The Florida Geriatric Head Trauma CT Clinical Decision Rule.

BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.

BACKGROUND: Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care. METHODS: A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated. RESULTS: A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care. CONCLUSION: Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Weight Estimation for Drug Dose Calculations in the Prehospital Setting - A Systematic Review.

BACKGROUND: Weight estimation is required to enable dose calculations for weight-based drugs administered during emergency care. The accuracy of the estimation will determine the accuracy of the administered dose. This is an important matter of patient safety. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature focusing on the accuracy of weight estimation in the prehospital environment. METHODS: This systematic review followed the PRISMA guidelines. Studies were identified and included if they were peer reviewed, full length, published in English, and contained original data. Studies utilizing any form of weight estimation methodology in the prehospital setting (in children or adults) were included. Data on the quality of the studies and accuracy of the weight estimation systems were extracted. Common themes were also identified. RESULTS: Twenty-five studies met the inclusion criteria, with only nine studies (36.0%) containing useful weight estimation accuracy data. The overall quality of the studies was poor. The Broselow tape and paramedic estimates were the most studied methods of weight estimation, but there was insufficient evidence to support conclusions about accuracy. The major themes identified included the importance of accurate weight estimation and drug dosing as critical matters of patient safety, and the need for training to ensure these processes are performed accurately. CONCLUSIONS: There were limited robust data identified on the accuracy of different weight estimation methods used in the prehospital setting. Future high-quality clinical research in this area is of critical importance to ensure patient safety in the prehospital environment.

An observational simulation-based study of the accuracy of intercostal drain placement and factors influencing placement.

Introduction: South Africa's significant burden of trauma and respiratory disease requires the regular need for intercostal drain (ICD) insertion. ICD misplacement is associated with significant complications. The aim of this study was to assess ICD insertion site accuracy and the factors affecting accuracy by Emergency Department doctors. Methods: This was a prospective, observational simulation-based study. Prior to participant admission, pertinent thoracic structures were marked on two simulated patients using an invisible marker which could only be seen using ultraviolet light. One by one, study participants were then asked to place a sticker on each side of each patient's chest to indicate where they would insert an ICD. Sticker placements were photographed under ultraviolet light. Placement sites were compared according to the most appropriate and accurate position for insertion (within the area superior to the 6th rib, posterior to pectoralis major and 1cm anterior to the mid-axillary line) as well as the British Thoracic Society's 'triangle of safety'. Comparisons of accuracy were made between participant rank (junior vs senior doctor), participant experience, simulated patient BMI category and placement side. Results: Insertion site was accurate in 47% of placements and within the 'triangle of safety' in 51% of placements. Improved accuracy was associated with greater participant experience (61% vs. 37%, p<0.01), and left-sided chest placement (54% vs 40%, p = 0.02). No difference was found when comparing simulated patient BMI category (low vs high, 43% vs 51%, p=0.18) or participant rank (junior vs senior, 41% vs 51%, p=0.10). Conclusion: Overall accuracy of ICD insertion site was low, and appropriate accuracy was only associated with greater participant experience and left sided placement. Further studies to determine methods to improve ICD placement accuracy are needed.

CT Utilization in a Level One Trauma Center in South Africa.

Introduction Computed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging. Methods This was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department's picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate. Results There were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan. Conclusions South Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting.

Estimating Lean Body Weight in Adults With the PAWPER XL-MAC Tape Using Actual Measured Weight as an Input Variable.

Introduction Accurate drug dose calculation in obese patients requires an estimation of lean body weight (LBW) for dosing hydrophilic medications. Inaccurate weight estimates during the management of critically ill obese adults may contribute to inaccurate drug doses and consequential poor outcomes. Existing methods of LBW estimation or measurement may be very difficult or impossible to use during emergency care. A point-of-care model that could provide rapid, accurate estimates of LBW would, therefore, be of significant clinical value. Methods A model was derived based using the adult version of the PAWPER XL-MAC tape. This derived model used recumbent length and measured total body weight (TBW) to estimate LBW. The derived model was used to generate LBW estimations in a random sample from National Health and Nutrition Examination Survey (NHANES) datasets (n=33,215). The benchmark outcome measure was to achieve >95% of LBW estimations within 20% of DXA-measured fat-free mass (P20>95%) and >70% of estimations within 10% of DXA-measured fat-free mass (P10>70%). Results The new model achieved a P20 of 99.7% and a P10 of 86.4% for LBW in the pooled sample and exceeded the minimum accuracy standards. This accuracy was maintained in both sexes, all ages, all ethnic groups, all lengths and in all habitus types. Conclusions The modified PAWPER XL-MAC model, using TBW as an input variable, proved to be an accurate method of LBW estimation. It could potentially have an important role in facilitating emergency drug dose calculations in critically ill or injured obese adult patients.

