Custody early warning scores; Do they predict patient deterioration in police custody?

This paper analyses the results of a three month trial based in a police custody suite, where we assigned a value; using the recently developed Custody Early Warning Score, to detainees arriving into police custody, as part of their 'booking in' process. We then compared this to the more established National Early Warning Scoring system and then looked at the predictive accuracy of these two systems and how they correlated to one another, when applied to three different clinical groups of detainees in police custody. Police Custody Sergeants and Custody Detention Officers continue to experience difficulties in identifying those detainees with health care needs; be they subtle, emerging or more evident. The introduction of a 'track and trigger' physiological scoring system has been seen to reduce morbidity in health care settings and so the adoption of an altered custodial version of such a system is an effort by some police forces to do likewise. Recent innovations in police custody have focussed on identifying and appropriately referring those detainees with mental health needs. There is a lack of research that examines the physical health needs of the custodial population and the risks that they might present. With detainee deaths and serious adverse events continuing to occur in police custody, forces are looking at ways to identify risk early on in the custodial process, to reduce such high profile occurrences. Police use of the Custody Early Warning Score system, is one effort to try and identify and reduce this risk, early on in the custodial process. OBJECTIVE: In an increasing number of police custody suites, the Custody Early Warning Score system has been, added to the normal, standardised police risk assessment process. This 'track & trigger' system has been adapted to the custody environment and is conducted by non-medical detention staff upon detainee arrival, in order to identify detainee morbidity and mortality risk. We wanted to test the predictive accuracy of this system at identifying detainee health need and prioritisation. We also wanted to know how well this tool correlated to another well-established monitoring tool and how accurate these two systems are at pre-empting the medical emergencies and hospital referrals that occur in police custody. RESULTS: 1'163 detainees were assessed by medical staff over a three month period, with staff blinded to the assigned scoring. 276 of these were identified as requiring further clinical assessment following this scoring with 29 of the 33 patients referred to hospital by medical staff, also scored, with some declining assessment or were serious enough to abandon scoring. Whilst we found a small correlation between increased scores and referral to hospital; we found that there was little correlation between assessment scores in general and the need for referral to hospital. We also found that most clinical risk was associated with lower or low scores. CONCLUSIONS: The scoring systems that we assessed were not sensitive enough to identify health need in the detainee population, due to frequent, altered physiological parameters. Life threatening conditions have low assessment scores, not reflective of the seriousness of medical conditions, nor the potential for rapid deterioration. Such scoring systems add little to the risk assessment process, with low scores allowing for complacency and a false reassurance, when using a system designed for very different circumstances.

Negative pressure wound therapy aids recovery following surgical debridement due to severe bacterial cellulitis with abdominal abscess post-cesarean: A case report (CARE-Compliant).

INTRODUCTION: Bacterial cellulitis post-Cesarean section is rare. Negative pressure wound therapy (NPWT) is widely used in various medical specialities; its effectiveness in obstetrics however remains the topic of debate-used predominantly as an adjunct to secondary intention specific to high-risk patient groups. Its application in the treatment of actively infected wounds post-Cesarean is not well documented. Here, we document NPWT in the treatment of an unusually severe case of bacterial cellulitis with abdominal abscess postpartum. We provide a unique photographic timeline of wound progression following major surgical debridement, documenting the effectiveness of 2 different NPWT systems (RENASYS GO and PICO, Smith & Nephew). We report problems encountered using these NPWT systems and "ad-hoc" solutions to improve efficacy and patient experience.A 34-year-old primiparous Caucasian female with no prior history or risk factors for infection and a normal body mass index (BMI) presented with severe abdominal pain, swelling, and extensive abdominal redness 7 days postemergency Cesarean section. Examination revealed extensive cellulitis with associated abdominal abscess. Staphylococcus aureus was identified in wound exudates and extensive surgical debridement undertaken day 11 postnatally due to continued febrile episodes and clinical deterioration, despite aggressive intravenous antibiotic therapy. Occlusive NPWT dressings were applied for a period of 3 weeks before discharge, as well as a further 5 weeks postdischarge into the community.NPWT was well tolerated and efficacious in infection clearance and wound healing during bacterial cellulitis. Wound healing averaged 1 cm per week before NPWT withdrawal; cessation of NPWT before full wound closure resulted in significantly reduced healing rate, increased purulent discharges, and skin irritation, highlighting the efficacy of NPWT. Five-month follow-up in the clinic found the wound to be fully healed with no additional scarring beyond the boundaries of the original Cesarean incision. The patient was pleased with treatment outcomes, reporting no lasting pain or discomfort from the scar. CONCLUSIONS: This report represents the first documented use of NPWT to aid healing of an actively infected, open wound following extensive surgical debridement 10 days post-Cesarean section, confirming both the efficacy and tolerability of NPWT for the treatment of severe bacterial cellulitis in obstetric debridement.

