London Teaching Hospital Research Articles

Books: Three Things About Elsie

Joanna Cannon The Borough Press, 2018, HB, 464pp, £14.99, 978-0008196912 I saw a frail, severely kyphotic 80-year-old lady mobilising slowly with her Zimmer frame in surgery this week. I confess to not being overly excited by her presenting complaint of a cough. However, as she apologised for coming to see me for what was ‘probably just a self-limiting viral infection, doctor, but I was worried I might not be able to compensate for much longer given my age and comorbidities’ , I sat up straight, turned my hunched body away from the computer, looked at my patient, and asked what she had done for work before. Her face blossomed into a knowing smile as she informed me that she was a retired casualty sister of a large London teaching hospital. In that instant I …

Implementation of the RCOG guidelines for prevention of obstetric anal sphincter injuries (OASIS) at two London Hospitals: A time series analysis

ObjectiveTo audit the impact of implementation of the RCOG guidelines for prevention of Obstetric anal sphincter injuries (OASIS) by introducing antenatal perineal massage, manual perineal protection, and cutting episiotomies at 60° to the midline at the time of crowning. DesignTime series analysis; Setting – Two London teaching hospitals; Royal Free London (RFL) and Barnet; Population or Sample – All nulliparous women undergoing vaginal birth; Methods – Training was provided for above techniques. EPISCISSORS-60 were introduced to perform 60° episiotomies. Data were extracted from maternity databases and dashboards; Main Outcome Measures – OASIS rates before and after implementation. ResultsData from 2566 births were analysed. In operative vaginal deliveries (OVD), OASIS declined from 9.6% to 2% (p = 0.001) at Barnet and from 5.6% to 4.2% (p = 0.4) at RFL. OASIS reduced in nulliparous OVD’s given episiotomies from 6.3% in the ‘before’ period to 0.6% in the ‘after’ period [p = 0.01] at Barnet. Before introduction of the EPISCISSORS-60, OASIS rate was 6.3% with episiotomies and 30% without episiotomies (p = 0.000). After introduction of the EPISCISSORS-60, OASIS rate was 0.63% with episiotomies v 16% without episiotomies (p = 0.000) at Barnet. At RFL, OASIS rate was 2.6% with episiotomies, and 42% without episiotomy (p = 0.000).In SVD’s at Barnet, OASIS declined from 6.6% before to 0% after (p = 0.000) in women given episiotomies while it declined from 5.4% to 3% (p = 0.12) in those not given episiotomies. After introduction of the EPISCISSORS-60, OASIS was 0% in women with episiotomies and 3% in those without episiotomies (p = 0.04).In SVD’s at RFL, OASIS was 0% in women given episiotomy v 4.7% without episiotomy (p = 0.03). ConclusionsDeliveries with EPISCISSORS-60 episiotomies had lesser OASIS than those without episiotomies in both nulliparous OVD’s and SVD’s. OASIS was lower with EPISCISSORS-60 episiotomies than those with eyeballed episiotomies.

A novel inpatient complex pain team: protocol for a mixed-methods evaluation of a single-centre pilot study

IntroductionComplex pain is a debilitating condition that is responsible for low quality of life and significant economic impacts. Although best practice in the treatment of complex pain employs a multidisciplinary...

Strategy to reduce E. coli bacteraemia based on cohort data from a London teaching hospital

Background and aimIn 2017, National Health Service Improvement set a 10% reduction target for Escherichia coli bacteraemia by 2018, followed by a 50% reduction in healthcare-associated Gram-negative bacteraemias by 2022....