Development and Validation of a Length- and Habitus-Based Method of Ideal and Lean Body Weight Estimation for Adults Requiring Urgent Weight-Based Medical Intervention.

BACKGROUND AND OBJECTIVE: Accurate drug dosing in obese patients requires an estimation of ideal body weight (IBW) or lean body weight (LBW) for dosing hydrophilic medications. Erroneous weight estimates during the management of adults requiring weight-based treatment may contribute to poor outcomes. Existing methods of IBW and LBW estimation or measurement are very difficult to use during emergency care. A new point-of-care model would be useful to provide rapid estimates of IBW and LBW for this purpose. METHODS: A model was derived based on the PAWPER XL-MAC tape, a pediatric weight estimation system which uses recumbent length and mid-arm circumference to estimate IBW and LBW. The new adult model was used to generate IBW and LBW estimations for a derivation sample (n = 33155) and a validation sample (n = 5926) from National Health and Nutrition Examination Survey (NHANES) datasets. The model was developed in two steps, with calibration at each step, before being validated on an unused dataset. The outcome measure was to achieve >95% of IBW and LBW estimations within 20% of recognized reference standards (P20 > 95%) and >70% of estimations within 10% of these standards (P10 > 70%). RESULTS: The new model achieved a P20 of 100% and a P10 of 99.9% for IBW and a P20 of 98.3% and a P10 of 78.3% for LBW. This accuracy was maintained in both sexes, all ages, all ethnic groups, all lengths, and in all habitus types, except for the severely obese female subgroup. CONCLUSIONS: The modified PAWPER XL-MAC model proved to be an accurate method of IBW and LBW estimation. It could, therefore, have an important role in facilitating emergency drug dose calculations in obese adult patients.

Development and validation of a length- and habitus-based method of total body weight estimation in adults.

BACKGROUND: Erroneous weight estimation during the management of emergency presentations in adults may contribute to patient harm and poor outcomes. Patients can often not be weighed during emergencies and a weight estimation is required to facilitate weight-based therapies. Many existing methods of weight estimation are either unacceptably inaccurate or very difficult to use during the provision of emergency care. METHODS: The weight estimation system developed in this study was based on and modified from the PAWPER XL-MAC method, a pediatric weight estimation system that uses recumbent length and mid-arm circumference (MAC) to predict total body weight. This model was validated in the 2015-2018 National Health and Nutrition Examination Survey (NHANES) datasets. The primary outcome measure was to achieve >95% of estimations within 20% of measured weight (P20 > 95%). RESULTS: The modified PAWPER XL-MAC model achieved a P20 of 96.0% and a P10 of 71.3% in the validation dataset (N = 11,520). This accuracy (P20 > 95%) was maintained in both sexes, all ages, all ethnic groups, all lengths and in all habitus-types, except for the subgroup of severely obese individuals. CONCLUSIONS: The modified PAWPER XL-MAC model proved to be a very accurate method of weight estimation. It is more accurate than most other published reports of existing methods of weight estimation, except for patients' own estimations. It therefore could have a role in facilitating emergency drug dose calculations, if prospective studies bear out the accuracy found in this study.

Human Factor Errors in the use of the PAWPER Tape Systems: An Analysis of Inter-Rater Reliability.

Background International guidelines have promoted the use of length-based tapes for emergency weight estimation in children. This is primarily because of a perception that more modern methods might require more training than can practically be achieved. This study aimed to evaluate the inter-rater reliability of novice users of the PAWPER XL (paediatric advanced weight-prediction in the emergency room) tape as an indicator of the ability to use the device effectively with limited training. Methods This was a secondary analysis of unpublished data from three previous studies. Inter-rater reliability analyses were performed for each study for the accuracy of weight estimations and for the assignment of body habitus score. Inter-rater reliability was analysed using percentage agreement and Cohen's Kappa for Study 1 and intraclass correlation (ICC) for Study 2 and Study 3. A value of <0.7 was considered to indicate inadequate agreement, 0.7 to 0.89 was considered to indicate good agreement and ≥0.9 was considered to indicate excellent agreement. Main Results A total of 7034 data points were available for analysis in the three studies. In Study 1, the percentage agreement of an accurate weight estimation in 50 children, with two raters, was 47/50 (94%) with a Cohen's Kappa of 0.93 (0.81 - 1.0). In Study 2, the ICC for 6720 habitus score assessments, with 112 raters, was 0.73 (0.68 - 0.80). In Study 3, the ICC for 264 weight estimations (in terms of an accurate weight estimation, with 33 raters) was 0.88 (0.72 - 0.97). Conclusions There was good inter-rater reliability in the assessment of habitus and the accuracy of weight estimation for the PAWPER XL tape in this secondary analysis. The findings suggest that reasonable proficiency with the system can be achieved with minimal training. It is therefore unlikely that systems such as this require too much training to be practical in emergency care.