A national study of paramedic and nursing students' readiness for interprofessional learning (IPL): Results from nine universities.

BACKGROUND: The development of successful and functional interprofessional practice is best achieved through interprofessional learning (IPL). Given that many paramedic programmes still take an isolative uni-professional educational approach to their undergraduate courses, it is unclear on their preparedness for students' IPL. Therefore, the objective of this study was to assess the attitudes of undergraduate paramedic and nursing/paramedic students from nine Australian universities towards IPL over a two year period. METHODS: Using a convenience sample of paramedic and nursing/paramedic students-attitudes towards IPL was measured using the Readiness for Interprofessional Learning Scale (RIPLS) 5-point Likert-scale (1=strongly disagree and 5=strongly agree). RESULTS: A total of 1264 students participated (n=303 in 2011 and n=961 in 2012) in this study, consistent with a 43% response rate. Surveyed students were predominantly first year n=506 (40.03%), female n=748 (59.2%) and undertaking single paramedic degrees n=948 (75.0%). Nursing/paramedic students demonstrated significantly lower Negative Professional Identity (M=6.26, p=0.004) and Roles and Responsibilities means (M=6.87, p<0.0001) and higher Positive Professional Identity means (M=15.68, p=0.011) compared with paramedic students. CONCLUSIONS: The impact of nursing/paramedic education was shown to significantly enhance student attitudes towards interprofessionalism and the individual universities involved in this study generated students at varying stages of IPL preparedness. Students' year level appeared to influence IPL readiness, yet there are compelling paradoxical arguments for both earlier and later inclusion of IPL within curricula.

Examining the measurement properties of the Interdisciplinary Education Perception Scale (IEPS) in paramedic education.

BACKGROUND: Healthcare systems are continuing searching for alternative service delivery models while at the same time also promoting interprofessional practice and cooperation among workers. One scale that aims to measure interprofessional cooperation is the Interdisciplinary Education Perception Scale (IEPS), although limited psychometric testing on its validity and reliability has been carried out. Therefore the aim of this study was to investigate the dimensionality and internal consistency of the IEPS (suggested by McFadyen and colleagues) when completed by a group of paramedic undergraduates. METHODS: Data from the IEPS were analysed with a factor analysis using a Principal Axis Factoring (PAF) with Oblique Oblimin rotation. RESULTS: A total of (n=303) undergraduate paramedic students participated in the study who reported having positive attitudes towards interprofessional cooperation. Factor analysis of the 12-items revealed two factors with eigenvalues above 1, accounting for 53.85% of the total variance. Items with loadings greater than ±.30, with the factor in question were used to describe the two factors: Cooperation and Teamwork, and Positivity. CONCLUSION: While data from this study produced a multi-dimensional scale with adequate eigenvalues and communalities, improvements to the scales internal consistency can be made with future data sets. The results from the IEPS suggest that undergraduate paramedics have positive regard towards interprofessional cooperation.

The Medical Condition Regard Scale (MCRS): an examination of its factor structure using paramedic students.

BACKGROUND: Understanding students' attitudes towards certain medical conditions and diagnoses is an important part of the foundational education that students receive prior to their progression into the health care workforce. Therefore having instruments such as the Medical Condition Regard Scale (MCRS) with strong measurement properties is important for health care professions. OBJECTIVES: The objective of this paper was to examine the factor structure of the MCRS when completed by a group of undergraduate paramedic and paramedic/nursing students. METHODS: Data from the MCRS completed by 783 paramedic students were analysed using exploratory factor analysis (EFA) followed by a maximum likelihood confirmatory factor analysis (CFA) to test goodness-of-fit to the sample data. RESULTS: Two factors emerged from the EFA labelled Positive Regard and Negative Regard that accounted for 52.67% of the total variance. The 10-item 2-factor model produced good model-fit and good reliability estimates. One MCRS item was discarded since it loaded on a single factor and was not considered to be viable as a stand-alone subscale. CONCLUSIONS: Findings from the CFA suggest that the new 10-item version of the MCRS is a valid and reliable measure for determining undergraduate paramedic students' regard for medical conditions. The new 2-factor model appears to be defined by Positive Regard and Negative Regard factors.