Adequacy of nutrition support during extracorporeal membrane oxygenation

The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasing in adults with severe respiratory failure. Observational data suggest that there are significant challenges to providing adequate nutrition support for patients on vv-ECMO. We aimed to describe firstly the nutrition support practices in a large single-centre providing vv-ECMO to adults and secondly any association with clinical outcome. We conducted a retrospective review of patients receiving vv-ECMO on the Intensive Care Unit (ICU) of a large London teaching hospital. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and December 2015 were included. Daily energy and protein delivery were compared with estimated targets and reasons for feeding interruptions were collected from electronic medical records. Adequate feeding was defined as 80-110% of estimated targets. We analysed 203 eligible patients. Median duration of ICU stay was 21.0 (IQR, 15.0-33.0) days and vv-ECMO 10.0 (IQR, 7.0-16.0) days. Although median energy (89.8% (IQR, 80.5-96.0%)) and protein (84.7% (IQR, 74.0-96.7%)) delivery was adequate, underfeeding of either energy or protein occurred on nearly one third (28.3%) of nutrition support days. A higher admission severity of illness score was associated with inadequate protein delivery (p=0.040). Patients with more severe organ dysfunction on the first day of vv-ECMO received inadequate energy (p=0.026). The most common reasons for interrupted feeding were medical procedures (39.1%) followed by poor gastric motility (22.8%). Adequate energy and protein delivery during vv-ECMO is possible but underfeeding is still common, especially in those who are more severely ill or who have more severe organ dysfunction. Patients with inadequate energy or protein delivery did not differ in ICU and 6-month survival. Prospective studies investigating optimal feeding in this patient cohort are required.

Abstract TP170: Social Deprivation and Stroke Severity at Presentation: Data From a London Teaching Hospital

Background: Stroke is the most common cause of adult disability and the second most common cause of death in London, United Kingdom. Social deprivation has been demonstrated to be an important risk factor for stroke. It is unclear whether individuals from a lower socioeconomic background suffer more severe strokes. In this study we aim to investigate the relationship between social deprivation and stroke severity at presentation to hospital. Method: Data was prospectively collected on all patients presenting to a London tertiary stroke centre between 1 st February 2014 and 1 st March 2017. Stroke severity on presentation to the emergency department was measured by the National Institute of Health Stroke Scale (NIHSS). This data was linked using the patient’s zip code to the UK government’s published index of multiple deprivation decile (IMDD) - 1 st decile being most deprived, 10 th decile being least deprived. Univariate and multivariate regression analyses were performed to evaluate the association between social deprivation and stroke severity. Results: Data was available for all 2514 patients that presented between 1 st February 2014 and 1 st March 2017. The median IMDD was 3. There was an association with an increase in IMDD and increasing age at presentation (p<0.05 OR 1.48), decreasing prevalence of hypertension (p<0.05 OR 0.93) and decreasing prevalence of diabetes (p<0.05 OR 0.88). Adjusting for patient characteristics and time from onset of symptoms to presentation to hospital, there was an association with an increase in IMDD and lower NIHSS at presentation to hospital (p<0.05 OR 0.76). Conclusion: The patients that presented to our hospital during this study were more likely to be from a deprived area. Despite being younger, patients from more deprived areas were observed to have higher rates of hypertension and diabetes compared with patients from less deprived areas, and this should be the subject of targeted intervention in primary care. In our analyses, deprivation was associated with a more severe clinical presentation of stroke. This finding may contribute to worse outcomes following stroke in patients from more deprived areas, and the factors underlying this relationship should be investigated further.

Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge: addressing time-varying confounding using appropriate methodology

Studies often ignore time-varying confounding or may use inappropriate methodology to adjust for time-varying confounding. To estimate the effect of intensive care unit (ICU)-acquired bacteraemia on ICU mortality and discharge using appropriate methodology. Marginal structural models with inverse probability weighting were used to estimate the ICU mortality and discharge associated with ICU-acquired bacteraemia among patients who stayed more than two days at the general ICU of a London teaching hospital and remained bacteraemia-free during those first two days. For comparison, the same associations were evaluated with (i) a conventional Cox model, adjusting only for baseline confounders and (ii) a Cox model adjusting for baseline and time-varying confounders. Using the marginal structural model with inverse probability weighting, bacteraemia was associated with an increase in ICU mortality (cause-specific hazard ratio (CSHR): 1.29; 95% confidence interval (CI): 1.02-1.63) and a decrease in discharge (CSHR: 0.52; 95% CI: 0.45-0.60). By 60 days, among patients still in the ICU after two days and without prior bacteraemia, 8.0% of ICU deaths could be prevented by preventing all ICU-acquired bacteraemia cases. The conventional Cox model adjusting for time-varying confounders gave substantially different results [for ICU mortality, CSHR: 1.08 (95% CI: 0.88-1.32); for discharge, CSHR: 0.68 (95% CI: 0.60-0.77)]. In this study, even after adjusting for the timing of acquiring bacteraemia and time-varying confounding using inverse probability weighting for marginal structural models, ICU-acquired bacteraemia was associated with a decreased daily ICU discharge risk and an increased risk of ICU mortality.

