Prognostic accuracy of the Hamilton Early Warning Score (HEWS) and the National Early Warning Score 2 (NEWS2) among hospitalized patients assessed by a rapid response team.

BACKGROUND: Rapid response teams (RRTs) respond to hospitalized patients experiencing clinical deterioration and help determine subsequent management and disposition. We sought to evaluate and compare the prognostic accuracy of the Hamilton Early Warning Score (HEWS) and the National Early Warning Score 2 (NEWS2) for prediction of in-hospital mortality following RRT activation. We secondarily evaluated a subgroup of patients with suspected infection. METHODS: We retrospectively analyzed prospectively collected data (2012-2016) of consecutive RRT patients from two hospitals. The primary outcome was in-hospital mortality. We calculated the number needed to examine (NNE), which indicates the number of patients that need to be evaluated in order to detect one future death. RESULTS: Five thousand four hundred ninety-one patients were included, of whom 1837 (33.5%) died in-hospital. Mean age was 67.4 years, and 51.6% were male. A HEWS above the low-risk threshold (≥ 5) had a sensitivity of 75.9% (95% confidence interval (CI) 73.9-77.9) and specificity of 67.6% (95% CI 66.1-69.1) for mortality, with a NNE of 1.84. A NEWS2 above the low-risk threshold (≥ 5) had a sensitivity of 84.5% (95% CI 82.8-86.2), and specificity of 49.0% (95% CI: 47.4-50.7), with a NNE of 2.20. The area under the receiver operating characteristic curve (AUROC) was 0.76 (95% CI 0.75-0.77) for HEWS and 0.72 (95% CI: 0.71-0.74) for NEWS2. Among suspected infection patients (n = 1708), AUROC for HEWS was 0.79 (95% CI 0.76-0.81) and for NEWS2, 0.75 (95% CI 0.73-0.78). CONCLUSIONS: The HEWS has comparable clinical accuracy to NEWS2 for prediction of in-hospital mortality among RRT patients.

Quantifying Clinically Meaningful Point-of-Care Ultrasound Interpretation Discrepancies Using an Emergency Department Quality Assurance Program.

OBJECTIVES: Emergency medicine professional associations recommend that quality assurance (QA) programs be implemented wherever emergency department (ED) point-of-care ultrasound (POCUS) is in use. The purpose of this study is to identify the rate of clinically meaningful interpretation discrepancies between initial ED POCUS interpretation and a gold standard using a QA program in a Canadian academic ED. METHODS: All POCUS examinations completed in our ED are subject to a QA process. The results of all POCUS examinations undergoing this process from July 1, 2014, to June 30, 2015, were retrospectively reviewed. Four blinded abstractors collected data with a standardized tool after a training session. Information regarding patient demographics, POCUS indication, emergency physician initial POCUS interpretation, physician POCUS expertise, the presence of an interpretation discrepancy, and whether the discrepancy was clinically meaningful was abstracted. The proportion of interpretation discrepancies, clinically meaningful discrepancies, discrepancies requiring remedial action, and differences in discrepancy rates between non-expert and expert sonographers were analyzed. RESULTS: A total of 2,869 POCUS studies were included for review, with 2,668 in the final data set after exclusions. In total, only 1.4% of all scans contained an interpretation discrepancy. The rate of clinically meaningful discrepancies was 0.5%, and the rate of scans requiring remedial action was 0.1%. Overall, 85.5% of all scans were performed by four POCUS expert physicians, with the remainder by a non-expert. Scans performed by non-expert sonographers were significantly more prone to discrepancies than those performed by experts. No single scan indication was more prone to discrepancy. CONCLUSIONS: The overall ED POCUS interpretation discrepancy rate and clinically meaningful discrepancy rate identified using our QA process were very low. The findings are limited by the small group of expert sonographers completing most scans.

Evaluating the diagnostic accuracy of point-of-care ultrasound for cholelithiasis and cholecystitis in a canadian emergency department.

