A new situation awareness model decreases clinical deterioration in the emergency departments-A controlled intervention study.

BACKGROUND: Studies have suggested that adding subjective parameters to early warning score (EWS) systems might prompt more proactive treatment and positively affect clinical outcomes. Hence, the study aimed to investigate effect of a situation awareness model consisting of objective and subjective parameters on clinical deterioration in adult emergency department (ED) patients. METHODS: This controlled pre-and-post interventional study was carried out in July-December 2016 and November 2017-April 2018. In ED patients ≥ 18 years, we examined if a situation awareness model compared with a conventional EWS system could reduce clinical deterioration. The new model consisted of a regional EWS, combined with skin observation, clinical concern and patients' and relatives' concerns, pain, dyspnea, and team risk assessment. Clinical deterioration was defined as change in vital signs requiring increased observation or physician assessment, that is, increase in early warning score from either 0 or 1 to score ≥2 or an increase from score ≥2 and above. Secondary outcomes were mortality, intensive care unit (ICU) admissions, and readmissions. RESULTS: We included 34 556 patients. Patients with two or more registered EWS were included in the primary analysis (N = 21 839). Using difference-in-difference regression, we found a reduced odds of clinical deterioration of 21% (OR 0.79 95% CI [0.69; 0.90]) in the intervention groups compared with controls. No impact on mortality, ICU, or readmissions was found. CONCLUSION: The situation awareness model reduces odds of clinical deterioration, defined as a clinically relevant increase in EWS, in an unselected adult population of ED patients. However, there was no effect on secondary outcomes.

Multiple somatic symptoms in primary care patients: a cross-sectional study of consultation content, clinical management strategy and burden of encounter.

BACKGROUND: Consultations involving patients with multiple somatic symptoms may be considered as challenging and time-consuming by general practitioners (GPs). Yet, little is known about the possible links between consultation characteristics and GP-experienced burden of encounter. We aimed to explore consultation content, clinical management strategies, time consumption and GP-experienced burden of encounters with patients suffering from multiple somatic symptoms as defined by the concept of bodily distress syndrome (BDS). METHODS: Cross-sectional study of patient encounters in primary care from December 2008 to December 2009; 387 GPs participated (response rate: 44.4 %). Data were based on a one-page registration form completed by the GP and a patient questionnaire including the 25-item BDS checklist for somatic symptoms. Using logistic regression analyses, we compared patients who met the BDS criteria with patients who did not. RESULTS: A total of 1505 patients were included (response rate: 55.6 %). Health problems were less frequently reported as 'new' in patients with BDS (odds ratio (OR) = 0.73, 95 % confidence interval (CI): 0.54; 0.97). Medical prescriptions and referral rates were comparable in the two patient groups. Consultations focusing on mainly biomedical aspects were less frequent among patients with BDS (OR = 0.31, 95 % CI: 0.22; 0.43), whereas additional biomedical and psychosocial problems were more often discussed. GPs were more likely to ensure continuity of care in BDS patients by watchful waiting strategies (OR = 2.32, 95 % CI: 1.53; 3.52) or scheduled follow-up visits (OR = 1.61, 95 % CI: 1.09; 2.37). Patients with BDS were found to be more time-consuming (OR = 1.77, 95 % CI: 1.26; 2.48) and burdensome (OR = 2.54, 95 % CI: 1.81; 3.55) than patients without BDS. However, after adjustments for biomedical and psychosocial content of the consultation, the identified differences for time consumption and burden were no longer statistically significant. CONCLUSIONS: Patients with BDS represent higher care complexity in terms of biomedical and psychosocial needs. GPs seem to allow space and time for discussing these issues and to aim at ensuring continuity in care through watchful waiting or scheduled follow-up consultations. However, the reported GP-experienced burden call for professional development.

Sick leave and work disability in primary care patients with recent-onset multiple medically unexplained symptoms and persistent somatoform disorders: a 10-year follow-up of the FIP study.

OBJECTIVE: The objective was to explore patient characteristics and 10-year outcome of sick leave and work disability for patients with recent-onset multiple medically unexplained symptoms (MUS) and persistent somatoform disorders (SD). METHOD: Consecutive patients consulting their family physician (FP) completed a preconsultation questionnaire on symptoms and mental illness (n=1785). The main problem was categorized by the FP after the consultation, and a stratified subsample was examined using a standardized diagnostic interview (n=701). Patients were grouped into three cohorts: recent onset of multiple MUS (n=84); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, persistent SD (n=183); and reference group with well-defined physical disease according to FP (n=833). Register data on sick leave and disability pension were obtained. RESULTS: At index consultation, disability pension was received by 8.3% (n=7) in the recent-onset multiple MUS group, 19.1% (n=35) in the SD group and 3.5% (n=29) in the reference group. Both the recent-onset multiple MUS group [hazard ratio (HR)=2.28, 95% confidence interval (CI): 1.14-4.55] and the SD group (HR=3.26, 95% CI:1.93-5.51) had increased risk of new disability pension awards. Furthermore, the SD group had increased risk of sick leave. CONCLUSIONS: Both recent-onset and persistent MUS have significant long-term impact on patient functioning in regard to working life; this calls for early recognition and adequate management of MUS in primary care.

Towards a clinically useful diagnosis for mild-to-moderate conditions of medically unexplained symptoms in general practice: a mixed methods study.

BACKGROUND: Symptoms that cannot be attributed to any known conventionally defined disease are highly prevalent in general practice. Yet, only severe cases are captured by the current diagnostic classifications of medically unexplained symptoms (MUS). This study explores the clinical usefulness of a proposed new diagnostic category for mild-to-moderate conditions of MUS labelled 'multiple symptoms'. METHODS: A mixed methods approach was used. For two weeks, 20 general practitioners (GPs) classified symptoms presented in consecutive consultations according to the International Classification of Primary Care (ICPC) supplemented with the new diagnostic category 'multiple symptoms'. The GPs' experiences were subsequently explored by focus group interviews. Interview data were analysed according to ethnographic principles. RESULTS: In 33% of patients, GPs classified symptoms as medically unexplained, but applied the category of 'multiple symptoms' only in 2.8%. The category was described as a useful tool for promoting communication and creating better awareness of patients with MUS; as such, the category was perceived to reduce the risk of unnecessary tests and referrals of these patients. Three main themes were found to affect the clinical usefulness of the diagnostic category of 'multiple symptoms': 1) lack of consensus on categorisation practices, 2) high complexity of patient cases and 3) relational continuity (i.e. continuity in the doctor-patient relationship over time). The first two were seen as barriers to usefulness, the latter as a prerequisite for application. The GPs' diagnostic classifications were found to be informed by the GPs' subjective pre-formed concepts of patients with MUS, which reflected more severe conditions than actually intended by the new category of 'multiple symptoms'. CONCLUSIONS: The study demonstrated possible clinical benefits of the category of 'multiple symptoms', such as GPs' increased awareness and informational continuity in partnership practices. The use of the category was challenged by the GPs' conceptual understanding of MUS and was applied only to a minority of patients. The study demonstrates a need for addressing these issues if sub-threshold categories for MUS are to be applied in routine care. The category of 'multiple symptoms' may profitably be used in the future as a risk indicator rather than a diagnostic category.