Patient Academy- A platform for collaborative working to improve Paediatric Child Health & to empower patients in the role of educators

Introduction: The expertise of parents and patients is often under-valued. Collaborative working with patients/parents has given new meaning to patient-centred care. Involving healthcare users from the outset and engaging them in healthcare decision making and in the wider context of healthcare, promotes understanding of healthcare use and has the potential to facilitate more effective design and development of educational interventions to improve higlighted problems. We were keen to develop a platform whereby patients, parents and healthcare professionals could come together, to identify barriers to healthcare and to use co-design and co-production models to develop educational initiatives which could improve self-management, access to healthcare and other health outcomes. Practice Change: The Patient Academy initiative was piloted in a busy central London teaching hospital. The first phase of the project was a scoping exercise to understand local services and pathways in our hospital setting. The next phase involved a large-scale collaborative event held at London Zoo. The aim was to bring together all those involved in looking after a child’s health, to understand parental influences around healthcare decision-making, to define characteristics of a positive health encounter and to co-design educational strategies to improve the management of children with mild-moderate acute health problems. Approximately 25 parents and 35 healthcare professionals from a wide range of disciplines across primary and secondary care attended. Theory of change: We hypothesised that the event would provide unique insights from various perspectives which it did. With this widened lens we were able to collaboratively create a guide for the most effective health encounter and to design sustainable interventions to empower patients/parents in the role of educators and to improve healthcare encounters. Five work-streams led by teams of parents and healthcare professionals have emerged, each focusing on a different educational intervention. Targeted population & Stakeholders: Aligned to the national agenda of ‘Early Years’ the project was focused on improving a number of components of healthcare in 0-5 year olds. Stakeholders were extensive and included parents, patients, hospital paediatricians, nurses, GPs, health visitors, midwives, school nurses, mental health teams, public health, schools, pharmacists and behavioural insights specialists. Timeline: A six-month time frame was dedicated to the scoping exercise, the launch collaborative event and initial formation of workstreams and collaborative design of educational interventions. Highlights/Sustainability/Transferability: The greatest outcome from the Patient Academy has been the connections and relationships formed between patients, parents and various healthcare professionals and organisations. Five exciting workstreams have emerged including; 1) development of multi-disciplinary learning events, 2) a community based educational programe designed entirely by parents for parents and healthcare professionals. The other work-streams involve the 3) creation of a consultation tool, 4) a wardround tool and the 5) inception of a children and young person’s advisory board. To ensure sustainability, interventions have been incorporated into existing networks of patients/parents and integrated into routine daily activities. The tools created could easily be adopted by other Paediatric departments but are equally transferrable to any adult medical discipline in the UK or abroad.

Mismatch between suspected pyelonephritis and microbiological diagnosis: a cohort study from a UK teaching hospital

Urinary tract infections are a common reason for prescribing empirical antibiotics in the emergency department. This study investigated the role of microbiological culture and urinalysis in the diagnosis of pyelonephritis by extracting data on 105 patients with a clinical diagnosis of pyelonephritis at a London teaching hospital. In total, 99 of 102 patients were treated empirically with intravenous antibiotics, but only 55 of 100 patients who were sampled had microbiological evidence of infection in urine and/or blood. Almost half (10/21) of the patients with a negative urine dipstick test had a positive urine culture. Diagnostic uncertainty in this context undoubtedly drives inappropriate antibiotic use.