OBJECTIVES: Cholelithiasis and cholecystitis are common conditions that frequently require patients to come to the Emergency Department (ED) and undergo diagnostic imaging. The purpose of this study was to evaluate the test characteristics of emergency physician performed point-of-care ultrasound (POCUS) to diagnose cholelithiasis and cholecystitis in a Canadian ED. METHODS: A health records review was performed on all ED patients > 17 years of age for whom POCUS was performed to diagnose cholelithiasis and cholecystitis in a Canadian academic ED over a 5-year period. The sensitivity, specificity, predictive values, and likelihood ratios were calculated. The gold standard used for diagnosis was pathology, laparoscopy, radiology-performed comprehensive ultrasonography, followed by computed tomography scans. RESULTS: A total of 577 patients were included in the study. The sensitivity and specificity of POCUS to diagnose cholelithiasis was 95.2% (95% CI 91.1-97.8%) and 93.1% (95% CI 90.1-95.4%). The positive and negative likelihood ratios for POCUS to diagnose cholelithiasis were found to be 14 and 0.05; the negative predictive value was 97.6% (95% CI 95.5-98.7%). The sensitivity and specificity of POCUS to diagnose cholecystitis was 67.1% (95% CI 54.9-77.9%) and 97.6% (95% CI 95.9-98.8%). The positive and negative likelihood ratios for POCUS to diagnose cholecystitis were found to be 28 and 0.34; the negative predictive value was 95.6% (95% CI 93.9-96.8%). CONCLUSION: POCUS is reliable for the diagnosis of cholelithiasis and for ruling in cholecystitis. In cases where POCUS is negative or indeterminate for cholecystitis, further imaging should be obtained as clinical suspicion warrants.

RéSUMé: OBJECTIFS: La cholélithiase et la cholécystite sont des troubles médicaux courants qui obligent fréquemment les patients à se rendre aux urgences et subir une imagerie diagnostique. Le but de cette étude était d'évaluer les caractéristiques des tests de l'échographie au point d'intervention (POCUS) effectuée par des médecins urgentistes pour diagnostiquer la cholélithiase et la cholécystite dans une urgence canadienne. MéTHODES: Un examen des dossiers médicaux a été effectué sur tous les patients des services d'urgence, âgés de plus de 17 ans pour lesquels POCUS a été réalisée pour diagnostiquer la cholélithiase et la cholécystite dans un service d'urgence universitaire canadien sur une période de 5 ans. La sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance ont été calculés. L'étalon-or utilisé pour le diagnostic était la pathologie, la laparoscopie, l'échographie complète réalisée par radiologie, suivie de la tomodensitométrie. RéSULTATS: Au total, 577 patients ont été inclus dans l'étude. La sensibilité et la spécificité de POCUS pour diagnostiquer la cholélithiase étaient de 95.2% (IC 95% 91.1­97.8%) et 93.1% (IC 95% 90.1­95.4%). Les rapports de vraisemblance positifs et négatifs pour POCUS pour diagnostiquer la cholélithiase se sont révélés à 14 et 0.05; la valeur prédictive négative était de 97.6% (IC à 95% 95.5­98.7%). La sensibilité et la spécificité de POCUS pour diagnostiquer la cholécystite étaient de 67,1% (IC à 95% 54.9­77.9%) et de 97.6% (IC à 95% 95.9­98.8%). Les rapports de vraisemblance positifs et négatifs pour POCUS pour diagnostiquer la cholécystite se sont révélés à 28 et 0.34; la valeur prédictive négative était de 95.6% (IC à 9.5% 93.9­96.8%). CONCLUSION: POCUS est fiable pour le diagnostic de la cholélithiase et de la cholécystite. Dans les cas où le POCUS est négatif ou indéterminé pour la cholécystite, une imagerie supplémentaire doit être obtenue en cas de suspicion clinique.

Attitudes of emergency department physicians and nurses toward implementation of an early warning score to identify critically ill patients: qualitative explanations for failed implementation.

BACKGROUND: Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings. OBJECTIVES: Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale. METHOD: Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees. RESULTS: The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED. CONCLUSIONS: In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.

Rumination in response to stress as a common vulnerability factor to depression and substance misuse in adolescence.

The current study examined rumination in response to stress as a common vulnerability factor to both depression and substance use problems in adolescence. Specifically, we used a multi-wave longitudinal design to examine whether adolescents who tend to ruminate in response to stress exhibit increases in depressive symptoms and substance misuse following the occurrence of negative events. At time 1, adolescents (n = 161) completed measures assessing depressive symptoms, substance misuse, and the tendency to ruminate in response to stress. Every 6 weeks for the next 18 weeks participants completed measures assessing the occurrence of negative events, depressive symptoms, and substance misuse. Hierarchical linear modeling analyses indicated that adolescents who tend to ruminate in response to stress report greater elevations in depressive symptoms and substance misuse following elevations in negative events than other adolescents. The relationship between rumination, negative events, and substance misuse was moderated by age. Support was not obtained for fluctuations in depressive symptoms as a mediator of the relationship between negative events and substance misuse. Fluctuations in negative affect, however, were found to mediate this relationship.

