Ronald's story illustrates how undiagnosed medical issues led to repeated falls and eventual loss of independence. The project aimed to use point-of-care blood testing (POCBT) by paramedics on elderly patients presenting with acute frailty syndromes to inform safe hospital avoidance, enable earlier disease management, and increase clinician confidence. Initial results found POCBT improved discharge rates and recontact rates compared to previous frailty projects, and case studies showed it supported earlier disease identification and management. While more research is needed, the quality improvement project demonstrated POCBT's potential positive impact on assessing and treating elderly patients experiencing acute frailty.
This document outlines a clinical audit project to prevent ventilator-associated pneumonia (VAP) at KSMC ICU. The audit team is led by Dr. Abdul-Rahman Al-Harthy and includes ICU consultants and fellows. The objectives are to meet guidelines-based criteria to reduce VAP, including elevating patient head, oral chlorhexidine, hand hygiene, ventilator circuit changes only when needed, daily sedation review and weaning assessment, and use of subglottic secretion drainage for long-term patients. Data will be collected from patient charts and observations from March 1 to April 30, 2014 on 88 patients and analyzed to measure compliance with the criteria and standards.
Pathology Optimisation in Chronic Blood Disease MonitoringAndrew O'Hara
Richard Croker shows how an innovative approach to service redesign can improve patient outcomes at pace and scale through the safe and effective use of testing at NHS Northern, Eastern and Western Devon CCG.
Early warning scores (EWS) are used to facilitate early detection of patient deterioration. The EWS system assigns points to physiological parameters like respiration, oxygen saturation, blood pressure, and temperature to determine a total score. This score dictates the frequency of monitoring and urgency of clinical review. Higher scores indicate more frequent monitoring and quicker medical review are needed. The system aims to standardize recognition of worsening conditions and ensure prompt treatment. Case studies are presented to demonstrate how EWS would be applied in clinical practice.
Patient selection and training for PERITONEAL DIALYSIS Ayman Seddik
This document discusses key considerations in assessing and initiating patients for peritoneal dialysis (PD). It notes that evaluating candidacy for PD is a multidisciplinary task involving nephrologists, nurses, and other specialists. Placement of the PD catheter 4-5 weeks before initiation allows time for healing and training. Training is critical and involves education on modalities, catheter care, exchanges, and documentation. The goal is to start PD without interim hemodialysis and avoid early problems that could discontinue PD.
This document summarizes guidelines for oxygen therapy in post-operative care. It recommends that oxygen therapy is an important part of recovery and can reduce post-operative complications. The summary outlines standards for best practice, such as all patients in recovery receiving oxygen according to local guidelines, and all high-risk patients who could benefit from post-operative oxygen being prescribed it and using it correctly. Audit indicators are proposed to measure adherence to these standards.
This document discusses optimizing bronchial hygiene therapy through 4 measures: 1) implementing a therapist-driven protocol program, 2) involving patients in selecting techniques, 3) establishing therapeutic and clinical objectives, and 4) using a combination and variety of techniques. It emphasizes that no single technique is best and therapists should work with patients to find the most suitable methods. The goal is to deliver individualized respiratory care through diagnostic evaluation and modifying therapy based on patients' immediate needs and symptoms.
VAP bundle compliance in ICU - Clinical Auditfaheta
This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.
This document outlines a clinical audit project to prevent ventilator-associated pneumonia (VAP) at KSMC ICU. The audit team is led by Dr. Abdul-Rahman Al-Harthy and includes ICU consultants and fellows. The objectives are to meet guidelines-based criteria to reduce VAP, including elevating patient head, oral chlorhexidine, hand hygiene, ventilator circuit changes only when needed, daily sedation review and weaning assessment, and use of subglottic secretion drainage for long-term patients. Data will be collected from patient charts and observations from March 1 to April 30, 2014 on 88 patients and analyzed to measure compliance with the criteria and standards.
Pathology Optimisation in Chronic Blood Disease MonitoringAndrew O'Hara
Richard Croker shows how an innovative approach to service redesign can improve patient outcomes at pace and scale through the safe and effective use of testing at NHS Northern, Eastern and Western Devon CCG.
Early warning scores (EWS) are used to facilitate early detection of patient deterioration. The EWS system assigns points to physiological parameters like respiration, oxygen saturation, blood pressure, and temperature to determine a total score. This score dictates the frequency of monitoring and urgency of clinical review. Higher scores indicate more frequent monitoring and quicker medical review are needed. The system aims to standardize recognition of worsening conditions and ensure prompt treatment. Case studies are presented to demonstrate how EWS would be applied in clinical practice.
Patient selection and training for PERITONEAL DIALYSIS Ayman Seddik
This document discusses key considerations in assessing and initiating patients for peritoneal dialysis (PD). It notes that evaluating candidacy for PD is a multidisciplinary task involving nephrologists, nurses, and other specialists. Placement of the PD catheter 4-5 weeks before initiation allows time for healing and training. Training is critical and involves education on modalities, catheter care, exchanges, and documentation. The goal is to start PD without interim hemodialysis and avoid early problems that could discontinue PD.
This document summarizes guidelines for oxygen therapy in post-operative care. It recommends that oxygen therapy is an important part of recovery and can reduce post-operative complications. The summary outlines standards for best practice, such as all patients in recovery receiving oxygen according to local guidelines, and all high-risk patients who could benefit from post-operative oxygen being prescribed it and using it correctly. Audit indicators are proposed to measure adherence to these standards.
This document discusses optimizing bronchial hygiene therapy through 4 measures: 1) implementing a therapist-driven protocol program, 2) involving patients in selecting techniques, 3) establishing therapeutic and clinical objectives, and 4) using a combination and variety of techniques. It emphasizes that no single technique is best and therapists should work with patients to find the most suitable methods. The goal is to deliver individualized respiratory care through diagnostic evaluation and modifying therapy based on patients' immediate needs and symptoms.
