Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study.

Background: Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department. Objectives: To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment. Design: Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness. Setting: Two ambulance services and four acute hospitals in England. Participants: Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded. Interventions: Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation. Main outcome measures: Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained. Results: Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed. Limitations: We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling. Conclusions: No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis. Study registration: This study is registered as Research Registry (reference: researchregistry5268). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Sepsis is a life-threatening condition in which an abnormal response to infection causes heart, lung or kidney failure. People with sepsis need urgent treatment. They need to be prioritised at the emergency department rather than waiting in the queue. Paramedics attempt to identify people with possible sepsis using an early warning score (based on simple measurements, such as blood pressure and heart rate) alongside their impression of the patient's diagnosis. They can then alert the hospital to assess the patient quickly. However, an inaccurate early warning score might miss cases of sepsis or unnecessarily prioritise people without sepsis. We aimed to measure how accurately early warning scores identified people with sepsis when used alongside paramedic diagnostic impression. We collected data from 71,204 people that two ambulance services transported to four different hospitals in 2019. We recorded paramedic diagnostic impressions and calculated early warning scores for each patient. At one hospital, we linked ambulance records to hospital records and identified who had sepsis. We then calculated the accuracy of using the scores alongside diagnostic impression to diagnose sepsis. Finally, we used modelling to predict how many patients (with and without sepsis) paramedics would prioritise using different strategies based on early warning scores and diagnostic impression. We found that none of the currently available early warning scores were ideal. When they were applied to all patients, they prioritised too many people. When they were only applied to patients whom the paramedics thought had infection, they missed many cases of sepsis. The NEWS2, score, which ambulance services already use, was as good as or better than all the other scores we studied. We found that using the NEWS2, score in people with a paramedic impression of infection could achieve a reasonable balance between prioritising too many patients and avoiding missing patients with sepsis.

Modeling nitrous oxide emissions from rough fescue grassland soils subjected to long-term grazing of different intensities using the Soil and Water Assessment Tool (SWAT).

Given the rising nitrous oxide (N2O) concentration in the atmosphere, it has become increasingly important to identify hot spots and hot moments of N2O emissions. With field measurements often failing to capture the spatiotemporal dynamics of N2O emissions, estimating them with modeling tools has become an attractive alternative. Therefore, we incorporated several semi-empirical equations to estimate N2O emissions with the Soil and Water Assessment Tool from nitrification and denitrification processes in soil. We then used the model to simulate soil moisture and the N2O flux from grassland soils subjected to long-term grazing (> 60 years) at different intensities in Alberta, Canada. Sensitivity analysis showed that parameters controlling the N2O flux from nitrification were most sensitive. On average, the accuracy of N2O emission simulations were found to be satisfactory, as indicated by the selected goodness-of-fit statistics and predictive uncertainty band, while the model simulated the soil moisture with slightly higher accuracy. As expected, emissions were higher from the plots with greater grazing intensity. Scenario analysis showed that the N2O emissions with the recommended fertilizer rate would dominate the emissions from the projected wetter and warmer future. The combined effects of fertilization and wetter and warmer climate scenarios would increase the current N2O emission levels by more than sixfold, which would be comparable to current emission levels from agricultural soils in similar regions.

Factors affecting decisions to extend access to primary care: results of a qualitative evaluation of general practitioners' views.