Acute Management of the Traumatically Injured Pelvis.

Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.

Point-of-care ultrasound to diagnose appendicitis in a Canadian emergency department.

OBJECTIVES: Appendicitis is a common surgical condition that frequently requires diagnostic imaging. Abdominal computed tomography (CT) is the gold standard for diagnosing appendicitis. Ultrasound offers a radiation-free modality; however, its availability outside business hours is limited in many emergency departments (EDs). The purpose of this study is to evaluate the test characteristics of emergency physician-performed point-of-care ultrasound (POCUS) to diagnose appendicitis in a Canadian ED. METHODS: A health records review was performed on all ED patients who underwent POCUS to diagnose appendicitis from December 1, 2010 to December 4, 2015. The sensitivity, specificity, and likelihood ratios were calculated. The gold standard used for diagnosis was pathology, laparoscopy, CT scans, and a radiologist-performed ultrasound. RESULTS: Ninety patients were included in the study, and 24 were diagnosed with appendicitis on POCUS. Ultimately, 18 were confirmed to have appendicitis through radiologist-performed imaging, laparoscopy, and pathology. The sensitivity and specificity of POCUS to diagnose appendicitis were 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%), respectively. CONCLUSION: POCUS has a high specificity for diagnosing acute appendicitis and has very similar characteristics to those of a radiologist-performed ultrasound. These findings are consistent with the current literature and have the potential to decrease patient morbidity, diagnostic delays, ED length of stay, and need for additional imaging.

Examining the utility of the Hamilton early warning scores (HEWS) at triage: Retrospective pilot study in a Canadian emergency department.

OBJECTIVES: Early warning scores use vital signs to identify patients at risk of critical illness. The current study examines the Hamilton Early Warning Score (HEWS) at emergency department (ED) triage among patients who experienced a critical event during their hospitalization. HEWS was also evaluated as a predictor of sepsis. METHODS: The study population included admissions to two hospitals over a 6-month period. Cases experienced a critical event defined by unplanned intensive care unit admission, cardiopulmonary resuscitation, or death. Controls were randomly selected from the database in a 2-to-1 ratio to match cases on the burden of comorbid illness. Receiver operating characteristic (ROC) curves were used to evaluate HEWS as a predictor of the likelihood of critical deterioration and sepsis. RESULTS: The sample included 845 patients, of whom 270 experienced a critical event; 89 patients were excluded because of missing vitals. An ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting the likelihood of experiencing a critical event 0.62 (95% CI 0.58-0.66). HEWS had a fair discriminative ability for meeting criteria for sepsis 0.77 (95% CI 0.72-0.82) and good discriminative ability for predicting the occurrence of a critical event among septic patients 0.82 (95% CI 0.75-0.90). CONCLUSION: This study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. However, HEWS may allow earlier identification of septic patients. Prospective studies are needed to further delineate the utility of the HEWS to identify septic patients in the ED.

Dysfunctional attitudes, self-esteem, and hassles: cognitive vulnerability to depression in children of affectively ill parents.

The current study tested the diathesis-stress component of Beck's [(1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row, (1983). Cognitive therapy of depression: New perspectives. In P.J. Clayton, J.E. Barnett (Eds.), Treatment of depression: Old controversies and new approaches (pp. 265-290). New York: Raven Press] cognitive theory of depression in a sample of children between the ages of 6 and 14. We also examined whether high self-esteem buffers cognitively vulnerable youth against experiencing increases in depressive symptoms following increases in hassles. To provide a effective test of hypotheses, an at-risk sample (children of parents with a history of major depressive episodes) and a multi-wave longitudinal design were used. At Time 1, children (n=140) completed measures assessing dysfunctional attitudes, self-esteem, and depressive symptoms. Every 6 weeks for the next year, children completed measures assessing depressive symptoms and hassles. Hierarchical linear modeling analyses indicated that children possessing high levels of dysfunctional attitudes and low levels of self-esteem reported greater elevations in depressive symptoms following elevations in hassles than other children.

Depressogenic inferential styles, negative events, and depressive symptoms in youth: an attempt to reconcile past inconsistent findings.

