Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Guest Editorial - Shifting Dynamics: ICU Admissions in Denmark during the First Wave of the COVID-19 Pandemic.

The advent of the SARS-CoV-2 pandemic brought unprecedented challenges to healthcare systems worldwide. As the virus spread across continents, hospitals faced a surge in patient admissions, particularly to intensive care units (ICUs). Understanding the impact of the pandemic on the sickest patients admitted to hospital is crucial for enhancing preparedness for future outbreaks. In this edition of the journal, authors from Denmark report on a register-based national observational study that sheds light on the changes in ICU admission rates and demographic profiles of patients during the initial phase of the pandemic.

Impact of assessment frequency of patient-reported outcomes: an observational study using an eHealth platform in cancer patients.

BACKGROUND AND AIM: The evaluation of patient-reported outcomes (PRO) in cancer has proven relevant positive clinical impact on patients' communication with healthcare professionals, decision-making for management, well-being, and overall survival. However, the optimal frequency of PRO assessment has yet to be defined. Based on the assumption that more frequent sampling would enhance accuracy, we aimed at identifying the optimal sampling frequency that does not miss clinically relevant insight. METHODS: We used pilot data from 31 advanced cancer patients who completed once daily the 19-item MD Anderson Symptom Inventory at home. The resulting dataset allowed us to compare different PRO assessment frequencies to daily sampling, i.e., alternate days (q2d), every third day (q3d), or once a week (q1w). We evaluated the sampling frequencies for two main outcomes: average symptom intensity and identification of severe symptoms. RESULTS: The majority of the differences between corresponding averages of daily data and those for q2d, q3d, and q1w datasets were close to 0, yet the extremes exceeded 5. Clinically meaningful differences, i.e., > 1, were observed in 0.76% of patient items for q2d, in 2.72% for q3d, and in 11.93% for q1w. Moreover, median values of missed instances of a severe symptom (i.e., > 6) were 14.6% for q2d, 27.8% for q3d, and 55.6% for q1w. CONCLUSIONS: Our analysis suggests that in patients receiving chemotherapy for advanced cancer, increasing the density of PRO collection enhances the accuracy of PRO assessment to a clinically meaningful extent. This is valid for both computations of averages symptom burden and for the recognition of episodes of severe symptom intensity.

Express check-in: developing a personal health record for patients admitted to hospital with medical emergencies: a mixed-method feasibility study.

BACKGROUND: Patient participation is increasingly recognized as a key component in the redesign of healthcare processes and is advocated as a means to improve patient safety. OBJECTIVE: To explore the usage of participatory engagement in patient-created and co-designed medical records for emergency admission to the hospital. METHODS: design: prospective iterative development and feasibility testing of personal health records; setting: an acute medical unit in a university-affiliated hospital; participants: patients admitted to hospital for medical emergencies; interventions: we used a design-led development of personal health record prototypes and feasibility testing of records completed by patients during the process of emergency admission. 'Express-check-in' records contained items of social history, screening questions for sepsis and acute kidney injury in addition to the patients' ideas, concerns and expectations; main outcome measures: the outcome metrics focused on feasibility and a selection of quality domains, namely effectiveness of recording relevant history, time efficiency of the documentation process, patient-centredness of resulting records and staff and patient feedback. The incidence of sepsis and acute kidney injury were used as surrogate measures for assessing the safety impact. RESULTS: The medical record prototypes were developed in an iterative fashion and tested with 100 patients, in which 39 patients were 70 or older and 25 patients were classified as clinically frail. Ninety-six per cent of the data items were completed by patients with no or minimal help from healthcare professionals. The completeness of these patient records was superior to that of the corresponding medical records in that they contained deeply held beliefs and fears, whereas concerns and expectations recorded by patients were only mirrored in a small proportion of the formal clinical records. The sepsis self-screening tool identified 68% of patients requiring treatment with antibiotics. The intervention was feasible, independent of the level of formal education and effective in frail and elderly patients with support from family and staff. The prototyped records were well received and felt to be practical by patients and staff. The staff indicated that reading the patients' documentation led to significant changes in their clinical management. CONCLUSIONS: Medical record accessibility to patients during hospital care contributes to the co-management of personal healthcare and might add critical information over and above the records compiled by healthcare professionals.