Student attitudes toward a web-based interprofessional education package.

UNLABELLED: The objective of this study was to examine undergraduate health science students' attitudes toward interprofessional learning using a web-based interprofessional education package. METHODS: A before and after study of student attitudes toward a web-based interprofessional education package was conducted using the 17-item Readiness for Interprofessional Learning Scale (RIPLS). Students completed the RIPLS before and after the educational package. RESULTS: Forty-six students commenced the study with 2 students failing to complete. The group contained mostly females with a mean age of 22.6 yrs. A statistically significant change was found for RIPLS subscale one, "shared learning," p=0.035. CONCLUSIONS: This study demonstrated that a web-based interprofessional education package did appear to have an impact on undergraduate students' attitudes toward interprofessional learning.

A cross-sectional study of paramedics' readiness for interprofessional learning and cooperation: results from five universities.

INTRODUCTION: Healthcare systems are evolving to feature the promotion of interprofessional practice more prominently. The development of successful and functional interprofessional practice is best achieved through interprofessional learning. Given that most paramedic programmes take an isolative uni-professional educational approach to their healthcare undergraduate courses, serious questions must be raised as to whether students are being adequately prepared for the interprofessional healthcare workplace. The objective of this study was to assess the attitudes of paramedic students towards interprofessional learning across five Australian universities. METHODS: Using a convenience sample of paramedic student attitudes towards interprofessional learning and cooperation were measured using two standardised self-reporting instruments: Readiness for Interprofessional Learning Scale (RIPLS) and Interdisciplinary Education Perception Scale (IEPS). RESULTS: Students' readiness for interprofessional learning did not appear to be significantly influenced by their gender nor the type of paramedic degree they were undertaking. As students progressed through their degrees their appreciation for collaborative teamwork and their understanding of paramedic identity grew, however this appeared to negatively affect their willingness to engage in interprofessional learning with other healthcare students. The tertiary institute attended also appeared to influence students' preparedness and attitudes to shared learning. CONCLUSIONS: This study has found no compelling evidence that students' readiness for interprofessional learning is significantly affected by either their gender or the type of degree undertaken. By contrast it was seen that the tertiary institutions involved in this study produced students at different levels of preparedness for IPL and cooperation.

One model of healthcare provision lessons learnt through clinical governance.

AIM: Clinical Governance describes a systematic approach to maintaining and improving the quality of patient care. Risk management includes a themes analysis of clinical incidents and positive interventions with the resulting information disseminated to staff through personal performance plans, and publication and development training workshops. Our model of healthcare provision utilises doctors, nurses and paramedics to assess individuals in custody and this paper discusses the implementation of clinical risk management within this setting. METHOD: A description of the model of healthcare provision, together with a themes analysis was undertaken for all clinical incidents received by the clinical team. Each incident receives an individual response and is discussed within the clinical risk management committee. From the review of each event, learning outcomes are identified and the information captured on a database. The information is analysed for reoccurring themes and further measures are introduced to ensure a high standard of healthcare provision to all counties. FINDINGS: Of the 86,184 patient/detainee episodes from 11 county forces, from January 2009-December 2009, 159 clinical incidents and positive interventions were generated. These were categorised into Clinical Near Misses--39, Prescribing issues--38, Health and Safety matters--13, Organisational matters--23, Positive Interventions--21 and Professional issues--25. CONCLUSION: Risk management, with a regular review of clinical incidents is an essential part of clinical governance especially when working in a multidisciplinary team providing safe and effective custody healthcare. This analysis contributes to the knowledge base in clinical forensic medicine and supports the importance of identifying educational requirements for staff, working in a multiagency partnership and continuous monitoring of the quality of care for detainees.