OBJECTIVES: To report general practitioners' (GPs') views and experiences of an Enhanced Primary Care programme (EPCP) funded as part of the Prime Minister's Challenge Fund (second wave) for England which aimed to extend patient access to primary care. SETTING: Primary care in Sheffield, England. PARTICIPANTS: Semi-structured interviews with a purposive sample of GPs working in 24 practices across the city. RESULTS: Four core themes were derived: GPs' receptivity to the aims of the EPCP, their capacity to support integrated care teams, their capacity to manage urgent care and the value of some new community-based schemes to enhance locality-based primary care. GPs were aware of the policy initiatives associated with out-of-hours access that aimed to reduce emergency department and hospital admissions. Due to limited capacity to respond to the programme, they selected elements that directly related to local patient demand and did not increase their own workload. CONCLUSIONS: The variation in practice engagement and capacity to manage changes in primary care services warrants a subtle and specialist approach to programme planning. The study makes the case for enhanced planning and organisational development with GPs as stakeholders within individual practices and groups. This would ensure that policy implementation is effective and sustained at local level. A failure to localise implementation may be associated with increased workloading in primary care without the sustained benefits to patients and the public. To enable GPs to become involved in systems transformation, further research is needed to identify the best methods to engage GPs in programme planning and evaluation.

Primary SWL Is an Efficient and Cost-Effective Treatment for Lower Pole Renal Stones Between 10 and 20 mm in Size: A Large Single Center Study.

INTRODUCTION: To assess the clinical features, outcomes, complications, and cost-effectiveness of shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) in the treatment of lower pole (LP) stones (10-20 mm) in a large tertiary referral center. PATIENTS AND METHODS: Consecutive patients treated for solitary LP stones (10-20 mm) between 2008 and 2013 were identified from a prospective database. SWL was used as primary treatment in all cases (following a stone multidisciplinary team assessment), with FURS and PCNL reserved for SWL contraindications, failure, or patient choice. "Success" was defined as stone free and/or clinically insignificant stone fragments (≤3 mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated for each group using the National Health Service England 2014/15 National Tariff Healthcare Resource Group codes. RESULTS: Two hundred twenty-five patients were included (mean age 54.9; median stone size 12 mm). One hundred ninety-eight (88%), 21 (9.3%), and 6 (2.7%) patients underwent SWL, FURS, and PCNL as primary treatments, respectively, for median stone sizes of 12, 12, and 20 mm. Overall success rates were 82.8%, 76.1%, and 66.7%, respectively (p < 0.05). Sixty-three percent of patients undergoing primary SWL were effectively treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients effectively treated with SWL (p = 0.04). The average cost per treatment modality was also significantly lower for SWL (£750) than for FURS (£1261) or PCNL (£2658) (p < 0.01). CONCLUSION: SWL is both an efficacious and cost-effective primary treatment for patients with solitary LP stones (10-20 mm). The majority of patients can be effectively treated with primary SWL in a dedicated stone center, with the benefits of a short length of stay, low complication, and auxiliary treatment rates. The referral of such patients to high-volume lithotripsy centers with demonstrable outcomes should be given due consideration.

Reducing health inequalities for older LGBTQ+ people.

The recent LGBTQ+ history exhibition Speak Out London, Diversity City presented a fantastic collection of stories, documents and photographs from LGBTQ+ Londoners. It also provided a reminder of how far we have come in reducing stigma, prejudice and discrimination.

Action plan flags opportunities to address health inequalities.

We know that health inequalities apply to people with mental health problems who have poorer physical health than the general population.

Mental and physical health comordibity: political imperatives and practice implications.

Insufficient priority is being given to meet the physical health-care needs of people with mental illness. Mental health nurses, as the largest professional group working in mental health care, have a pivotal role in improving the physical health and well-being of people with mental illness. Through health-promotion strategies, alongside recovery-focused support aimed at avoiding deteriorating physical health, mental health nurses can significantly contribute to improving the current rate of premature death experienced by people with enduring mental illness. Drawing from contemporary policy, alongside practical examples taken from the published literature, this paper considers what constitutes recommended best practice in dealing with the physical health-care needs of people with mental illness. The role that UK-based health-care policy plays in shaping care delivery that meets the needs of people with mental illness is explored and placed within the context of global health concerns. Recommendations are made on how mental health nursing can work to provide evidence for a reassertion that nurses are well placed to work across organizational and professional boundaries to deliver person-centred care and a holistic approach to population health and well-being.