The impact of body weight on rivaroxaban pharmacokinetics

Unlabelled Box BackgroundThere is concern amongst clinicians that the fixed dosing strategy of rivaroxaban for the treatment of venous thromboembolism (VTE) might not be optimal in those patients under or overweight. ObjectiveTo develop a pharmacokinetic model for rivaroxaban, based on real‐world patients, specifically focusing on the impact of patients’ body weight on rivaroxaban pharmacokinetics. Patients/methodsOne hundred and one patients prescribed rivaroxaban prophylactic or treatment doses for the prevention or treatment of VTE were recruited at a London teaching hospital. Subjects had up to 3 rivaroxaban concentrations measured during a single dosing period (trough, 1 and 3 hours post dose). Population pharmacokinetic analyses was conducted to develop a rivaroxaban model, which was subsequently evaluated. ResultsA one‐compartment model with between‐subject variability on rivaroxaban clearance and volume of distribution, with a combined (additive and proportional) error model, best fitted the data. Following a full covariate analysis, creatinine clearance on rivaroxaban clearance was found to be the significant covariate impacting on the pharmacokinetic profile of rivaroxaban in the dataset. ConclusionsOur results suggest that the most important covariate impacting on rivaroxaban pharmacokinetics is creatinine clearance and the weight alone has little effect. These findings are in line with previous studies for rivaroxaban. Larger datasets, from real‐world patients who are followed longitudinally, should be conducted to provide front‐line clinicians with further reassurance when prescribing rivaroxaban for the acute management of VTE.

Falls re‐audit

PurposeThe economic burden and health consequences of falls are underestimated. Forty per cent of over 65 year olds will fall at least once each year, with half of these having multiple episodes. Visual impairment is common in the elderly and is associated with a higher falls risk. NICE recommends visual testing as part of a ‘multifactorial falls risk assessment’. However, during a recent audit on three elderly care wards at a central London teaching hospital, only 11% of patients who presented with a fall had visual assessment during their admission.MethodsA series of interventions were delivered in December 2016 to ‘Educate, Equip, and Emphasise’ clinicians. These included displaying posters on the wards, checking whether bedside equipment e.g. Snellen charts were available and facilitating replacement if missing, and a teaching presentation delivered to the elderly care team. A re‐audit was performed in February 2017 to ‘close the audit loop’.ResultsIn this cross‐sectional re‐audit, 9/64 of patients on the three wards (14%) originally presented with a fall (mean age 85.9 years; 6 were female; 3 were aided (i.e. used spectacles). 9/9 (100%) were visually impaired (best corrected visual acuity ≤ 6/12), most to a significant degree, however 0/9 (0%) had an assessment of vision during their admission. None of these patients were known to ophthalmic services previously.ConclusionsThe interventions were shown to be unsuccessful in improving adherence to guidelines. This highlights the need for awareness of the association between visual impairment and falls, and suggests education in training programmes may be necessary. The small sample size is a limitation to extrapolating the results on a national scale. Visual assessment and prompt referral to the eye clinic when necessary may prevent patients having future falls and readmissions to hospital.

Assessment of Haemodynamic Response to Induction of General Anaesthesia in Healthy Adult Patients Undergoing Elective Orthopaedic Surgery by Using a Continuous Non-invasive Cardiovascular Monitoring

Background: Continuous cardiovascular monitoring as part of management of high-risk surgical patients is widely practiced, however the role of continuous monitoring as part of routine management in low-risk surgical patients is unclear. Our aim was to investigate haemodynamic and Bispectral Index (BIS) changes in healthy patients undergoing surgery following induction of anaesthesia with propofol using a continuous non-invasive blood pressure device (LiDCO rapid™). We sought to obtain detailed monitoring of cardiovascular parameters from the pre-induction stage. Methods: This prospective, observational single-centre study was conducted at a London teaching hospital between June-November 2014. Patients aged between 18-45 years, American Society of Anesthesiologists grade I-II undergoing elective lower-limb arthroscopic procedures were included. Variables including heart rate (HR), mean arterial pressure (MAP), stroke volume (SV), cardiac output (CO), systemic vascular resistance (SVR) and BIS were recorded continuously prior to induction and up to 3-minutes after. Results: The following relative haemodynamic changes were noted between baseline and 1-minute post-induction with propofol: CO +15.2%, HR +10.1%, SVR -22.9% and MAP -10.1% (p<0.001 for each parameter). There was a mean change of: HR -10.1%, CO -14% and MAP -18.0%(p<0.001 for each parameter) between baseline and 3-minutes post-induction. Median change of BIS was -61.7% (p<0.001) between baseline and 3-minutes post-induction. Significant, positive correlations were noted between MAP and BIS at 30-seconds (r=0.60, p<0.001) and 1-minute post-induction (r=0.61, p<0.001). Conclusion: Our study shows that healthy patients undergoing continuous minimally invasive orthopaedic surgery experience significant haemodynamic and BIS changes following induction of anaesthesia. Our findings highlight the importance of baseline cardiovascular and BIS monitoring as part of routine perioperative management.