Research examining the diathesis-stress component of the hopelessness theory (HT) in youth has provided mixed support for the theory. One explanation for inconsistent findings is the failure to consider relationships among the three inferential styles posited to serve as vulnerability factors by the theory. The weakest link hypothesis posits that an individual is as vulnerable to depression as his/her most depressogenic inferential style (DIS) makes him/her. A second explanation is that researchers have operationalized "high stress" from a nomothetic, as opposed to an idiographic, perspective. The current study tested the diathesis-stress component of the HT in 230 third-grade and 152 seventh-grade schoolchildren using both a weakest link and an idiographic approach towards analysis. Children completed measures assessing depressive symptoms and DISs. Children subsequently completed measures assessing depressive symptoms and negative events once a week for 6 weeks. Hierarchical linear modeling and time-lagged analyses indicated that a depressogenic weakest link was associated with greater elevations in depressive symptoms following elevations in stress.

The impact of parental borderline personality disorder on vulnerability to depression in children of affectively ill parents.

Children of parents with major depressive disorder (MDD) are four to six times more likely than other children to develop MDD. Little research has examined whether comorbid parental diagnoses further increase children's risk. This study examines whether children of parents with comorbid MDD and Borderline Personality Disorder (BPD) (1) are at greater risk for experiencing depressive symptoms and/or episodes and (2) whether such increased risk may be due, in part, to their exhibiting higher levels of cognitive/interpersonal vulnerability factors. Children (n = 140; ages 6-14) of parents with MDD completed measures assessing cognitive/interpersonal vulnerability factors. Parents completed semi-structured clinical interviews assessing severity of current depressive symptoms and BPD. Both children and parents completed a semi-structured clinical interview assessing the child's current and past history of MDD. Children of parents with comorbid MDD and BPD exhibited higher levels of current depressive symptoms and higher levels of cognitive/interpersonal vulnerability factors than children of parents with MDD but no BPD, even after controlling for parents' current levels of depressive symptoms. The relationship between parental BPD and chil-dren's current levels of depressive symptoms was partially mediated by children's cognitive/interpersonal vulnerability factors. Last, children of parents with comorbid BPD and MDD were 6.84 times more likely to exhibit a current or past diagnosis of MDD.

Treatment of Pediatric Diabetic Ketoacidosis in Canada: A Review of Treatment Protocols from Canadian Pediatric Emergency Departments.

OBJECTIVE: Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences. METHODS: Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema. RESULTS: Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5-20 mL/kg) and length of time boluses should be administered (20-120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration. CONCLUSIONS: This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

Self-criticism, dependency, and stress reactivity: an experience sampling approach to testing Blatt and Zuroff's (1992) theory of personality predispositions to depression in high-risk youth.

S. J. Blatt and D. C. Zuroff's 1992 theory of personality predispositions to depression posits that individuals who possess high levels of self-criticism and/or dependency are vulnerable to developing depression following negative events. The current study used experience sampling methodology to test this theory in a sample of 49 children ages 7 to 14. Children completed measures of dependency, self-criticism, and depressive symptoms. Subsequently, children were given a handheld computer that signaled them to complete measures of depressive symptoms and negative events at randomly selected times over 2 months. Results of hierarchical linear modeling analyses indicated that higher levels of both self-criticism and dependency were associated with greater elevations in depressive symptoms following negative events. Furthermore, each personality predisposition remained a significant predictor of such elevations after controlling for the interaction between the other personality predisposition and negative events. The results suggest that dependency and self-criticism represent distinct vulnerability factors to depression in youth.

The timing of parent and child depression: a hopelessness theory perspective.

This study examined whether children's inferential styles moderate the association between the onset of depressive symptoms in children and their parents. To provide a powerful test of our hypotheses, we utilized a high-risk sample (parents with a history of major depressive episodes and their children) and a multiwave longitudinal design. During the initial assessment, 140 children (ages 6 to 14) completed measures assessing depressogenic inferential styles. Parents and children also completed measures assessing current level of depressive symptoms. Following the initial assessment, children and parents were contacted every 6 weeks for the next year to complete measures assessing depressive symptoms. The results of hierarchical linear modeling analyses indicated that children who exhibited depressogenic inferential styles reported greater elevations in depressive symptoms following elevations in their parent's level of depressive symptoms than did children who did not exhibit such styles. The strength of this association was greater in girls.