VAP bundle compliance in ICU - Clinical Auditfaheta
This study aimed to measure compliance with ventilator-associated pneumonia (VAP) bundle components in an intensive care unit (ICU) in Saudi Arabia. An audit of 88 mechanically ventilated patients found high compliance (87.5-100%) with hand hygiene, mouth care, and avoiding routine ventilator tubing changes. Compliance was lower for head-of-bed elevation (95.2%) and daily sedation vacations (65.5%). No patients received endotracheal tubes with subglottic suction ports due to unavailability. The authors recommend increasing education, minimizing provider workload, improving equipment maintenance, and ensuring access to recommended ventilation equipment.
The document discusses the Early Warning Score (EWS) system, which is a simple scoring method used to rapidly identify clinically deteriorating patients based on 5 physiological parameters. Studies have shown that implementing an EWS protocol can effectively reduce mortality and morbidity for deteriorating patients as well as prevent ICU admissions. The EWS allows for early detection of patients who need urgent medical review and intervention to avoid further physiological deterioration.
Surviving sepsis, 2013 kristy molnar, critical care consultantsKristy Molnar
Surviving Sepsis: Improving Care, Saving Lives
Kristy Molnar
Critical Care Consultants
(sponsored by Philips Healthcare, Alberta Health Services and supported by Edwards Lifesciences)
The HiSTORIC Trial evaluated the safety and efficacy of implementing a high-sensitivity troponin early rule-out pathway for consecutive patients with suspected acute coronary syndrome (ACS). The trial found that using the pathway, which utilized a double risk threshold based on high-sensitivity cardiac troponin I levels, reduced length of stay in the emergency department and increased the proportion of patients discharged from emergency without increasing adverse events at 30 days or 1 year. The pathway was both more effective and safe for ruling out myocardial infarction compared to standard of care testing.
The document discusses Modified Early Obstetric Warning Scores (MEOWS), which were introduced in the UK to decrease maternal mortality by improving early detection of clinical deterioration in pregnant women. MEOWS involves routinely monitoring and recording vital signs and assigning a score based on abnormalities, with higher scores triggering more urgent review. It is a standardized screening tool used to assist in early recognition of physiological signs of deterioration and intervention for at-risk pregnant women. Regular MEOWS assessments performed by trained midwives can help identify issues earlier before signs worsen and improve outcomes.
This document discusses surgical audits, which involve systematically analyzing healthcare quality against standards to improve patient care. Surgical audits aim to ensure standards are met, identify problems, and improve outcomes. They have advantages like identifying issues and guiding improvements, but also disadvantages like taking significant time. The stages of a surgical audit include collecting data, analyzing results against criteria, discussing findings, implementing solutions, and re-auditing to verify improvements.
The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) was established in the UK in 1988 to comprehensively and authoritatively review clinical practice surrounding deaths within 30 days of surgery. NCEPOD aims to maintain and improve standards of care for both adults and children through confidential case reviews, research, and publishing results. The National Early Warning Score (NEWS) is an excellent initiative that helps staff recognize patient deterioration earlier through standardized scoring of physiological parameters, enabling sicker patients to receive timely intensive care.
The History and Future of the SDA: Sustaining and Expanding the Role of an Op...Duke Heart
The document discusses the history and future of the Duke Heart Failure Same Day Access (SDA) Clinic. It began in 1998 as a Heart Failure Disease Management program and transitioned in 2012 to the SDA Clinic in response to penalties for hospital readmissions. The SDA Clinic provides an alternative to the emergency room for HF patients, using tools like IV diuretics and frequent monitoring to safely treat patients and avoid unnecessary hospital stays. Going forward, the document discusses expanding SDA services using remote monitoring, wearables, telehealth, hospital-at-home programs, and HF titration clinics to better serve patients wherever they receive care.
This document provides guidance for developing clinical practice guidelines at the Royal Children's Hospital in Melbourne, Australia. It outlines a 17 step process for guideline development that involves identifying a topic, forming an authoring team, reviewing evidence, drafting content, obtaining stakeholder feedback, finalizing and approving the guideline, implementing it, and evaluating its impact. Key principles include developing guidelines through a multidisciplinary process, basing them on the best available research evidence, and involving consumers throughout. The overall goal is to improve healthcare quality and outcomes for patients.
The document reviews the integrated medicine and emergency medicine services at a hospital, identifying areas of good practice including improved staffing levels, quality improvements, and patient experience initiatives, but also notes ongoing issues with staffing shortages, response times, overcrowding, and interdepartmental collaboration that could still be strengthened.
A pilot study to investigate the feasibility and acceptability of Telehealth ...3GDR
Dr Kenneth Law, MBChB MRCGP MSc Health Informatics, GP and Clinical Lead of Innovation Local Care Direct, University of Leeds.
https://mhealthinsight.com/2016/06/27/join-us-at-the-kings-funds-digital-health-care-congress/
Part of the joint International Fluid Academy and World Society of Abdominal Compartment Syndrome workshop at the Emirates Critical Car Conference 2018
Coordinating care of chronically ill women (≥ 45heynassau
This document provides resources and guidelines for coordinating care for chronically ill women over 45 with multiple health issues. It outlines topics like menopause, HRT, weight management, cardiovascular health, and diabetes. Evidence sources include systematic reviews from databases like Cochrane and clinical practice guidelines from sources such as the National Guidelines Clearinghouse. Key areas for improvement in care coordination identified are communication between primary and specialized care, sharing medical histories, and promoting understanding among healthcare professionals.
This document discusses clinical audits, which systematically review patient care against criteria to improve outcomes. Clinical audits compare current practices to standards to identify any gaps and drive improvements. They have been incorporated worldwide as part of clinical governance efforts since the 1990s. Some key points made include:
- Clinical audits can reduce risks, ensure cost-effectiveness, and improve patient care and outcomes.
- One of the earliest clinical audits was conducted by Florence Nightingale during the Crimean War, which significantly reduced mortality rates.
- Audits ask if standards are being followed correctly, while research asks if the right approach is being taken.