Continuous monitoring and feedback of quality of recovery indicators for anaesthetists: a qualitative investigation of reported effects on professional behaviour

BackgroundResearch suggests that providing clinicians with feedback on their performance can result in professional behaviour change and improved clinical outcomes. Departments would benefit from understanding which characteristics of feedback support effective quality monitoring, professional behaviour change and service improvement. This study aimed to report the experience of anaesthetists participating in a long-term initiative to provide comprehensive personalized feedback to consultants on patient-reported quality of recovery indicators in a large London teaching hospital. MethodsSemi-structured interviews were conducted with 13 consultant anaesthetists, six surgical nursing leads, the theatre manager and the clinical coordinator for recovery. Transcripts were qualitatively analysed for themes linked to the perceived value of the initiative, its acceptability and its effects upon professional practice. ResultsAnalysis of qualitative data from participant interviews suggested that effective quality indicators must address areas that are within the control of the anaesthetist. Graphical data presentation, both longitudinal (personal variation over time) and comparative (peer-group distributions), was found to be preferable to summary statistics and provided useful and complementary perspectives for improvement. Developing trust in the reliability and credibility of the data through co-development of data reports with clinical input into areas such as case-mix adjustment was important for engagement. Making feedback specifically relevant to the recipient supported professional learning within a supportive and open collaborative environment. ConclusionsThis study investigated the requirements for effective feedback on quality of anaesthetic care for anaesthetists, highlighting the mechanisms by which feedback may translate into improvements in practice at the individual and peer-group level.

Do nurse staffing levels affect patient mortality in acute secondary care?

This systematic literature review explores and considers whether registered nurse staffing levels affect patient mortality in acute secondary care settings. A discussion makes particular reference to the philosophical foundations of contrasting research approaches used within the literature. At the time of writing, the author was a modern matron for surgery, managing the ear, nose and throat; head and neck; airway; and reconstructive plastic surgery services in a large acute teaching hospital in central London. Effective management and leadership of acute clinical areas requires appropriate nurse:patient ratios. In practice settings, patient to staff ratios are based on care being provided by highly skilled and competent nurses providing best-quality, evidence-based practice.

Aetiology and outcome of massive transfusion in two large London teaching hospitals over a 3‐year period (2012–2014)

The objectives of this study were to determine: (i) the incidence of massive transfusion (MT) (defined as transfusion of ≥5 red-blood-cell (RBC) units within 4 h, and/or ≥10 RBC units within 24 h of bleeding) over a 3-year period; (ii) the cause, and mortality rate of patients who received MT (from any cause); and (iii) the risk factors for death. MT can occur in different clinical settings, yet little is known about its epidemiology/clinical outcomes. Data was extracted using transfusion laboratory information management system (LIMS) and patients' electronic databases. We identified 701 episodes (incidence 1.7 per 1000 admissions [95% confidence interval (CI): 1.6-1.9], belonging to 678 patients (225 females and 453 males, median age 61). Main causes of MT were cardiac surgery (35%), trauma (28%), medical (10%) and vascular surgery (9%). The overall mortality was 32%, and the median number of days spent in hospital was 14 and 2 for those who survived and those who died, respectively. Multivariable analysis showed that cardiac surgery was associated with 56% (95% CI: 9-78%) lower odds of death compared to other surgery, and transfusion of 10-14 RBC and >15 RBC units (compared with 5-9 RBC units) were associated with 2.1 (95% CI: 1.4-3.3) and 9.9 (95% CI: 4.6-21.1) times higher odds of dying, respectively. In-hospital morbidity and mortality of MT is high. Future research should focus on unifying the definition of MT, and early identification of the MT markers in order to improve outcomes.