The utility of pediatric age-based weight estimation formulas for emergency drug dose calculations in obese children.

OBJECTIVES: In obese children, when drug therapy is required during emergency care, an estimation of ideal body weight is required for certain drug dose calculations. Some experts have previously speculated that age-based weight estimation formulas could be used to predict ideal body weight. The objectives of this study were to evaluate how accurately age-based formulas could predict ideal body weight and total body weight in obese children. METHODS: Three age-based weight estimation formulas were evaluated in a secondary analysis, using a pooled sample of children from 3 academic emergency departments in South Africa. The estimates produced by the 3 formulas (and the PAWPER XL tape as a control) were compared against measured total body weight and ideal body weight. The percentages of estimates falling within 10% of the standard weight were used as the primary outcome measure (PW10). RESULTS: This study included 1026 children. For ideal body weight estimations in obese children, the old Advanced Life Support formula, the new Advanced Life Support formula, and the Best Guess formula achieved PW10s (with 95% confidence intervals [CIs]) of 29% (27.2%, 30.8%), 41.4% (38.9%, 43.9%), and 48.3% (45.3%, 51.3%), respectively. For total body weight estimations, the formulas achieved PW10s of 3.6% (3.4%, 3.8%), 5.2% (4.9%, 5.5%), and 19.0% (17.8%, 20.2%). The PAWPER XL tape achieved an accuracy of ideal body weight estimation of 100% (93.9%, 100%) and total body weight estimation of 49.7% (46.7%, 52.7%) in obese children. CONCLUSIONS: The age-based formulas were substantially less accurate at estimating total body weight and ideal body weight than existing length-based methods such as the PAWPER XL tape, and should not be used for this purpose.

Drug dosing errors in simulated paediatric emergencies - Comprehensive dosing guides outperform length-based tapes with precalculated drug doses.

BACKGROUND: The accuracy of drug dosing calculations during medical emergencies in children has not been evaluated extensively. The objectives of this study were to evaluate the accuracy of drug dose calculations using the Broselow tape, the PAWPER XL tape plus its companion drug-dosing guide, a custom-designed mobile phone app and no drug-dosing aid (control group). METHODS: This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used the three methods to estimate the children's weight and calculate drug doses. The accuracy of and time taken for the drug dose determinations were then evaluated for each of the methods. RESULTS: The overall accuracy of drug dose determinations was extremely and potentially dangerously low in the control group in which no dosing guide was used as well as in the Broselow tape group (<20% of doses were correct). The accuracy was significantly higher with the PAWPER XL tape group and the mobile app group (47% and 31% respectively). The times taken to obtain the required information did not differ in a clinically meaningful magnitude. CONCLUSIONS: Both an accurate weight estimation and a dosing guide with comprehensive information were necessary to produce an accurate prescription. The information on the Broselow tape was not sufficient for this purpose. The current guidelines recommending the use of tapes with limited information should be revised. The results from the comprehensive dosing guides were substantially better, but still had a lower proportion of accurate prescriptions than desirable. The role of training in every aspect of the emergency paediatric weight estimation and drug dosing procedure cannot be underestimated and should be routine in any environment where emergency care may be needed.

Using the Mercy Method to Estimate Ideal Body Weight in Children: A Description and Validation of a New Methodology.