- Successful audits include clear, measurable criteria; objective data collection; analysis
- The document compares the accuracy of the Alvarado score, Appendicitis Inflammatory Response score (AIRS), and clinical assessment by an experienced surgeon in diagnosing acute appendicitis.
- A prospective study of patients with right lower quadrant pain found that AIRS had higher sensitivity and specificity than the Alvarado score or clinical assessment alone in predicting appendicitis.
- The study concludes that AIRS is accurate for diagnosing high probability appendicitis cases and ruling out low probability cases, making it a useful decision support tool.
Monitoring and surveillance_of_vascular_accessNaveen Kumar
This document discusses surveillance of vascular access in hemodialysis patients. It notes that while arteriovenous fistulas and grafts are superior to catheters, vascular access complications are common. Guidelines suggest various surveillance methods to maintain access patency, including monitoring physical signs and using tests like access flow measurements and ultrasound imaging to detect stenosis early. Randomized controlled trials on the benefits of surveillance vs monitoring alone have shown conflicting results, but surveillance is generally associated with fewer thrombotic events, hospitalizations, and missed treatments. However, there is no conclusive evidence yet that surveillance prolongs overall access lifespan.
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINESMary Ann Adiong
This document discusses clinical pathways and clinical practice guidelines. It defines clinical pathways as multidisciplinary plans of best clinical practices for specific patient groups. Clinical pathways help improve quality of care, reduce variation, and enhance communication. The document outlines the components and development process of clinical pathways, including establishing multidisciplinary teams, collecting data, and monitoring variances. It also discusses how clinical practice guidelines are evidence-based statements that optimize patient care through systematic reviews and benefit-harm assessments.
1) A study of 174 patients with severe alcoholic hepatitis found that those who received steroids plus N-acetylcysteine had improved one-month survival and a decreased risk of hepatic renal syndrome, though no overall improvement in six-month survival.
2) A randomized trial of 26 patients with severe alcoholic hepatitis who did not respond to medical therapy found that early liver transplantation improved six-month survival to 77% compared to 23% for matched non-transplanted controls.
3) Two studies found that rifaximin significantly improved cognitive function and quality of life in patients with minimal hepatic encephalopathy, with one study also finding an improvement in driving simulator performance with rifaximin treatment.
The document summarizes evidence on using chlorhexidine gluconate (CHG) baths to reduce hospital-acquired infections (HAIs) compared to traditional soap and water baths. Soap and water bath basins are found to harbor bacteria and increase HAI risk. Studies show CHG bathing reduces acquisition of various drug-resistant bacteria in intensive care units. While CHG bathing has added costs, it can reduce unnecessary antibiotic use, testing, and hospital stays associated with HAIs, thereby saving the healthcare system billions annually. The document recommends making CHG bathing standard care for all patients to lower HAI risk.
This randomized controlled trial evaluated the effectiveness of double sequential external defibrillation (DSED) and vector change defibrillation compared to standard care for patients with refractory ventricular fibrillation. The trial was stopped early due to staffing shortages from COVID-19. DSED and vector change defibrillation were both associated with improved survival to hospital discharge compared to standard care. However, the treatment effect sizes may be overestimated due to the small sample size and early trial termination. [/SUMMARY]
The document discusses the Early Warning Score (EWS) system, which is a simple scoring method used to rapidly identify clinically deteriorating patients based on 5 physiological parameters. Studies have shown that implementing an EWS protocol can effectively reduce mortality and morbidity for deteriorating patients as well as prevent ICU admissions. The EWS allows for early detection of patients who need urgent medical review and intervention to avoid further physiological deterioration.
Surviving sepsis, 2013 kristy molnar, critical care consultantsKristy Molnar
Surviving Sepsis: Improving Care, Saving Lives
Kristy Molnar
Critical Care Consultants
(sponsored by Philips Healthcare, Alberta Health Services and supported by Edwards Lifesciences)
The HiSTORIC Trial evaluated the safety and efficacy of implementing a high-sensitivity troponin early rule-out pathway for consecutive patients with suspected acute coronary syndrome (ACS). The trial found that using the pathway, which utilized a double risk threshold based on high-sensitivity cardiac troponin I levels, reduced length of stay in the emergency department and increased the proportion of patients discharged from emergency without increasing adverse events at 30 days or 1 year. The pathway was both more effective and safe for ruling out myocardial infarction compared to standard of care testing.
The document discusses Modified Early Obstetric Warning Scores (MEOWS), which were introduced in the UK to decrease maternal mortality by improving early detection of clinical deterioration in pregnant women. MEOWS involves routinely monitoring and recording vital signs and assigning a score based on abnormalities, with higher scores triggering more urgent review. It is a standardized screening tool used to assist in early recognition of physiological signs of deterioration and intervention for at-risk pregnant women. Regular MEOWS assessments performed by trained midwives can help identify issues earlier before signs worsen and improve outcomes.
This document discusses surgical audits, which involve systematically analyzing healthcare quality against standards to improve patient care. Surgical audits aim to ensure standards are met, identify problems, and improve outcomes. They have advantages like identifying issues and guiding improvements, but also disadvantages like taking significant time. The stages of a surgical audit include collecting data, analyzing results against criteria, discussing findings, implementing solutions, and re-auditing to verify improvements.
The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) was established in the UK in 1988 to comprehensively and authoritatively review clinical practice surrounding deaths within 30 days of surgery. NCEPOD aims to maintain and improve standards of care for both adults and children through confidential case reviews, research, and publishing results. The National Early Warning Score (NEWS) is an excellent initiative that helps staff recognize patient deterioration earlier through standardized scoring of physiological parameters, enabling sicker patients to receive timely intensive care.