Do mHealth applications improve clinical outcomes of patients with cancer? A critical appraisal of the peer-reviewed literature.

PURPOSE: Patients undergoing systemic anti-cancer treatment experience distressing side effects, and these symptoms are often experienced outside the hospital setting. The impact of usage of cancer-related mobile health (mHealth) applications on patient-related outcomes requires investigation. METHODS: A critical appraisal of the literature was performed for the following question: 'In patients with cancer have mHealth applications been compared with usual care to examine impact on commonly used clinical outcomes'. Literature searches were undertaken with the help of a research librarian and included Medline, Cochrane Collaboration, clinical trial databases and grey searches. RESULTS: Seventeen studies including between 12 and 2352 patients were identified and reviewed. Smartphone applications or internet portals collected data on symptoms or patient activity. Several studies showed statistically significant differences in patient-reported outcomes when symptom monitoring using mobile health application was compared to usual care. Change in mobility was the only outcome that was related directly to toxicity. Only limited data on mortality, cancer-related morbidity including complications of care, health-economic outcomes or long-term outcomes were reported. CONCLUSIONS: Studies on mHealth applications might improve aspects of symptom control in patients with cancer, but there is currently little evidence for impact on other outcomes. This requires future research in interventional studies.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Feasibility and reliability of frailty assessment in the critically ill: a systematic review.

BACKGROUND: For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care. METHODS: Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability. RESULTS: Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and single-centre study. CONCLUSION: Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FI-based assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation. PROSPERO REGISTRATION NUMBER: CRD42016052073 .

Continuous Monitoring of Respiratory Rate in Emergency Admissions: Evaluation of the RespiraSense™ Sensor in Acute Care Compared to the Industry Standard and Gold Standard.

Respiratory Rate (RR) is the best marker to indicate deterioration but measurement are often inaccurate. The RespiraSense™ is a non-invasive, wireless, body worn, motion-tolerant and continuous respiratory rate monitor. We aimed to determine whether the performance of RespiraSense™ was equivalent to that of a gold standard measurement technique of capnography and the industry standard of manual counts. RespiraSense™ measures respiratory rate and transmit signals wirelessly to a tablet device. We measured respiratory rate in 24 emergency admissions to an Acute Medical Unit in the UK. Patients were observed for two hours. Manual counts were undertaken every 15 min and compared to measurements with capnography and RespiraSense™. Data from 17 patients admitted as medical emergencies was evaluated. For measurements obtained at rest a mean RR of 19.3 (SD 4.89) for manual measurements compared to mean RR of 20.2 (SD 4.54) for measurements obtained with capnography and mean RR of 19.8 (SD 4.52) with RespiraSense™. At rest, RespiraSense™ has a bias of 0.38 and limits of agreement of 1.0 to 1.8 bpm, when compared to the capnography derived RR. Measurements were within pre-defined limits of error at rest. Continuous measurement of RR with RespiraSense™ in patients admitted as acute emergencies is both feasible and reliable.

Effect of an automated notification system for deteriorating ward patients on clinical outcomes.

BACKGROUND: Delayed response to clinical deterioration of ward patients is common. METHODS: We performed a prospective before-and-after study in all patients admitted to two clinical ward areas in a district general hospital in the UK. We examined the effect on clinical outcomes of deploying an electronic automated advisory vital signs monitoring and notification system, which relayed abnormal vital signs to a rapid response team (RRT). RESULTS: We studied 2139 patients before (control) and 2263 after the intervention. During the intervention the number of RRT notifications increased from 405 to 524 (p = 0.001) with more notifications triggering fluid therapy, bronchodilators and antibiotics. Moreover, despite an increase in the number of patients with "do not attempt resuscitation" orders (from 99 to 135; p = 0.047), mortality decreased from 173 to 147 (p = 0.042) patients and cardiac arrests decreased from 14 to 2 events (p = 0.002). Finally, the severity of illness in patients admitted to the ICU was reduced (mean Acute Physiology and Chronic Health Evaluation II score: 26 (SD 9) vs. 18 (SD 8)), as was their mortality (from 45% to 24%; p = 0.04). CONCLUSIONS: Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration in ward patients was associated with significant improvements in key patient-centered clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01692847 . Registered on 21 September 2012.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative.

