A whole healthcare system mortality review of the second wave COVID-19 pandemic response, were lessons learned?

We previously reported a study of features of emergency healthcare response to COVID-19 that could be modified to mitigate against future excess deaths. Here we determined what themes persisted in later waves. This was an expert panel review of all components of care delivered to COVID-19 patients who died (primary and secondary care, community services, NHS 111 and 999, COVID oximetry at home, virtual wards). 174 deaths were included. 5% were deemed >50% avoidable, 75% included avoidability themes. Contact with primary care remains mostly via telephone, creating diagnostic risk. Patient decision to avoid healthcare contact was common. Recommendations include: better utilisation of home monitoring in future pandemics; improved avoidance of nosocomial spread; patients be encouraged to seek medical advice earlier.

Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom.

BACKGROUND: The response to the COVID-19 pandemic in the United Kingdom included large scale changes to healthcare delivery, without fully understanding the potential for unexpected effects caused by these changes. The aim was "to ascertain the characteristics of patients, uncertainty over diagnosis, or features of the emergency response to the pandemic that could be modified to mitigate against future excess deaths". METHODS: Review of the entire pathway of care of patients whose death was registered in Salford during the 8 week period of the first wave (primary care, secondary care, 111 and 999 calls) in order to create a single record of healthcare prior to death. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale. The panel identified themes using a structured judgement review format. RESULTS: There were 522 deaths including 197 in hospital, and 190 in care homes. 51% of patients were female, 81% Caucasian, age 79 ± 9 years. Dementia was present in 35%, COVID-19 was cause of death in 44%. Healthcare contact prior to death was most frequently with primary care (81% of patients). Forty-six patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9). Fewer than half of NHS 111 calls were answered during this period. 18% of deaths contained themes consistent with some degree of avoidability. In people aged ≥75 years who lived at home this was 53%, in care home residents 29% and in patients with learning disability 44% (n = 9). Common themes were; delays in patients presenting to care providers (10%), delays in testing (17%), avoidable exposure to COVID-19 (26%), delays in provider response (5%), and sub-optimal care (11%). For avoidability scores of 2 or 3 (indicating more than 50% chance of avoidability), 44% of cases had > 2 themes. CONCLUSIONS: The initial emergency response had unforeseen consequences resulting in late presentation, sub-optimal assessments, and delays in receiving care. Death in more vulnerable groups was more likely to display avoidability themes.

Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence.

BACKGROUND: The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known. METHODS: This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent "intermediate" patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages. RESULTS: Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood. CONCLUSIONS: This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.

Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance.

BACKGROUND: UK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme. METHODS: This was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality. RESULTS: Older individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14-5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58-3.65). CONCLUSIONS: Despite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care.

Diffraction in volume reflection gratings with variable fringe contrast.

The PSM model is used to analyze the process of diffraction occurring in volume reflection gratings in which fringe contrast is an arbitrary function of distance within the grating. General analytic expressions for diffraction efficiency at Bragg resonance are obtained for unslanted panchromatic lossless reflection gratings at oblique incidence. These formulas are then checked for several diverse fringe contrast profiles with numerical solutions of the Helmholtz equation, where exceptionally good agreement is observed. Away from Bragg resonance, the case of the hyperbolically decaying fringe contrast profile is shown to lead to an analytic expression for the diffraction efficiency and this is again compared successfully with numerical solutions of the Helmholtz equation.

Comparative study of the accuracy of the PSM and Kogelnik models of diffraction in reflection and transmission holographic gratings.

Calculated diffractive efficiencies in the visible spectral band from lossless planar holographic gratings are studied using the PSM and Kogelnik models of diffraction for the case of the σ-polarization. The results are numerically compared with rigorous coupled wave calculations over a wide parameter space covering both transmission and reflection geometries. For most reflection gratings, the PSM model is shown to consistently provide a marginally superior estimation of the diffractive efficiency. This is particularly evident in a clearly superior description of the diffractive sideband structure for most gratings, both in terms of angle and wavelength. For the transmission grating, the PSM model continues to provide a relatively good description of diffraction at low permittivity modulations and lower incidence angles with respect to the grating plane normal. However, overall Kogelnik's theory is shown to provide a somewhat superior estimation of diffractive efficiency and a clearly superior description of the diffractive side-band structure in the transmission case.

Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder.

BACKGROUND: English Ambulance Services are faced with annual increases in emergency demand. Addressing the demand for low acuity emergency calls relies upon the ability of ambulance clinicians to accurately identify the most appropriate destination or referral pathway. Given the risk of undertriage, the challenge is to develop processes that can safely determine patient dispositions, thereby increasing the number of patients receiving care closer to home. AIMS: The aim of the study was to evaluate the clinical utility and safety of triage support tools (Paramedic Pathfinders). METHODS: Two triage filters (Pathfinders) were developed (one medical, one trauma). These were applied by ambulance clinicians to 481 patients who had been transported to emergency departments (EDs). Preferred (gold standard) patient dispositions were established by senior medical practitioners using both ambulance and ED clinical records. The clinical utility of ambulance clinicians using Pathfinders was evaluated against this gold standard. RESULTS: The Medical Pathfinder was applied to 367 patients (76.3%) and the Trauma Pathfinder to 114 (23.7%). Agreement between ambulance clinician and gold standard was achieved in 387 cases (80.5%) giving the tools a combined sensitivity of 94.83% and specificity of 57.9%. 20.9% of medical patients and 30.7% of trauma patients who had been transported to hospital could have been safely cared for elsewhere. CONCLUSIONS: Ambulance clinicians using Pathfinders have demonstrated acceptable levels of sensitivity in identifying patients who require ED care. The actual impact of the tools in clinical practice will be dependent on the provision of suitable alternatives to ED.

Analytical treatment of the polychromatic spatially multiplexed volume holographic grating.

An alternative model to N-coupled wave theory of the spatially multiplexed finite thickness volume holographic reflection grating is developed from the parallel stacked mirrors (PSM) model in terms of N infinite arrays of parallel stacked mirrors each characterized by a different grating vector. A plane reference wave interacts with each of the N sets of stacked mirrors, producing N signal waves. First-order coupled partial differential equations describing the detailed process of Fresnel reflection within the grating are derived for the reference and N signal waves. These equations can be solved analytically at Bragg resonance where agreement with conventional N-coupled wave theory is exact. The new model is compared for the case of some simple multiplexed volume phase reflection gratings at and away from Bragg resonance with a rigorous coupled-wave solution of the Helmholtz equation. Good agreement is attained for even rather high values of index modulation. For lower modulations more characteristic of modern holographic materials, agreement appears extremely good at and around Bragg resonance, although differences inevitably appear in the higher-order diffractive sideband structure. The analytic model is extended to cover polychromatic spatially multiplexed volume phase gratings at Bragg resonance, where once again agreement with rigorous coupled-wave calculations is very good for index modulations typical for modern holographic gratings. Finally, the model is extended to cover the case of the lossless multicolor phase-reflection hologram, where analytic and graphical results are presented concerning diffractive efficiency.

On the need for an international effort to capture, share and use crystallization screening data.

When crystallization screening is conducted many outcomes are observed but typically the only trial recorded in the literature is the condition that yielded the crystal(s) used for subsequent diffraction studies. The initial hit that was optimized and the results of all the other trials are lost. These missing results contain information that would be useful for an improved general understanding of crystallization. This paper provides a report of a crystallization data exchange (XDX) workshop organized by several international large-scale crystallization screening laboratories to discuss how this information may be captured and utilized. A group that administers a significant fraction of the world's crystallization screening results was convened, together with chemical and structural data informaticians and computational scientists who specialize in creating and analysing large disparate data sets. The development of a crystallization ontology for the crystallization community was proposed. This paper (by the attendees of the workshop) provides the thoughts and rationale leading to this conclusion. This is brought to the attention of the wider audience of crystallographers so that they are aware of these early efforts and can contribute to the process going forward.