The History and Future of the SDA: Sustaining and Expanding the Role of an Op...Duke Heart
The document discusses the history and future of the Duke Heart Failure Same Day Access (SDA) Clinic. It began in 1998 as a Heart Failure Disease Management program and transitioned in 2012 to the SDA Clinic in response to penalties for hospital readmissions. The SDA Clinic provides an alternative to the emergency room for HF patients, using tools like IV diuretics and frequent monitoring to safely treat patients and avoid unnecessary hospital stays. Going forward, the document discusses expanding SDA services using remote monitoring, wearables, telehealth, hospital-at-home programs, and HF titration clinics to better serve patients wherever they receive care.
This document provides guidance for developing clinical practice guidelines at the Royal Children's Hospital in Melbourne, Australia. It outlines a 17 step process for guideline development that involves identifying a topic, forming an authoring team, reviewing evidence, drafting content, obtaining stakeholder feedback, finalizing and approving the guideline, implementing it, and evaluating its impact. Key principles include developing guidelines through a multidisciplinary process, basing them on the best available research evidence, and involving consumers throughout. The overall goal is to improve healthcare quality and outcomes for patients.
The document reviews the integrated medicine and emergency medicine services at a hospital, identifying areas of good practice including improved staffing levels, quality improvements, and patient experience initiatives, but also notes ongoing issues with staffing shortages, response times, overcrowding, and interdepartmental collaboration that could still be strengthened.
A pilot study to investigate the feasibility and acceptability of Telehealth ...3GDR
Dr Kenneth Law, MBChB MRCGP MSc Health Informatics, GP and Clinical Lead of Innovation Local Care Direct, University of Leeds.
https://mhealthinsight.com/2016/06/27/join-us-at-the-kings-funds-digital-health-care-congress/
Part of the joint International Fluid Academy and World Society of Abdominal Compartment Syndrome workshop at the Emirates Critical Car Conference 2018
Coordinating care of chronically ill women (≥ 45heynassau
This document provides resources and guidelines for coordinating care for chronically ill women over 45 with multiple health issues. It outlines topics like menopause, HRT, weight management, cardiovascular health, and diabetes. Evidence sources include systematic reviews from databases like Cochrane and clinical practice guidelines from sources such as the National Guidelines Clearinghouse. Key areas for improvement in care coordination identified are communication between primary and specialized care, sharing medical histories, and promoting understanding among healthcare professionals.
This document discusses clinical audits, which systematically review patient care against criteria to improve outcomes. Clinical audits compare current practices to standards to identify any gaps and drive improvements. They have been incorporated worldwide as part of clinical governance efforts since the 1990s. Some key points made include:
- Clinical audits can reduce risks, ensure cost-effectiveness, and improve patient care and outcomes.
- One of the earliest clinical audits was conducted by Florence Nightingale during the Crimean War, which significantly reduced mortality rates.
- Audits ask if standards are being followed correctly, while research asks if the right approach is being taken.
- Successful audits include clear, measurable criteria; objective data collection; analysis
- The document compares the accuracy of the Alvarado score, Appendicitis Inflammatory Response score (AIRS), and clinical assessment by an experienced surgeon in diagnosing acute appendicitis.
- A prospective study of patients with right lower quadrant pain found that AIRS had higher sensitivity and specificity than the Alvarado score or clinical assessment alone in predicting appendicitis.
- The study concludes that AIRS is accurate for diagnosing high probability appendicitis cases and ruling out low probability cases, making it a useful decision support tool.
Monitoring and surveillance_of_vascular_accessNaveen Kumar
This document discusses surveillance of vascular access in hemodialysis patients. It notes that while arteriovenous fistulas and grafts are superior to catheters, vascular access complications are common. Guidelines suggest various surveillance methods to maintain access patency, including monitoring physical signs and using tests like access flow measurements and ultrasound imaging to detect stenosis early. Randomized controlled trials on the benefits of surveillance vs monitoring alone have shown conflicting results, but surveillance is generally associated with fewer thrombotic events, hospitalizations, and missed treatments. However, there is no conclusive evidence yet that surveillance prolongs overall access lifespan.
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINESMary Ann Adiong
This document discusses clinical pathways and clinical practice guidelines. It defines clinical pathways as multidisciplinary plans of best clinical practices for specific patient groups. Clinical pathways help improve quality of care, reduce variation, and enhance communication. The document outlines the components and development process of clinical pathways, including establishing multidisciplinary teams, collecting data, and monitoring variances. It also discusses how clinical practice guidelines are evidence-based statements that optimize patient care through systematic reviews and benefit-harm assessments.
1) A study of 174 patients with severe alcoholic hepatitis found that those who received steroids plus N-acetylcysteine had improved one-month survival and a decreased risk of hepatic renal syndrome, though no overall improvement in six-month survival.
2) A randomized trial of 26 patients with severe alcoholic hepatitis who did not respond to medical therapy found that early liver transplantation improved six-month survival to 77% compared to 23% for matched non-transplanted controls.
3) Two studies found that rifaximin significantly improved cognitive function and quality of life in patients with minimal hepatic encephalopathy, with one study also finding an improvement in driving simulator performance with rifaximin treatment.
The document summarizes evidence on using chlorhexidine gluconate (CHG) baths to reduce hospital-acquired infections (HAIs) compared to traditional soap and water baths. Soap and water bath basins are found to harbor bacteria and increase HAI risk. Studies show CHG bathing reduces acquisition of various drug-resistant bacteria in intensive care units. While CHG bathing has added costs, it can reduce unnecessary antibiotic use, testing, and hospital stays associated with HAIs, thereby saving the healthcare system billions annually. The document recommends making CHG bathing standard care for all patients to lower HAI risk.
This randomized controlled trial evaluated the effectiveness of double sequential external defibrillation (DSED) and vector change defibrillation compared to standard care for patients with refractory ventricular fibrillation. The trial was stopped early due to staffing shortages from COVID-19. DSED and vector change defibrillation were both associated with improved survival to hospital discharge compared to standard care. However, the treatment effect sizes may be overestimated due to the small sample size and early trial termination. [/SUMMARY]
Point of Care Testing (POCT) refers to medical testing that is conducted outside of a laboratory setting, typically near or at the location of a patient. This can include testing in a physician's office, at home, in the field, or in a hospital room. POCT is usually performed using portable, handheld, or small benchtop devices. Here are some main features and advantages of POCT:
Convenience and Speed: Since POCT can be done at or near the patient's location, it eliminates the need to send samples to a lab and wait for the results. This can result in quicker diagnosis and treatment.
