Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital.

OBJECTIVES: To assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice. METHODS: All paediatric (<17 years) patients with head injuries presenting to Frimley Park Emergency Department (ED), England from 1 May to 31 October 2018 were prospectively screened by a nurse using a mandated electronic 'Head Injury Discharge At Triage' questionnaire (HIDATq). We determined which patients underwent CT of brain and whether there was a clinically important intracranial injury or re-presentation to the ED. The negative predictive value of the screening tool was assessed. We determined what proportion of patients could have been sent home from triage using this tool. RESULTS: Of the 1739 patients screened, 61 had CTs performed due to head injury (six abnormal) with a CT rate of 3.5% and 2% re-presentations. Of the entire cohort, 1052 screened negative. 1 CT occurred in this group showing no abnormalities. Of those screened negative, 349 (33%)/1052 had 'no other injuries' and 543 (52%)/1052 had 'abrasions or lacerations'. HIDATq's negative predictive value for CT was 99.9% (95% CI 99.4% to 99.9%) and 100% (95% CI 99.0% to 100%) for intracranial injury. The positive predictive value of the tool was low. Five patients screened negative and re-presented within 72 hours but did not require CT imaging. CONCLUSION: A negative HIDATq appears safe in our ED. Potentially 20% (349/1739) of all patients with head injuries presenting to our department could be discharged by nurses at triage with adequate safety netting advice. This increases to 50% (543/1739), if patients with lacerations or abrasions were given advice and discharged at triage. A large multicentre study is required to validate the tool.

Predicting the Burden of Revision Knee Arthroplasty: Simulation of a 20-Year Horizon.

OBJECTIVES: To estimate future utilization scenarios for knee arthroplasty (KA) revision in the Spanish National Health System in the short- and long-term and their impact on primary KA utilization. METHODS: A discrete-event simulation model was built to represent KA utilization for 20 years (2012-2031) in the Spanish National Health System. Data on KA utilization from 1997 to 2011 were obtained from the minimum data set. Three scenarios of future utilization of primary KA (1, fixed number since 2011; 2, fixed age- and sex-adjusted rates since 2011; and 3, projection using a linear regression model) were combined with two prosthesis survival functions (W [worse survival], from a study including primary KA from 1995 to 2000; and B [better survival], from the Catalan Registry of Arthroplasty, including primary KA from 2005 to 2013). The simulation results were analyzed in the short-term (2015) and the long-term (2030). RESULTS: Variations in the number of revisions depended on both the primary utilization rate and the survival function applied, ranging from increases of 8.3% to 31.6% in the short- term and from 38.3% to 176.9% in the long-term, corresponding to scenarios 1-B and 3-W, respectively. The prediction of increases in overall surgeries ranged from 0.1% to 22.3% in the short-term and from 3.7% to 98.2% in the long-term. CONCLUSIONS: Projections of the burden of KA provide a quantitative basis for future policy decisions on the concentration of high-complexity procedures, the number of orthopedic surgeons required to perform these procedures, and the resources needed.

Cost-Effectiveness and Burden of Disease for Adjuvanted Quadrivalent Influenza Vaccines Compared to High-Dose Quadrivalent Influenza Vaccines in Elderly Patients in Spain.

Influenza is a contagious respiratory disease that causes severe illness and death, particularly in elderly populations. Two enhanced formulations of quadrivalent influenza vaccine (QIV) are available in Spain. Adjuvanted QIV (aQIV) is available for those aged 65+ and high-dose QIV (HD-QIV) for those aged 60+. In this study, we used a health economic model to assess the costs and outcomes associated with using aQIV or HD-QIV in subjects aged 65+. Using aQIV instead of HD-QIV to vaccinate an estimated 5,126,343 elderly people results in reductions of 5405 symptomatic cases, 760 primary care visits, 171 emergency room visits, 442 hospitalizations, and 26 deaths in Spain each year. Life-years (LYs) and quality-adjusted LYs (QALYs) increases by 260 and 206, respectively, each year. Savings from a direct medical payer perspective are EUR 63.6 million, driven by the lower aQIV vaccine price and a minor advantage in effectiveness. From a societal perspective, savings increase to EUR 64.2 million. Results are supported by scenario and sensitivity analyses. When vaccine prices are assumed equal, aQIV remains dominant compared to HD-QIV. Potential savings are estimated at over EUR 61 million in vaccine costs alone. Therefore, aQIV provides a highly cost-effective alternative to HD-QIV for people aged 65+ in Spain.

Exploring emergency department 4-hour target performance and cancelled elective operations: a regression analysis of routinely collected and openly reported NHS trust data.

OBJECTIVE: To quantify the effect of intrahospital patient flow on emergency department (ED) performance targets and indicate if the expectations set by the National Health Service (NHS) England 5-year forward review are realistic in returning emergency services to previous performance levels. DESIGN: Linear regression analysis of routinely reported trust activity and performance data using a series of cross-sectional studies. SETTING: NHS trusts in England submitting routine nationally reported measures to NHS England. PARTICIPANTS: 142 acute non-specialist trusts operating in England between 2012 and 2016. MAIN OUTCOME MEASURES: The primary outcome measures were proportion of 4-hour waiting time breaches and cancelled elective operations. METHODS: Univariate and multivariate linear regression models were used to show relationships between the outcome measures and various measures of trust activity including empty day beds, empty night beds, day bed to night bed ratio, ED conversion ratio and delayed transfers of care. RESULTS: Univariate regression results using the outcome of 4-hour breaches showed clear relationships with empty night beds and ED conversion ratio between 2012 and 2016. The day bed to night bed ratio showed an increasing ability to explain variation in performance between 2015 and 2016. Delayed transfers of care showed little evidence of an association. Multivariate model results indicated that the ability of patient flow variables to explain 4-hour target performance had reduced between 2012 and 2016 (19% to 12%), and had increased in explaining cancelled elective operations (7% to 17%). CONCLUSIONS: The flow of patients through trusts is shown to influence ED performance; however, performance has become less explainable by intratrust patient flow between 2012 and 2016. Some commonly stated explanatory factors such as delayed transfers of care showed limited evidence of being related. The results indicate some of the measures proposed by NHS England to reduce pressure on EDs may not have the desired impact on returning services to previous performance levels.