >48 h, had chest radiographs, and received antibiotics at four children's hospitals between 2014 and 2020. Data were obtained from the Pediatric Health Information System and manual chart review. The exposure was initial antibiotic route (i.e., first antibiotic given intravenously or orally). We performed multivariable regression modeling using inverse probability treatment weights from propensity scores. Outcomes included LOS, oxygen duration, cost, care escalation, and readmission or emergency department revisit. Of 1147 included children, 37% received initial oral antibiotics. Within the propensity balanced sample, LOS was 73.5 h (IQR 61.0, 99.5) and 78.7 (61.0, 118.0) for patients with initial oral and IV antibiotics, respectively. Children receiving initial oral antibiotics had an 8% reduction in LOS (OR 0.92 [95% CI: 0.87, 0.94]) and 14% reduction in cost (OR 0.86 [95% CI 0.79, 0.94]) versus those receiving initial IV antibiotics. There were no differences in other outcomes. Children with CAP receiving initial oral antibiotics had reduced LOS and hospital cost without differences in escalated care or return visits. Starting hospitalized children on oral antibiotics is likely a safe and effective alternative to IV treatment.

Risk factors associated with escalation of care in a quaternary academic hospital at home program.

Hospital-at-home has become a more recognized way to care for patients requiring inpatient hospitalization. At times, these patients may require escalation of care (transfer from home back to the brick-and-mortar (BAM) hospital for ongoing hospitalization care needs), a process that has not been extensively studied. To evaluate what patient factors contribute to escalations of care in the hospital-at-home delivery model. We conducted a retrospective review of all patients admitted to Mayo Clinic's Advanced Care at Home (ACH) program from January 1, 2022 to December 31, 2022. None. Patient information was collected via electronic health record including demographic, socioeconomic, and clinical status. The primary outcome was the of occurrence of an escalation. A total of 904 patients were included, of whom 80 (8.8%) required an escalation of care. In multivariable analysis, risk of an escalation was significantly higher for patients who were married or had a life partner (HR: 1.82, 95% CI: 1.05-3.23, p = .033) for patients admitted with procedure-related disorders (HR: 2.61, 95% CI: 1.35-5.05, p = .005) and patients with an increased mortality risk score (HR [per each 1-category increase] = 1.86, 95% CI: 1.39-2.50, p < .001).

Outcomes of patients with cancer cared for in a multisite home hospital program.

394 Background: Home hospital provides hospital-level care for acutely ill patients in their homes as a substitute for care in brick-and-mortar hospitals. Since the Centers for Medicare and Medicaid Services’ acute hospital care at home waiver in November 2020, 330 hospitals have received approval to launch home hospital programs. Prior research has shown that patients cared for in home hospital have improved physical activity, and lower mortality and readmission rates. However, many of these programs exclude patients with cancer, and data describing outcomes of patients with cancer cared for in home hospital programs are limited. Methods: We identified patients admitted to a multisite home hospital program affiliated with an urban health system between February 1, 2020 and May 1, 2024 who had a diagnosis of cancer (ICD-10: C00-C96) or myelodysplastic syndrome (ICD-10: D46) managed by an oncologist within the health system. For each admission we conducted chart reviews to determine whether the malignancy was active at the time of admission, defined by ongoing antineoplastic treatment or an admission directly related to the malignancy. We also captured the patient’s cancer diagnosis, the admission diagnosis, total length of stay, and length of time in home hospital. We identified readmissions within 30 days of discharge and escalations of care, defined as a return to a brick-and-mortar hospital for additional care spanning at least one midnight, and calculated rates of these outcomes. Results: There were 141 home hospital admissions among 128 patients with cancer diagnoses (mean age: 77, 36% female). The most common oncologic diagnoses were lymphoma (16%, N = 22), chronic leukemias and MDS (14%, N = 20), and lung cancer (13%, N = 18). Seventy-one patients (50%) had active cancer at the time of admission. The leading admission diagnoses were pneumonia (N = 28, 16%), heart failure exacerbations (N = 19, 13%), complicated urinary tract infections (N = 12, 9%) and soft tissue infections (N = 10, 7%). The mean total length of stay was 7.9 days (SD 5.6) and patients were admitted to home hospital for a mean of 4.9 days (SD: 3.5). Escalation rates and 30-day readmission rates were 7% (N = 10) and 13% (N = 19), respectively, among all patients, and 5% (N = 4) and 14% (N = 10) among patients with active malignancies. Conclusions: These data describe a cohort of patients with cancer cared for in a multisite home hospital program. They show low rates of transfer back to brick-and-mortar hospitals and low 30-day readmission rates, and they demonstrate that patients with cancer can be safely cared for in a home hospital. As home hospital programs build new capabilities, a larger proportion of oncology patients will be eligible for home hospital. More work is needed to estimate risk-adjusted outcomes among these populations and to understand the patient and caregiver experience with oncology home hospital.