Immediate Decision Making: With instant results, healthcare providers can make immediate decisions about a patient's care, leading to improved patient outcomes.
Reduced Costs: While some POCT devices can be expensive, they may reduce overall healthcare costs by shortening hospital stays, reducing the number of follow-up visits, and preventing complications.
Simplicity: Many POCT devices are designed to be user-friendly, allowing non-laboratory personnel or even patients themselves to conduct tests.
Connectivity: Modern POCT devices often come with connectivity options, enabling the integration of test results into electronic health records.
Versatility: There's a wide range of tests available for POCT, from blood glucose testing to rapid strep tests and coagulation tests.
However, it's also important to note some challenges with POCT:
Quality Control: Ensuring the accuracy and reliability of POCT results can be challenging, especially if tests are being conducted by non-laboratory personnel.
Cost: Some advanced POCT devices can be costly, and there may be additional costs associated with training and quality control.
Regulation and Oversight: Because POCT is performed outside of the traditional lab setting, there can be challenges related to oversight, regulation, and ensuring that tests meet necessary standards.
In summary, while POCT offers many advantages in terms of speed and convenience, it's essential to ensure that tests are accurate, reliable, and meet necessary standards.
Rapid diagnostic tests (RDTs) in India play a crucial role in the detection and management of various diseases, including infectious diseases like malaria, dengue, and more recently, COVID-19. Here's an overview of RDTs in India:
Importance in Disease Management: In a vast and diverse country like India, with varied healthcare infrastructure across its regions, RDTs provide a quick and effective way to diagnose diseases, especially in remote areas where sophisticated laboratory setups might not be available.
Malaria and Dengue Detection: RDTs for malaria (based on the detection of antigens produced by malaria parasites) and dengue (based on the detection of dengue NS1 antigen and anti-dengue antibodies) are widely used. They offer results in less than
Rapid Diagnostic Tests (RDTs) in India play a crucial role in the quick detection and diagnosis of various diseases. They are espec
This document discusses recent advances in the management of pediatric septic shock. It summarizes that evidence is shifting away from protocolized care to more individualized, physiology-based approaches. Specifically, the evidence no longer supports aggressive fluid resuscitation and liberal blood transfusions. Instead, more conservative fluid and transfusion strategies are favored. The document also reviews new evidence regarding use of biomarkers, inotrope selection, antibiotic timing, and steroid use in managing pediatric septic shock.
This document reviews several topics in neonatology, including:
1) Delayed cord clamping which provides benefits like increased hemoglobin but risks like polycythemia. Guidelines recommend 30-60 seconds for vigorous infants.
2) Therapeutic hypothermia for hypoxic ischemic encephalopathy, which improves mortality and neurodevelopment when started in the first 6 hours of life.
3) Exogenous surfactant for respiratory distress syndrome, which is most effective with early administration and antenatal steroids. Less invasive methods like INSURE/MIST provide benefits over intubation.
4) Non-invasive ventilation strategies to reduce intubation including CPAP developed in the 1970s.
This document discusses the implementation of clinical practice guidelines for sepsis, specifically the Surviving Sepsis Campaign guidelines. It finds that while guidelines can be helpful, they are often not followed by more than 50% of clinicians. The document presents strategies to improve adherence through performance improvement initiatives at one medical center. These include identifying gaps in timely screening, diagnosis, initial resuscitation, antibiotics, and addressing goals of care. The focus is on both early identification and treatment of sepsis as well as the critical role of nurses in performance improvement efforts to optimize outcomes for patients with sepsis.
This document discusses definitions related to sepsis and septic shock. It summarizes several key studies on early goal-directed therapy (EGDT) for sepsis, including the original 2001 Rivers study. The document outlines the Surviving Sepsis Campaign (SSC) 3-hour and 6-hour bundles. It discusses trials that compared higher vs lower hemoglobin thresholds for blood transfusion in septic shock and trials that compared EGDT to standard therapy. The document also summarizes studies on compliance with SSC bundles and harmonization of EGDT trial designs.
Patient selection and training for peritoneal dialysisAyman Seddik
This document discusses key considerations in assessing patients for peritoneal dialysis and initiating the therapy. It addresses issues like timing of catheter placement, adequacy of training, and management of early complications. Selection of appropriate patients and initiation of peritoneal dialysis is positioned as a multidisciplinary task requiring close monitoring by the renal team. Placement of the catheter 4-5 weeks before starting therapy and adherence to protocols for catheter care and training are emphasized.
Journal Club Group fffffffffffffffffffffff1.pptxMyThaoAiDoan
This journal club discusses a randomized controlled trial that compared a restrictive fluid strategy with early vasopressor use to a liberal fluid strategy in patients with sepsis-induced hypotension. The trial found no significant difference in mortality before discharge home by day 90 between the two strategies. Some strengths were its randomized design and excellent safety outcome reporting. Limitations included being unblinded and possibly underpowered. The results do not strongly support changing clinical practice but add to evidence that a restrictive fluid approach may be safe.
aaohnsf_bppv_cpg_update_slide_set_new_template_0.pptxThuyamani M
Clinicians should not order radiographic imaging or vestibular testing for patients who meet the diagnostic criteria for benign paroxysmal positional vertigo (BPPV) unless additional signs/symptoms exist that are inconsistent with BPPV. Obtaining unnecessary tests exposes patients to risks like radiation without clinical benefit and can delay appropriate treatment. The guidelines recommend diagnosing BPPV using the Dix-Hallpike maneuver and differentiating it from other causes of dizziness based on symptoms.
