Necrotising fasciitis, invasive Group A Streptococcus (iGAS) infection; a case series of 8 patients requiring surgical debridement in one trauma unit within 9 months.

Necrotising fasciitis (NF) is a rare but life-threatening skin and soft tissue infection. It requires urgent surgical debridement. The most common cause of monomicrobial NF is invasive Group A Streptococcus (IGAS). We present eight patients who were all treated in a single trauma unit within a 9-month period. All cases required surgical debridement and had positive microbiology testing for IGAS. The eight patients did not present typically for NF, nor did they all have typical risk factors for the development of NF. The in-hospital mortality rate was 37.5%. This series represents an epidemiological spike of IGAS infections causing NF. The findings from this series could inform future practice if similar spikes were to be encountered.

The accuracy of existing prehospital triage tools for injured children in England: an analysis using emergency department data.

OBJECTIVE: To investigate the performance characteristics in children with moderate and minor injuries of prehospital paediatric triage tools currently in use in England for identifying seriously injured children. METHODS: Eight prehospital paediatric triage tools were identified from literature review and a survey of the lead trauma clinicians across the 10 English strategic health authorities. Retrospective clinical data from 2934 patient records collected by four emergency departments were used to analyse each tool. A target sensitivity of >95% and specificity of 50-75% was set based on the literature. RESULTS: Three tools (East Midlands, North West and Northern) demonstrated acceptable sensitivity (all 100%). The other five tools fell below the target sensitivity of >95%. All eight tools had acceptable specificity (with results between 79% and 99%). CONCLUSIONS: Three tools (East Midlands, North West and Northern) demonstrated acceptable over- and under-triage rates in this population of minor and moderately injured children. All tools reached recommended standards for over-triage, but the majority favoured under-triage.

Educating future leaders in patient safety.

Education of health care professionals has given little attention to patient safety, resulting in limited understanding of the nature of risk in health care and the importance of strengthening systems. The World Health Organization developed the Patient Safety Curriculum Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into higher educational curricula. The World Health Organization Curriculum Guide uses a health system-focused, team-dependent approach, which impacts all health care professionals and students learning in an integrated way about how to operate within a culture of safety. The guide is pertinent in the context of global educational reforms and growing recognition of the need to introduce patient safety into health care professionals' curricula. The guide helps to advance patient safety education worldwide in five ways. First, it addresses the variety of opportunities and contexts in which health care educators teach, and provides practical recommendations to learning. Second, it recommends shared learning by students of different professions, thus enhancing student capacity to work together effectively in multidisciplinary teams. Third, it provides guidance on a range of teaching methods and pedagogical activities to ensure that students understand that patient safety is a practical science teaching them to act in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and learning, emphasizing the need to establishing teaching environments in which students feel comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient safety topics across all areas of clinical practice.

The accuracy of existing prehospital triage tools for injured children in England--an analysis using trauma registry data.

OBJECTIVES: To investigate the performance characteristics of prehospital paediatric triage tools for identifying seriously injured children in England. DESIGN: Eight prehospital paediatric triage tools were identified by literature review and by survey of the Lead Trauma Clinicians across English Strategic Health Authorities. Retrospective clinical registry data from the Trauma Audit and Research Network were used to determine the performance characteristics of each tool, using 'gold standards' for under- and over-triage of <5% and <25-50%, respectively, as benchmarks for performance. PARTICIPANTS: 701 patient records were included. Inclusion criteria were all injured patients aged <16 years admitted to a receiving unit direct from the scene of accident in the period 2007-2010, for whom all key discriminator fields were recorded in the Trauma Audit and Research Network database. OUTCOME MEASURES: The main outcome measure was how each tool functioned with regard to their under- and over-triaging features. Other performance characteristics, for example, predictive values and likelihood ratios were also calculated. RESULTS: Two (of eight) triage tools demonstrated acceptable under-triage rates (3% and 4%) but had unacceptably high over-triage rates (83% and 72%). Two tools demonstrated acceptable over-triage rates (7% and 16%), but with unacceptably high under-triage rates (61% and 63%). Four tools had unacceptably high under- and over-triage rates. CONCLUSIONS: None of the prehospital triage tools currently used or being developed in England meet recommended criteria for over- and under-triage rates. There is an urgent need for the development of triage tools to accurately risk-stratify injured children in the prehospital setting.

Digital calcinosis circumscripta: case series and review of the literature.