Evaluation of an electronic clinical decision support algorithm to improve primary care management of acute febrile illness in rural Cambodia: protocol for a cluster-randomised trial

IntroductionAcute febrile illness (AFI), traditionally attributed to malaria, is a common reason for seeking primary healthcare in rural South and Southeast Asia. However, malaria transmission has declined while health workers...

Airway Management in Microvascular Reconstruction of the Oral Cavity: Is Immediate Extubation Possible?

A tracheostomy is routinely performed following free tissue transfer (FTT) for oral cavity reconstruction; however, its avoidance whenever possible is advocated to enhance patient recovery and reduce hospital length of stay (LOS). This study aims to measure and compare clinically relevant outcomes for patients who have endotracheal intubation versus tracheostomy for FTT for oral cavity reconstruction. A retrospective cohort study was conducted to evaluate subjects undergoing FTT of the oral cavity for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Subjects with unresectable tumors or defects that were not primarily located in the oral cavity were excluded. The independent variable was perioperative airway management and was divided into 2 groups: 1) endotracheal intubation or 2) tracheostomy. The main outcome measure was defined as a postoperative airway-related complication and required escalation of care to an intensive care unit. LOS and surgical complications were also analyzed. The covariates were classified as demographic, medical, pathologic, and operative. Bivariate and multivariate statistical analyses were conducted to compare the outcomes between subjects who were immediately extubated and tracheotomized. Subject demographics and operative parameters were also analyzed. A total of 560 subjects met the inclusion criteria, with 122 subjects in the immediate extubation group and 438 subjects in the tracheostomy group. The mean age was 59.7±16.3years in the immediate extubation group and 59.3±13.8years in the tracheostomy group (P=.8). The proportion of males was 57.4% in the immediate extubation group and 60% in the tracheostomy group (P=.6). No postoperative airway-related complications occurred in the endotracheal intubation group. After controlling for confounding factors, tobacco use was associated with airway-related complications (odds ratio [OR]: 2.66; 95% confidence interval: 1.1-6.3; P=.03). LOS was shorter in the endotracheal intubation versus tracheostomy group (6.8 vs 9days, P<.01). In subjects who underwent FTT for oral cavity reconstruction, postoperative airway-related complications were associated with a tracheostomy and tobacco use status.

"I Had No Idea This Happened": Electronic Feedback on Clinical Reasoning for Hospitalists.

Feedback on the diagnostic process has been proposed as a method of improving clinical reasoning and reducing diagnostic errors. Barriers to the delivery and receipt of feedback include time constraints and negative reactions. Given the shift toward asynchronous, digital communication, it is possible that electronic feedback ("e-feedback") could overcome these barriers. We developed an e-feedback system for hospitalists around episodes of care escalation (transfers to ICU and rapid responses). The intervention was evaluated by measuring hospitalists' satisfaction with e-feedback and commitment to change. A qualitative survey study conducted at one academic medical center from February to June 2023. Hospitalists - physicians and advanced practice providers. Two hospitalists, one internal medicine resident, and a nurse reviewed escalations of care on the hospitalist service each week using the Revised Safer Dx framework. Confidential feedback was emailed to the hospitalists involved in the patient's care. Hospitalists were asked to rate and explain their satisfaction with the e-feedback and whether they might modify their clinical practice based on the e-feedback. The open-ended text comments from the hospitalists were analyzed using a thematic analysis framework. Forty-nine out of fifty-eight hospitalists agreed to participate. One hundred five out of one hundred twenty-four (85%) e-feedback surveys that were sent were returned by the hospitalists. Hospitalists were highly satisfied with 67% (n = 70) of the e-feedback reports, moderately satisfied with 23% (n = 24), and not satisfied with 10% (n = 11). Six themes were identified based on analysis of the comments. Themes related to satisfaction with the intervention included appreciation for learning about patient outcomes, general appreciation of feedback on clinical care, and importance of detailed and specific feedback. Themes related to changing clinical practice included reflection on clinical decision-making, value of new insights, and anticipated future behavior change. E-feedback was well received by hospitalists. Their perspectives offer useful insights for enhancing electronic feedback interventions.