BACKGROUND: 'Failure to rescue' of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology. METHODS: A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use. RESULTS: Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. 'Check In'), a list of prompts regarding common omissions (i.e. 'Stop & Think'), and, a list of items required for the safe "handover" of patients that remain on the general ward (i.e. 'Check Out'). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients. CONCLUSIONS: Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

Role of Psychological Resilience on Health-Outcomes in Hospitalized Patients with Acute Illness: A Scoping Review.

Recovery from Acute Illness is dependent on severity of illness. We aimed to investigate whether resilience as the 'ability to bounce back' might also affect recovery. We conducted a scoping review to identify gaps in the existing literature. We used emergency care, intensive care, critical care and trauma as surrogates for acute illness. We mapped synonyms for resilience and selected 'resilience' and 'robustness'. The search was limited to adult patients admitted to hospitals. We found strong evidence for psychological sequelae of acute illness but no research focusing specifically on the concepts of resilience or robustness and no interventional studies in the acute hospital setting. The concept of resilience might be applicable to unscheduled admissions to hospital. Measurements and potential interventions require further research.

Measuring impact of telephone triage in Acute Medicine.

The Society for Acute Medicine's Benchmarking Audit (SAMBA) was undertaken for the 5th time in June 2016. For the first time, data on telephone triage calls prior to admission to Acute Medical Units were collected: 1238 patients were referred from Emergency Departments, 925 from General Practitioners (GPs), 52 from clinics and 147 from other sources. Calls from Emergency Departments rarely resulted in admission avoidance. Calls from Primary Care resulted in avoidance of an admission in 115 (12%) patients; the percentage of avoided admissions was highest if the call was taken by a Consultant. Consultant triage might result in admission avoidance but the impact of local context on the effectiveness is not clear.

The Team at Work--The Society for Acute Medicine's Benchmarking Audit 2014 (SAMBA'14).

BACKGROUND: The Society for Acute Medicine's Benchmarking Audit (SAMBA) serves as a tool for Acute Medical Units to compare and improve their quality of care. AIM: To audit the performance of Acute Medical Units against clinical quality indicators, standards by the Royal College of Physicians and Specialist Societies relevant to the practice of Acute Medicine. METHODS: An online survey of unit profiles and staffing levels on the audit day was followed by a 24-hour data collection on Thursday the 19th of June 2014 for all patients seen by the local Acute Medicine teams as part of the general medical take. Patients were followed-up for 72 hours. We reviewed the impact of staffing levels on performance indicators. RESULTS: 66 Acute Medical Units admitted 2333 patients during the 24-hour period. Compliance with the quality standards of SAM was as follows: 84% of patients had an early warning score recorded within 30 minutes of admission, 81% of patients had been seen by a competent decision maker within four hours and 73% of patients were seen by a consultant physician within the appropriate period of time. Only 56% of patients received a standard of care compatible with all three quality standards. We found no relation between unit characteristics, staffing and performance indicator. CONCLUSION: There remains a gap between the standard described by the quality indicators and the performance of Acute Medical Units during a one-day audit.

Society for Acute Medicine Benchmarking Audit 2015: The Patient Perspective.

INTRODUCTION: The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual national audit in the UK. METHODS: In SAMBA 2015 patient feedback questionnaires were introduced to help measure the quality of patient experience on Acute Medical Units (AMUs) over a 24-hour period on 25th June 2015. RESULTS: 55 AMUs submitted data on 945 patients, of these 824 (87.2%) would be extremely likely or likely to recommend the AMU. Patients below the age of 50 were less likely to recommend the admitting unit (p<0.013). Positive comments were three times more common than critical comments (976 vs 323). Categories of staff attitude, quality of communication, timeliness of care and catering were dominant themes. CONCLUSION: This survey has identified key themes for patients being managed on an AMU that can be used to guide future innovations.

Blockchain: What is the use case for physicians in 2024? A rapid review of the literature.

Blockchain is topical in many areas of science. The impact on clinical care of physicians is not known. We undertook a rapid review of the literature to identify areas of interest for clinicians in active practice focusing on evidence relevant to clinical care. We found limited evidence for use blockchain in clinical practice with most studies focusing on technical aspects of prototypes and implementation with no evidence of standardised metric to measure impact for patients, clinicians, and organisations. Personal Health Records for use across organisational and geographic boundaries emerged as the strongest clinical use-case. Defined metrics by professional bodies might aid research, development, and future impact.