This document provides an overview of the key changes and recommendations in the 2019 guidelines for pulmonary embolism (PE). Some of the major updates include: revised criteria for diagnosing PE using D-dimer tests and imaging; a new definition of high-risk PE and assessment of severity; and preference for non-vitamin K antagonist oral anticoagulants as first-line treatment in eligible patients. The guidelines also provide new algorithms for diagnosing and managing PE in pregnancy and long-term follow-up care after PE.
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
Sickle Cell Disease (SCD) is major health problem in
Tanzania. Every year, approximately 11000 babies are born
with SCD1, and this number is expected to double by the year
2050. Tanzania has the fourth greatest number of annual
SCD births in all of Africa, and the fifth greatest in the world.
In addition, almost 20% of the Tanzanian population carries a
copy of the sickle gene in a form of sickle cell trait (AS).
Despite these staggering statistics, Tanzania has made
progress in the fight against SCD over the past decade. In
2008, the Ministry of Health and Social Welfare by then,
recognized SCD as a priority disease in the National strategy
for Non-communicable disease 2009- 2015, calling for all
sector to cooperate in combating the disease. A chapter on
SCD was also included in the national Non-communicable
Disease Treatment Manual.
Hydroxyurea is useful in the management of individuals with SCD. It reduces the complications
of SCD in infants, children and adults based on its ability to:
o Increase haemoglobin F levels
o Increase steady state hemoglobin counts
o Lower WBC and PLTs hence moderate the chronic inflammation state in SCD
Indications for starting hydroxyurea:
All children 9 months and above with proven SCD
Adolescents and adults with the following:
o Recurrent VOC ( 3 or more severe episodes requiring admission in the last 12
months)
o Severe and/or recurrent ACS (2 or more episodes in a lifetime)
o History of stroke or abnormal TCD (≥199cm/sec)
o Severe symptomatic chronic anemia that interferes with daily activities or quality of
life
o To reduce the risk of new or recurrent stroke where chronic transfusion therapy is not
feasible.
o Recurrent priapism
o Patient with chronic kidney disease on erythropoietin to improve anemia
#SickleCell disease#Indications for Hydroxyurea#Hamisi Mkindi#CKD#Investigations:
FBP - absolute neutrophil count (ANC) > 1,500/µl, platelet > 100,000/ul, Hb> 6g/dl.
If Hb is less than 6gm/dl do Reticulocyte Count[Do not start hydroxyurea in patients with
Hgb< 6 g/dl AND absolute reticulocyte count (ARC)<100,000/µL]
Serum Creatinine - should be within normal range,
Serum ALT – should not be greater than twice the upper limit of normal,
Bilirubin Total and direct
Urine Pregnancy Test in women
HPLC - Quantification of HbF (if this test cannot be done, Hydroxyurea should be prescribed
nevertheless and an elevated baseline HbF should not affect the decision to initiate
hydroxyurea)
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and outlines anticipated critical care bed needs for a hospital. It also discusses ventilation strategies, the use of ECMO, guidelines from medical societies, PPE recommendations, management of shock, antibiotics, experimental drug treatments and ongoing clinical trials. The overall focus is on evaluating and treating critically ill Covid-19 patients from an intensive care perspective.
The document summarizes information and recommendations regarding the Covid-19 pandemic from the perspective of intensive care and critical care specialists. It provides worldwide case statistics and projections for hospital bed and ventilator needs in California. Guidelines are presented on testing, diagnosis, treatment strategies including ventilation, use of sedatives, ECMO, and experimental drugs. Risk stratification, PPE guidance, and management of complications like shock are also addressed. Clinical trials and the potential use of convalescent plasma are discussed.
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Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
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Recordings are on YouTube and the company website.
https://www.youtube.com/@jenniferschaus/videos
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1. POINT OF CARE BLOOD TESTING (POCBT)
FOR PATIENTS >65 YEARS PRESENTING
WITH ACUTE FRAILTY SYNDROMES.
Using diagnostics to improve clinician confidence in discharge
of patients presenting with acute frailty syndromes.
3. RONALD’S STORY
Fall 1:
• Ambulance
• Non Injury
• Non urgent
falls referral
Fall 2:
• 111 - GP
• Non Injury
• Not seen
Fall 3:
• Ambulance
• Non Injury
• No referral
made
Fall 4:
• Neck of Femur #
• Loss of independence
• Complaint from hospital
Hb 75 g/L
4. BIOCHEMICAL AND
HAEMATOLOGICAL
CONTRIBUTORS TO FALLS WHO epidemiology of falls
Cognitive deficit
hypercalcaemia,
hyponatraemia,
hypo/ hyperglycaemia
Renal failure
hypoxia from respiratory failure,
Muscle weakness
Anaemia,
Hypocalcaemia
Hypokalaemia/ hyperkalaemia
5. THE PROJECT
1 x iSTAT alinity
CRG4+ and CHEM8 Cartridges
4 Specialist Paramedics + 4 Frailty Paramedics
Patients >65 years presenting with acute frailty
syndromes
11. DEPLOYMENT AND
REFERRALS
Device used on specialist Paramedic car
plus falls and frailty response vehicle
Deployment
Self deployment
Specialist Paramedic Hub
Referrals
Crew referrals
12. SAFETY NETS
• Standard Operating
procedures
• Team training
• Access to previous
results
• GP telephone triage
and advice
• Multiple PDSA cycles
13. RESULTS
78 patients involved
Improvement in reported
clinician confidence
Improved discharge on
scene and recontact
rates (when compared
with frailty specific
project)
Case studies support
earlier disease
management.
19. KEY LEARNINGS
Learning
Cost vs benefit Patient demographic selection is vital
Targeted use of device on selected resources
Access to
previous results
Recognition of the normally abnormal
ICE (Integrated Clinical Access) access
Appropriate
training of the
team
Initial group training run by qualified ACP
Monthly 1-2-1 sessions with team
Senior support – GP or Medical team
Use in
prognosticating
infection
Lactate alone is not sufficient to identify early sepsis
Logistics Temperature management
Cartridge management
21. CONCLUSION
Whilst formal research is required
to validate its use, this
QIP showed POCbT to have a
positive impact on all stated
aims. The projects results,
whilst taken from a small sample
size and of limited transferability,
show promise for POCbT
in both the pre-hospital environment
and in the field of frailty.