Goals of Care Discussions Among Patients Who Suffer Cardiac Arrest

Abstract Background Outcomes following in-hospital cardiac arrest remain poor despite advances in resuscitation techniques. Establishing “goals of care” is crucial to optimizing patient care and avoiding burdensome interventions in those who are unlikely to benefit from resuscitation. Doctors often avoid discussions regarding ‘goals of care’ with patients in whom cardiac arrest is not deemed likely at the time of admission. Methods All cardiac arrest team activations for non-pregnant, adult inpatients on medical and surgical wards at our institution from December 2022 – June 2023 were prospectively analysed. Qualitative analysis of inpatient charts was performed to assess; incidence of cardiac arrest, demographic and clinical data, and the degree to which discussions regarding escalation of care had taken place. Results 66 cardiac arrest team activations were screened, of which 23 calls were included for analysis. The estimated incidence of cardiac arrest was 1.11-1.67 events per 1,000 patient discharges. 18 patients (78.2%) were under the care of general medicine or geriatric teams at the time of arrest call. 12 (52%) patients were older than 70 and 4 (17%) were older than 80. Falls were the most common reason for admission (22.7%) among patients for whom the cardiac arrest team was activated. 2 patients (12.5%) with confirmed cardiac arrest survived to hospital discharge. Discussions regarding goals of care were documented for 8/23 patients (34.7%). Conclusion Cardiac arrests were uncommon in our institution. Discussions regarding goals of care were documented in only a third of cases, possibly because many patients presented with issues not typically associated with a risk of subsequent arrest. Given the low survival rates to discharge, routine discussion of goals of care should be considered at the point of admission in all patients who are unlikely to benefit from resuscitation, regardless of the presenting complaint.

DNAR: All or Nothing: Impact of Education Sessions Re-Audit in a Model 3 Hospital

Abstract Background Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national HSE guidelines after education sessions, comparing results with the pre-education audit in a Model 3 Hospital. Methods A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants. Results Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both of which were unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%. This elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. Therefore, we posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan. Conclusion Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science.

Optimal communication between care teams is a critical component in providing safe, timely, and appropriate patient care. Labor and delivery (L&D) units experience rapidly changing clinical scenarios often requiring escalation in care and unplanned cesarean deliveries (CDs). The University of Cincinnati Medical Center (UCMC) is a 550-bed academic level 4 maternal care center with a 13-bed L&D unit in Cincinnati, OH. There are approximately 2500 deliveries/y with a CD rate of 33%. The L&D unit is staffed with dedicated anesthesia personnel 24 hours a day. In our L&D unit, there was widespread dissatisfaction with multidisciplinary communication surrounding unscheduled CD. Near-miss safety events in our obstetric unit were attributed to preoperative communication failures. Initial surveys identified challenges in preoperative communication among nursing, anesthesiology, and obstetric teams leading to potential risk for compromised care. Using the UC Health Performance Improvement Way, we first sought to understand the process leading up to unscheduled CD. Change ideas were developed based on observed failures in communication. Interventions were tested and refined through iterative plan-do-study-act (PDSA) cycles. One key intervention was the introduction of a bedside, multidisciplinary, patient-centered, pre-CD huddle attended by nursing, anesthesia, and obstetrics representatives using a standard checklist for critical information. Qualitative patient feedback was elicited to inform change efforts. We compared patient and procedure characteristics from the baseline and huddle implementation phases. Our primary outcome measure was the satisfaction of care team members with communication around unscheduled CD. A secondary outcome was the general anesthesia (GA) rate for unscheduled CD. Our key process measure was adherence to the preoperative huddle. We tracked decision-to-incision interval (DTI) as a balancing measure. Huddle adherence reached 96% for unscheduled CD within 6 months of testing and implementation. A combined survey of anesthesia, nursing, and obstetrics showed that satisfaction scores related to unscheduled CD communication improved from 3.3/5 to 4.7/5 after huddle implementation. The rate of GA use and the median DTI remained unchanged. Patients felt more engaged and reported positive experiences by being a part of the huddle discussion. In an academic obstetric unit, communication failures surrounding unscheduled CD were identified as a contributor to staff dissatisfaction and perception of safety risk. Implementation of a bedside multidisciplinary pre-CD huddle improved communication between teams and contributed to creating a culture of safety without causing significant delays in care.