The incidence and severity of errors in pharmacist-written discharge medication orders

Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists’ medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate—0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists’ discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.

P-194 - Evaluation of CA 19-9, a predictive biomarker of response and survival in patients undergoing chemotherapy for metastatic pancreatic ductal adenocarcinoma

Introduction: Patients with pancreatic ductal adenocarcinoma (PDAC) are subject to poor outcomes, with a median overall survival of 6-12 months in patients treated with palliative chemotherapy for metastatic disease. Appropriate patient selection for palliative chemotherapy is therefore critical to avoid detrimental outcomes1. Although CA 19-9 is the only recommended biomarker for clinical use in PDAC, it is not routinely used as a predictive marker of response to chemotherapy. We hypothesised that falls in CA 19-9 > 50% at the end of chemotherapy are associated with improved survival outcomes. Methods: We conducted a retrospective review of patients treated with palliative chemotherapy for metastatic PDAC over a 9-year period, at two separate university teaching hospitals in London, UK (n = 179). Median progression free (PFS) and overall survival (OS) were correlated with patient specific factors including CA 19-9, gender, age, number of visceral sites affected, previous surgical/adjuvant therapy and palliative chemotherapy. Results: 93% of patients had an elevated CA 19-9 at diagnosis. Median PFS and OS were significantly greater when serum CA 19-9 fell > 50% from the initiation of chemotherapy to the end of treatment. Patients demonstrating a fall in CA 19-9 >50%, who received 1 line of palliative chemotherapy, had a median PFS of 5.3 months compared with 3 months for patients who did not (p = <0.001), regardless of whether they received subsequent lines of chemotherapy. Patients only receiving 1 line of chemotherapy with a fall in CA 19-9 >50% had a PFS of 4.5 months, compared with 2.9 months (p = 0.005). In patients who received 1st line chemotherapy (n = 150), median OS was 5.6 months, when associated with a fall in CA 19-9 >50%, compared with 5.3 months (p = 0.017). Similarly, those who received 2nd line chemotherapy (n = 29) had an OS of 16 months versus 13.4 months (p = 0.703). Compared with the other measured variables, for 1st line treatment, this was an independent prognostic factor in multivariate analysis. We also demonstrated that the higher the level of CA 19-9, both prior to chemotherapy and at the end of treatment, the poorer the prognosis and earlier the relapse. Those with pre-treatment CA 19-9 levels between 0-100 kU/L had a median OS of 6.9 months (p = 0.034) compared with 4.6 months (p = <0.001), when greater than 1000 kU/L. Conclusion: We demonstrate that patients receiving chemotherapy with lower baseline CA 19-9 levels and reductions > 50% at the end of treatment are associated with improved survival outcomes. Regular CA 19-9 testing should be used to aid decision making in these patients. These results should be validated with prospective data from randomised clinical trials of patients undergoing palliative chemotherapy for metastatic PDAC.

HIV testing in general medical admissions – a missed ­opportunity

To assess the rate of HIV testing in general medical admissions to a London teaching hospital. All general medical admissions under the acute medical team from 1–14 January 2016 were recorded using the medical take list. The virology results and discharge summaries of all these patients were

Point-of-care tests for infectious diseases: barriers to implementation across three London teaching hospitals.

Existing Point-of-care tests (POCT) to help identify infection-related causes of illness can complement diagnostic and disposition decisions in children attending emergency departments.(1) Evidence-based clinical algorithms can integrate such POCT to aid in the admission and discharge decision process. Paediatric studies validating these tools are scarce, with very few studies conducted in UK centres.(2-5) POCT can be based on host infection markers (e.g. finger prick tests for C-reactive protein (CRP) to help decide if the patient has a bacterial or viral infection) or pathogen detection tests (e.g. throat/nose swabs to rapidly diagnose viral infections such as RSV or influenza). This article is protected by copyright. All rights reserved.

Violent injury predicts poor psychological outcomes after traumatic injury in a hard-to-reach population: an observational cohort study

BackgroundPeople who experience physical trauma face a range of psychosocial outcomes. These may be overlooked by busy clinicians. While some risk factors are understood, understanding of the psychological effects of...