Introduction to the project
My background is as a specialist paramedic with south central ambulance and I am currently training as an advanced clinical practitioner at the University hospital Southampton. Last year I was fortunate enough to be on a HEETV funded program for trainee ACPs which gave me the opportunity to develop a quality improvement plan aimed at improving diagnostics for the frail older person.
About 10% of people with a hip fracture die within 1 month and about 30% within 12 months – NICE
In sept 2017 – March 2018 I trained 4 Sps and 4 frailty paramedics in the use of the iSTAT Alinity device with CRG4+ and CHEM8 Cartridges.
Specialist Paramedics are Paramedics who have gone on to do masters modules to specialise in critical or urgent care and frailty paramedics are Paramedics who work on the falls and frailty car and have a special interest in frailty.
We targeted Patients >65 years old presenting to the ambulance service with acute frailty syndromes and in whom their disposition is unclear – Just to explain that – In the ambulance service once assessing a patient we must make a decision about their best treatment location – For some it is very clear that definitive care should be provided in hospital, for others it is abundantly clear that either primary care management (or no management at all) is required. However often patients sit in an area of uncertainty between the two which can cause a great deal of anxiety among a paramedic who is often working without senior support. In particular, the frail older person – through no fault of their own, commonly falls into this group of unclear disposition.
Rationale
Specialist Paramedics are currently used within the south central ambulance service to make advanced decisions regarding hospital admission, treatment and referral. They do this utilising a range of advanced assessment skills and treatment skills however have no additional diagnostic tools. It stood to reason that a workforce trained in advanced diagnostics could utilise PoCT bloods to assist their decision making and perhaps enable more appropriate treatment and referral thus preventing deterioration of illness and or avoidable hospital admissions. Observation from practice identified that patients with frailty in the emergency department are commonly investigated with basic blood tests, ECGs, observations and physical examination. In the absence of blood tests in the pre hospital environment staff may be susceptible to over sensitive triage of the frail older person which in turn can contribute to inappropriate admission21. Admission to hospital results in poor functional outcomes for patients living with frailty4 thus increasing the need to avoid unnecessary admission from the pre-hospital environment. This knowledge provided the basis for formulation of this quality improvement project.
Acute frailty syndromes
Acute frailty syndromes, like the proverbial tip of the iceberg, are seemingly benign symptoms that can mask serious underlying injury. It is vital we go looking for the cause.
Aims
When I started out with this project I had three main aims. These were:
Safer discharges - measured by recontact rates and results affecting decision making
Earlier disease management - measured by onward referrals and hospital length of stay
Increased clinician confidence - measured by self report in response to qualitative questions
However as I began to do background research and even more so as the project commenced another aim developed and this was to increase the knowledge of Point-of -care-blood-testing in the pre hospital environment.
The reason for this final aim was that despite a fairly robust literature search there seemed to be a significant lack of published evidence in its use.
Evidence
The most notable use of pre-hospital point of care testing I found was the Labkit® Near Patient Diagnostics service tested with Surry pathology services and South East Coast ambulance service. This project involved a three phase trial that researched effective functionality, pre-hospital suitability and impact on patient management20, the outcomes of which are unclear. Whilst promotional material for the study reported positive outcomes I was unable to find a full peer reviewed publication of the study.
There were two pre-hospital studies carried out in Germany, the first looking at using the i-STAT troponin I to facilitate the early identification of Non ST Segment Elevation Myocardial Infarction and the second to monitor critical care patients during Helicopter Emergency Medical Services (HEMS) transfer to hospital.
The troponin study found the POCT results to be accurate but not diagnostic due to the common requirement for serial troponin monitoring in hospital9. The second study into use of POCT on HEMS inter hospital transfers identified a need for transfer of real time results to achieve patient benefit. Whist interesting, both studies lack transferability to the UK pre-hospital see and treat model due to their focus on critically ill patients whose trajectory of care is pre-determined by their potential or realised illness.
It seemed to me that I was hearing of many NHS services ranging from OOH primary care to emergency services and secondary care using POCbT but that no-one seemed to be sharing their learning.
So, In addition to trying to use this diagnostic tool to facilitate the assessment and management of acute frailty syndromes I hoped to generate knowledge that could be disseminated on pre-hospital POCbT.
Project - iSTAT
So how did the project actually work?
Firstly we used the iSTAT alinity device – this is an example of it here and I also have one that I will pass around the room for you to look at.
The iSTAT device is a handheld device that uses only a small sample of blood inserted into single use cartridges producing a result within minutes. This met the requirements of the pre-hospital environment for a number of reasons. Firstly it was small enough to carry around (has anyone seen the amount of kit a paramedic carries into any job – trust me a small lightweight device was essential), secondly it was quick (when we are asked to make a transport decision with 30 minutes on scene it is vital that results return quickly) and finally it was simple to use. (Vital because it was me using it!!)
We chose the CRG4+ and CHEM8 cartridges as they most closely resembled routine bloods carried out in the hospital environment and could identify common causes of acute frailty syndromes such as anaemia, electrolyte disturbances and altered respiratory or metabolic function.
The device was placed on the Reading specialist paramedic car during the week and the falls and frailty response car Saturday – Monday.
Project – Patient selection and referrals
Patient were identified through a number of means – the most common was specialist paramedic selection once with the patient or via the CAD system as jobs came in.
We also used the specialist paramedic hub to notify of us of any jobs in the area presenting with acute frailty syndromes
And we also received crew referrals from other paramedics and technicians who were with a patient and were unsure of their disposition.
Once with the patient, informed consent was obtained and the patient outcome later followed up through the ambulance CAD system or hospital notes.
Safety netting
Of course the introduction of a new diagnostic tool is not without its risks so it was important to put some safety nets in place.