Initial assessment and management of adults with suspected acute respiratory infection: a rapid evidence synthesis of reviews and cost-effectiveness studies.

This work was undertaken to inform a National Institute for Health and Care Excellence guideline on the initial assessment of adults with suspected acute respiratory infection. To undertake a rapid evidence synthesis of systematic reviews and cost-effectiveness studies of signs, symptoms and early warning scores for the initial assessment of adults with suspected acute respiratory infection. MEDLINE, EMBASE and Cochrane Database of Systematic Reviews were searched for systematic reviews and MEDLINE, EMBASE, EconLit and National Health Service Economic Evaluation Database were searched for cost-effectiveness studies in May 2023. References of relevant studies were checked. Clinical outcomes of interest included escalation of care, antibiotic/antiviral use, time to resolution of symptoms, mortality and health-related quality of life. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool or the National Institute for Health and Care Excellence economic evaluations checklist. Results were summarised using narrative synthesis. Nine systematic reviews and one cost-effectiveness study met eligibility criteria. Seven reviews assessed several early warning scores for patients with community- acquired pneumonia, one assessed early warning scores for nursing home-acquired pneumonia and one assessed individual signs/symptoms and the Centor score for patients with sore throat symptoms; all in face-to-face settings. Two good-quality reviews concluded that further research is needed to validate the CRB-65 in primary care/community settings. One also concluded that further research is needed on the Pneumonia Severity Index in community settings; however, the Pneumonia Severity Index requires data from tests not routinely conducted in community settings. One good-quality review concluded that National Early Warning Score appears to be useful in an emergency department/acute medical setting. One review (unclear quality) concluded that the Pneumonia Severity Index and CURB-65 appear useful in an emergency department setting. Two poor-quality reviews concluded that early warning scores can support clinical judgement and one poor-quality review found numerous problems with using early warning scores in a nursing home setting. A good-quality review concluded that individual signs and symptoms have a modest ability to diagnose streptococcal pharyngitis, and that the Centor score can enhance appropriate prescribing of antibiotics. The cost-effectiveness study assessed clinical scores and rapid antigen detection tests for sore throat, compared to delayed antibiotic prescribing. The study concluded that the clinical score is a cost-effective approach when compared to delayed prescribing and rapid antigen testing. Several early warning scores have been evaluated in adults with suspected acute respiratory infection, mainly the CRB-65, CURB-65 and Pneumonia Severity Index in patients with community-acquired pneumonia. The evidence was insufficient to determine what triage strategies avoid serious illness. Some early warning scores (CURB-65, Pneumonia Severity Index and National Early Warning Score) appear to be useful in an emergency department/acute medical setting; however, further research is required to validate the CRB-65 and Pneumonia Severity Index in primary care/community settings. The economic evidence indicated that clinical scores may be a cost-effective approach to triage patients compared with delayed prescribing. Only systematic reviews were eligible for inclusion in the synthesis of clinical evidence. There was a great deal of overlap in the primary studies included in the reviews, many of which had significant limitations. No studies were undertaken in remote settings (e.g. NHS 111). Only one cost-effectiveness study was identified, with limited applicability to the review question. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR159945.

Maternal Sepsis.

Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.