Wearables in Wales: Entering clinical practice through the backdoor?

The number of people using wearable technology such as smartwatches and fitness trackers is increasing. Many of these devices can alert the user to a potential arrhythmia such as atrial fibrillation. We aimed to assess potential changes to cardiology practice resulting from their use. An online questionnaire consisting of 12 questions was created and distributed to all consultant cardiologists in Wales. 25 of 102 participants replied, with 92% of these using consumer wearable technology to diagnose atrial fibrillation either 'often' or 'sometimes'. One in four cardiologists received new referrals relating to wearable technology at least weekly. The results demonstrate that cardiologists across Wales are using data from wearable technology in the diagnosis and management of cardiac conditions in the absence of formal guidance. Standardisation of guidelines and pathways is needed to support patients and clinicians and avoid the introduction of wearables through the unregulated backdoor.

Martha's rule: applying a behaviour change framework to understand the potential of complementary roles of clinicians and patients in improving safety of patients deteriorating in hospital.

AIMS/BACKGROUND: Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.. METHODS: A descriptive analysis was undertaken of interactions between patients, family, friends and clinicians during clinical deterioration in hospital. The capability-opportunity-motivation behaviour change framework was applied to understand reasons for failure to respond to deterioration. RESULTS: Care of deteriorating patients requires recording of vital signs, recognition of abnormalities, reporting through escalation and response by a competent clinician. Regarding the care of patients who deteriorate in hospital, healthcare professionals have capability and motivation to provide safe, high-quality care, but often lack the physical and social opportunity to report or respond through lack of time and peer pressure. Patients and family members have motivation and might have time to support safety systems. Martha's rule or similar arrangements allow healthcare organisations to create opportunities for patients and families to report and escalate care to experts in critical care when they recognise deterioration. CONCLUSIONS: The capability-opportunity-motivation behaviour change framework provides insights into the causes of failure to rescue in deteriorating patients and an argument for opportunities through escalation by patients and families through Martha's rule. This might reduce the number of system failures and enable safer care.

A model-based cost-utility analysis of an automated notification system for deteriorating patients on general wards.

BACKGROUND: Delayed response to clinical deterioration of hospital inpatients is common. Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration is associated with significant improvements in clinical outcomes but there is no evidence on the cost-effectiveness compared with routine monitoring, in the National Health Service (NHS) in the United Kingdom (UK). METHODS: A decision analytic model was developed to estimate the cost-effectiveness of an electronic automated advisory notification system versus standard care, in adults admitted to a district general hospital. Analyses considered: (1) the cost-effectiveness of the technology based on secondary analysis of patient level data of 3787 inpatients in a before-and-after study; and (2) the cost-utility (cost per quality-adjusted life-year (QALY)) over a lifetime horizon, extrapolated using published data. Analysis was conducted from the perspective of the NHS. Uncertainty in the model was assessed using a range of sensitivity analyses. RESULTS: The study population had a mean age of 68 years, 48% male, with a median inpatient stay of 6 days. Expected life expectancy at discharge was assumed to be 17.74 years. (1) Cost-effectiveness analysis: The automated notification system was more effective (-0.027 reduction in mean events per patient) and provided a cost saving of -£12.17 (-182.07 to 154.80) per patient admission. (2) Cost-utility analysis: Over a lifetime horizon the automated notification system was dominant, demonstrating a positive incremental QALY gain (0.0287 QALYs, equivalent to ~10 days of perfect health) and a cost saving of £55.35. At a threshold of £20,000 per QALY, the probability of automated monitoring being cost-effective in the NHS was 81%. Increased use of cableless sensors may reduce cost-savings, however, the intervention remains cost-effective at 100% usage (ICER: £3,107/QALY). Stratified cost-effectiveness analysis by age, National Early Warning Score (NEWS) on admission, and primary diagnosis indicated the automated notification system was cost-effective for most strategies and that use representative of the patient population studied was the most cost-saving strategy. CONCLUSION: Automated notification system for adult patients admitted to general wards appears to be a cost-effective use in the NHS; adopting this technology could be good use of scarce resources with significance for patient safety.