A series of three paediatric cases of digital calcinosis circumscripta is presented. Digital calcinosis circumscripta is an unusual form of calcinosis circumscripta occurring specifically in the digits. The condition is rare among the paediatric population. The cases serve to clarify the clinical and radiographic features of the condition and to discuss suggested treatment options.

Outcome measures in major trauma care: a review of current international trauma registry practice.

Multiple reports over the past 20 years have criticised the care delivered to major trauma patients in England. The setting up of regional trauma networks is well underway to address these deficiencies. Outcomes currently collected in major trauma are restricted to mortality rates and process measures; however, many patients are left with long-term disabilities and reduced quality of life (QoL), which are not measured at present. Trauma systems need to develop outcome measures that capture this important information to judge the quality of care and influence the development of services. This review aimed to identify the current practice of international trauma registries with regard to outcome measurement and review the literature surrounding these measures. An internet-based search of international trauma registry websites including data dictionaries and annual reports was carried out as well as a literature review to determine what outcome measures are routinely collected by trauma registries. All registries were found to look at mortality and process measures, but only one registry routinely collected morbidity outcome measures for both adults and children. There is a considerable amount of disability and reduced QoL in survivors of major trauma that lasts for years following the injury. At present only the Victorian State Trauma Registry collects outcome measures that evaluate the extent of this. English regional trauma networks and the Trauma Audit and Research Network have the opportunity to learn from this experience and routinely start to collect measures of outcome that can drive service improvement and reduce patient morbidity.

Experimental study of forearm compartmental pressures.

PURPOSE: Chronic compartment syndrome is well recognized, although it is rare in the forearm. Diagnosis is based on history, clinical examination, and compartment pressure readings. Existing normal pressure ranges for the forearm are based on lower limb measurements. This study aimed to establish normal pre- and post-exercise forearm compartment pressures. METHODS: Using a Stryker intracompartmental pressure monitor (Stryker, Kalamazoo, MI), 41 volunteers had pressure measurements of the extensor and flexor forearm compartments before and after exercise. RESULTS: Normal ranges were established for pre-exercise extensor compartment (2-27 mm Hg; upper confidence interval [CI] 18.8-25.2 mm Hg), post-exercise extensor compartment (2-24 mm Hg; upper CI 16.8-22.8 mm Hg), pre-exercise flexor compartment (1-19 mm Hg; upper CI 13.3-17.4 mm Hg), and post-exercise flexor compartment (0-19 mm Hg; upper CI 16-21.4 mm Hg) pressures. No significant difference was found between pressures before and after exercise. There was no correlation between whether pressures increased or decreased following exercise. There was a significant gender difference. Normal ranges were 0 to 25.2 mm Hg for the extensor compartment and 0 to 21.4 mm Hg for the flexor compartment. CONCLUSIONS: This study has shown a significant difference in normal forearm compartment pressures between genders. A normal reference range of flexor and extensor forearm compartment pressures to aid diagnosis of chronic compartment syndrome has been determined. This might also prove useful in aiding the diagnosis of acute forearm compartment syndrome.

Specialised chronic compartment measurement clinic in a district general hospital: is it worthwhile?

INTRODUCTION: Chronic compartment syndrome is one of the conditions that cause exertional pain in the young. In this condition, a careful history taking is usually the key for making the correct diagnosis, but intracompartmental pressure measurement that has high sensitivity and specificity rates can add invaluable confirmation, especially when surgical decompression is indicated. In a district general hospital there is usually a logistical problem in performing compartmental pressure measurement. In this study, we describe our experience in dealing with such a problem by setting up a quarterly specialised clinic for intracompartmental pressure measurement that, according to our knowledge, is unique in the UK. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 42 patients referred to our specialised clinic and documented the referral patterns, clinical picture, additional investigations, pressure measurement results, final diagnosis and outcome of treatment. The intracompartmental measurement was recorded pre- and post-exercise on the treadmill for 1 min or 5 min and results were interpreted according to published criteria. RESULTS: The mean age of the referred 42 patients was 33.1 years (range, 15-78 years). There were 16 positive results (38%) confirming the diagnosis of chronic compartment syndrome and four clinically characteristic cases of this condition with negative results. There were 22 negative results (53%), one borderline, and three patients were not tested for different reasons. All of the 10 patients who were treated surgically had positive pre-operative test results. CONCLUSIONS: An inappropriate referral rate of approximately 52% was encountered that had a significant impact on the waiting time for the proposed test (5.7 months), which is far longer than the 18-week target for treatment in the NHS. We found that a positive test is a strong predictor of a successful outcome of surgical treatment. Such a specialised clinic, therefore, should only receive carefully assessed patients.