Unobtrusive Monitoring of Clinical Deterioration in Smart Homes.

Clinical deterioration (CD) is the physiological decompensation that incurs care escalation, protracted hospital stays, or even death. The early warning score (EWS) calculates the occurrence of CD based on five vital signs. However, there are limited reports regarding EWS monitoring in smart home settings. This study aims to design a CD detection system for health monitoring at home (HM@H) that automatically identifies unstable vital signs and alarms the medical emergency team. We conduct a requirement analysis by interviewing experts. We use unified modeling language (UML) diagrams to define the behavioral and structural aspects of HM@H. We developed a prototype using a SQL-based database and Python to calculate the EWS in the front end. A team of five experts assessed the accuracy and validity of the designed system. The requirement analysis for four main users yielded 30 data elements and 10 functions. Three main components of HM@H are the graphical user interface (GUI), the application programming interface (API), and the server. Results show the possibility of using unobtrusive sensors to collect smart home residents' vital signs and calculate their EWS scores in real-time. However, further implementation with real data, for frail elderly and hospital-discharged patients is required.

Evaluating the Utility of Clinical Scores APACHE, CURB, SOFA, and NEWS2 at Admission and 5-Days after Symptom Onset in Predicting Severe COVID-19 in Patients with Diabetes.

The elevated risk of severe COVID-19 outcomes in patients with diabetes underscores the need for effective predictive tools. This study aimed to assess the predictive accuracy of APACHE II, CURB-65, SOFA, and NEWS2 scores at critical time points in diabetic patients diagnosed with COVID-19, aiming to guide early and potentially life-saving interventions. In a prospective cohort study conducted from January 2021 to December 2023, adult patients with type 1 or type 2 diabetes and confirmed SARS-CoV-2 infection were evaluated. Clinical scores were calculated at admission and five days post-symptom onset, with data analyzed using receiver operating characteristic (ROC) curves and logistic regression to determine areas under the curve (AUC) and hazard ratios (HR) for severe outcomes. Among the 141 diabetic patients studied, ROC analysis revealed high AUC values for SOFA (0.771 at admission, 0.873 at day five) and NEWS2 (0.892 at admission, 0.729 at day five), indicating strong predictive accuracy for these scores. The APACHE II score's AUC improved from 0.698 at admission to 0.806 on day five, reflecting worsening patient conditions. Regression analysis showed significant HRs associated with exceeding threshold scores: The SOFA score HR at day five was 3.07 (95% CI: 2.29-4.12, p < 0.001), indicating a threefold risk of severe outcomes. Similarly, the APACHE II score showed an HR of 2.96 (95% CI: 2.21-3.96, p < 0.001) at day five, highlighting its utility in predicting severe disease progression. The SOFA and NEWS2 scores demonstrated excellent early predictive accuracy for severe COVID-19 outcomes in diabetic patients, with significant AUC and HR findings. Continuous score monitoring, especially of APACHE II and SOFA, is crucial for managing and potentially mitigating severe complications in this vulnerable population. These tools can effectively assist in the timely escalation of care, thus potentially reducing morbidity and mortality among diabetic patients during the COVID-19 pandemic.

Dose Finding in Oncology Trials Guided by Ordinal Toxicity Grades Using Continuous Dose Levels.

We present a Bayesian adaptive design for dose finding in oncology trials with application to a first-in-human trial. The design is based on the escalation with overdose control principle and uses an intermediate grade 2 toxicity in addition to the traditional binary indicator of dose-limiting toxicity (DLT) to guide the dose escalation and de-escalation. We model the dose-toxicity relationship using the proportional odds model. This assumption satisfies an important ethical concern when a potentially toxic drug is first introduced in the clinic; if a patient experiences grade 2 toxicity at the most, then the amount of dose escalation is lower relative to that wherein if this patient experienced a maximum of grade 1 toxicity. This results in a more careful dose escalation. The performance of the design was assessed by deriving the operating characteristics under several scenarios for the true MTD and expected proportions of grade 2 toxicities. In general, the trial design is safe and achieves acceptable efficiency of the estimated MTD for a planned sample size of twenty patients. At the time of writing this manuscript, twelve patients have been enrolled to the trial.