Background In obese children, lipophilic medications should be dosed to total body weight (TBW) and hydrophilic medications to ideal body weight (IBW). During emergencies, these weights need to be estimated to ensure that urgent drug therapy is accurate and safe. The Mercy method is a well-established weight estimation system that has recently been adapted to provide estimations of body length in children. It was therefore conceivable that this could be further modified to provide estimations of IBW. Methods A model was developed a priori using the Mercy method's humeral length (HL) segments to predict IBW. The accuracy of this model was then tested in a sample of 13,134 children from the National Health and Nutrition Examination Survey (NHANES) datasets. The accuracy of IBW estimation was determined from the percentage of estimations falling within 10% (p10) and 20% (p20) of true IBW. The model was also tested to see the accuracy of the detection of obesity in the study sample. Results From the sample of 13,134 children, a subset of 1,318 obese children were identified. In this subset, the new Mercy method model achieved an IBW estimation accuracy p10 of 66.9% and a p20 of 95.1%. For the detection of the obese child, the model had a sensitivity of 88.6% and a specificity of 75.8%. Conclusions This study established that the Mercy method can be modified to provide a reasonably accurate estimation of IBW in obese children, with very few critical errors. The ability of the model to identify the obese child was also reasonably accurate, on a par with other such predictive methods. While other accurate methods of estimating both TBW and IBW exist, such as the Paediatric Advanced Weight Prediction in the Emergency Room eXtra-Long tape (PAWPER XL tape), the modified Mercy method is an acceptable alternative if such other devices are not available.

How and Why Paediatric Weight Estimation Systems Fail - A Body Composition Study.

Background Weight estimation during medical emergencies in children is essential, but fraught with errors if the wrong techniques are used, which may result in critical drug dosing errors. Individualised weight estimation is required to allow for accurate dosing in underweight and obese children in particular. This study was designed to evaluate the associations between weight estimations from different systems and body composition in order to establish how and why they may perform well or poorly. Methods A convenience sample of 332 children aged from one month to 16 years had weight estimations using four age-based formulas: the Broselow™ Pediatric Emergency Tape (Armstrong Medical Industries, Inc., Lincolnshire, IL), the Mercy Method, and the Pediatric Advanced Weight Prediction in the Emergency Room, Extra-large/Extra-long Tape (PAWPER XL) Tape. They also had an assessment of body composition using dual x-ray absorptiometry (DXA). The weight estimates were compared against total body weight (TBW), calculated ideal body weight (IBW), and DXA-measured fat-free mass (FFM). Analyses of associations between age, length, weight estimation outcomes, and body composition were performed. Results Age-based formulas were very inaccurate because of the erratic relationship between age and body composition. The Broselow tape estimated IBW well in obese children because of the strong relationship between length and fat-free mass. It predicted TBW poorly in underweight and obese children, however, because of the poor relationship between length and fat mass. The Mercy Method's performance was unrelated to body composition, but estimated TBW reasonably well and could not predict IBW or FFM. The PAWPER XL Tape's performance was the most closely associated with body composition and, therefore, achieved an acceptable accuracy for estimations of TBW, IBW, and FFM. Conclusions Of the systems evaluated, the PAWPER XL Tape has the best association with body composition and the most accurate estimations of TBW, IBW, and FFM.

The cost-effectiveness of upfront point-of-care testing in the emergency department: a secondary analysis of a randomised, controlled trial.

BACKGROUND: Time-saving is constantly sought after in the Emergency Department (ED), and Point-of-Care (POC) testing has been shown to be an effective time-saving intervention. However, when direct costs are compared, these tests commonly appear to be cost-prohibitive. Economic viability may become apparent when the time-saving is translated into financial benefits from staffing, time- and cost-saving. The purpose of this study was to evaluate the cost-effectiveness of diagnostic investigations utilised prior to medical contact for ED patients with common medical complaints. METHODS: This was a secondary analysis of data from a prospective, randomised, controlled trial in order to assess the cost-effectiveness of upfront, POC testing. Eleven combinations of POC equivalents of commonly-used special investigations (blood tests (i-STAT and complete blood count (CBC)), electrocardiograms (ECGs) and x-rays (LODOX® (Low Dose X-ray)) were evaluated compared to the standard ED pathway with traditional diagnostic tests. The economic viability of each permutation was assessed using the Incremental Cost Effectiveness Ratio and Cost-Effectiveness Acceptability Curves. Expenses related to the POC test implementation were compared to the control group while taking staffing costs and time-saving into account. RESULTS: There were 897 medical patients randomised to receive various combinations of POC tests. The most cost-effective combination was the i-STAT+CBC permutation which, based on the time saving, would ultimately save money if implemented. All LODOX®-containing permutations were costlier but still saved time. Non-LODOX® permutations were virtually 100% cost-effective if an additional cost of US$50 per patient was considered acceptable. Higher staffing costs would make using POC testing even more economical. CONCLUSIONS: In certain combinations, upfront, POC testing is more cost-effective than standard diagnostic testing for common ED undifferentiated medical presentations - the most economical POC test combination being the i-STAT + CBC. Upfront POC testing in the ED has the potential to not only save time but also to save money. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03102216.