Standard Operating procedures were written up and reviewed by specialist paramedic managers and staff were given training in both the use of the iSTAT and the interpretation of blood results.
I was able to establish access to the Integrated Clinical Environment (ICE) which gave us access to our patients most recent blood results – this was done in recognition of the fact that this patient group often has normally abnormal blood results and we needed to know when to act on abnormal results.
As paramedics we have access to GP telephone triage (which if there are any GPs in the room we are eternally grateful for!!). All staff trained on the iSTAT were encouraged to discuss abnormal results with the patients GP or OOH GP if there was any difficulty interpreting these.
And finally the project was subject to multiple PDSA cycles with changes being made to improve safety throughout as learning increased.
Results:
The quality improvement project recruited 78 patients aged 65 years to 97 years
There was an even split between male and female
The majority of presenting complaints were falls – I think this is for two reasons – firstly the use of the falls and frailty response car pre-disposed clinicians to this presenting complaint but secondly falls are a very common presenting complaint to the ambulance service and would be more common and easier to identify that other acute frailty syndromes.
Results outside of reference ranges were found in 55.1% of the cases with only half of these requiring clinical action or referral.
Only 14 of the 73 patients required transport to the emergency department as a result of abnormal blood results and all of these were subsequently admitted under specialty into hospital. Patients who returned abnormal blood results but that were not transported to hospital received an outpatient frailty specific referral such as falls clinic, Parkinson’s specialist team or a rapid access clinic for the older person
Clinicians reported improved decision making and confidence in >75% of the cases however in some circumstances clinicians felt that blood results actually confused them further.
And finally the project showed to have improved discharge on scene rates and reduced recontact rates when compared with a similar frailty specific project the previous year.
It is important to note when hearing these results that further formal research is required to validate these results but it does show promise for the use of POCbT both pre-hospital and in the field of frailty.
Case examples
Case 1: Brenda was an 84 year old female with learning difficulties, HTN and osteoporosis presenting with an explained fall in the early hours of the morning. On initial assessment the patient was uninjured, fully mobile, alert and orientated with a slightly raised respiratory rate and SP02 of 88% in the presence of sever kyphosis. The clinician was unsure if this respiratory rate and oxygen saturations were normal for her due to her severe kyphosis and Initial thought was given to providing oral antibiotics and discharging on scene. When POCbT results returned and were compared with results taken 10 days earlier she was found to have a new severe hyponatraemia and respiratory acidosis. With these new findings it was deemed necessary to admit the patient to the emergency department to investigate the underlying cause of these acute findings. The patient was subsequently admitted to the medical team with a diagnosis of pneumonia and hyponatraemia from ED and the receiving medical doctor provided positive feedback regarding its use on this job.
Case 2: 94 year old male who had fallen but due to advanced dementia could not remember how. He had last been seen by his carers late the evening before and was found first thing on the morning beside his bed. Clinical examination was able to rule out significant head injury or acute illness but in these patients a creatine kinase is usually required to exclude acute kidney injury. However due to the availability of urea and creatinine through the iSTAT and access to recent results we could apply the RIFLE and AKIN criteria for acute kidney injury and refer the patient to GP for follow up bloods to ensure no further progression.
Case 3: Dot was an 86 year old lady who had been recently discharged from hospital on furosemide for fluid overload secondary to heart failure. She had been doing well at home up until the last couple of days when her mobility started to progressively worsen. Family had called 999 because they were due to go home and were concerned about her ability to safely mobilise around the flat. The patient was observed to mobilise safely however fatigued easily and complained of muscle cramps. One member of the ambulance crew felt the patient was safe to discharge on scene whilst the other remained unsure. POCbT revealed a furosemide induced metabolic alkalosis with a hypokalaemia of 2.3. This knowledge when combined with the patients significant cardiac history made the decision to admit the patient to hospital the safest option and possibly avoided a significant adverse event.
Case 4: 92 year old Bob presented to the ambulance service after a non-injury fall however was noted to have been experiencing increased falls over the last month. In addition to interventions put in place by the falls and frailty team, POCbT discovered a new Hb of 84. The patient was reporting some fatigue but no heart failure symptoms and had not had a full blood count since 2015. A referral was made back to her GP who booked a review of her anaemia with her own GP. This patients regularity of falls decreased once her anaemia was addressed and it is hoped that an injury and or admission was avoided.
Learnings:
As I mentioned earlier, an initially unintended aim of the project was to develop learnings in the practical implementation of pre-hospital point of care blood testing. So I just wanted to talk through some of these.
Cost vs benefit: When considering point of care diagnostics for any environment it is important to consider the cost vs benefit ratio. I felt that in order to justify the cost of POCbT it needed to have the ability to alter decision making and determine the trajectory of the patient journey. To my mind it is pointless doing a test that will only be repeated in a patient that is already destined for hospital. It was also vital to target the device to selected resources not only to optimise training and safety but also to be able to target a patient demographic.
Access to previous results and staff training: As mentioned earlier – this patient group often has normally abnormal results so it was incredibly important to have access to old results and the appropriate training of staff is vital to the success of the project.
I found that due to the lack of WCC or CRP the device was least useful in the assessment of infection for the purposes of hospital avoidance. Whilst lactate is available, a raised lactate indicates hypoperfusion in the presence of sepsis which can typically be identified by SIRS criteria without this. For this reason staff were encouraged not to use the device to assist decision making if the patient had been recently diagnosed with infection of gave a history of infective symptoms.
Logistics: As you might imagine the ambulance service isn’t the most controlled environment with most of our kit being exposed to the elements and the occasional clumsy hand. The iSTAT device didn’t work under 16 degrees which during the winter months proved tricky but It did warm up quickly when in a warm house or warmed against the body so it didn’t prevent us using it. The cartridges also have a strict storage temperature and once warmed had an accelerated expiry date so a fridge on the ambulance station was required.
Thanks
I do need to take this time to thank some of the participating trusts and companies who provided time, money or support to the project. These things are never achieved by a single person!