Screening instruments to predict adverse outcomes for undifferentiated older adults attending the Emergency Department: Results of SOAED prospective cohort study.

BACKGROUND: frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention. We assessed the validity of the Identification of Seniors at Risk (ISAR), Clinical Frailty Scale (CFS), Programme on Research for Integrating Services for the Maintenance of Autonomy seven item questionnaire (PRISMA-7) and InterRAI-ED at predicting adverse outcomes at 30 days and 6 months amongst older adults presenting to the Emergency Department (ED). METHODS: a prospective cohort study of adults ≥65 years who presented to the ED was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were assessed. Blinded follow-up telephone interviews were completed at 30 days and 6 months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity, specificity, negative predictive value and positive predictive value of the screening tools were calculated using 2 × 2 tables. RESULTS: a total of 419 patients were recruited; 47% female with a mean age of 76.9 (Standard deviation = 7.2). The prevalence of frailty varied across the tools (CFS 57% versus InterRAI-ED 70%). At 30 days, the mortality rate was 5.1%, ED re-attendance 18.1%, hospital readmission 14%, functional decline 47.6% and nursing home admission 7.1%. All tools had a high sensitivity and positive predictive value for predicting adverse outcomes. CONCLUSION: older adults who screened positive for frailty were at significantly increased risk of experiencing an adverse outcome at 30 days with the ISAR being the most sensitive tool. We would recommend the implementation of the ISAR in the ED setting to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention.

Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland.

BACKGROUND: Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland. METHODS: The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels. RESULTS: The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites. CONCLUSIONS: Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study.

BACKGROUND: Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED. METHOD: The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS. RESULTS: For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived ≥50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05). CONCLUSIONS: Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.

The "better data, better planning" census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland.

BACKGROUND: Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of "Corridor Medicine" and "Trolley Crises" have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. METHODS: This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. RESULTS: Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the "best place" for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. CONCLUSIONS: This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective.

BACKGROUND: The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort. METHODS: This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics. RESULTS: The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05). CONCLUSIONS: Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

Raman spectroscopy as a predictive tool for monitoring osteoporosis therapy in a rat model of postmenopausal osteoporosis.

Pharmacological therapy of osteoporosis reduces bone loss and risk of fracture in patients. Modulation of bone mineral density cannot explain all effects. Other aspects of bone quality affecting fragility and ways to monitor them need to be better understood. Keratinous tissue acts as surrogate marker for bone protein deterioration caused by oestrogen deficiency in rats. Ovariectomised rats were treated with alendronate (ALN), parathyroid hormone (PTH) or estrogen (E2). MicroCT assessed macro structural changes. Raman spectroscopy assessed biochemical changes. Micro CT confirmed that all treatments prevented ovariectomy-induced macro structural bone loss in rats. PTH induced macro structural changes unrelated to ovariectomy. Raman analysis revealed ALN and PTH partially protect against molecular level changes to bone collagen (80% protection) and mineral (50% protection) phases. E2 failed to prevent biochemical change. The treatments induced alterations unassociated with the ovariectomy; increased beta sheet with E2, globular alpha helices with PTH and fibrous alpha helices with both ALN and PTH. ALN is closest to maintaining physiological status of the animals, while PTH (comparable protective effect) induces side effects. E2 is unable to prevent molecular level changes associated with ovariectomy. Raman spectroscopy can act as predictive tool for monitoring pharmacological therapy of osteoporosis in rodents. Keratinous tissue is a useful surrogate marker for the protein related impact of these therapies.The results demonstrate utility of surrogates where a clear systemic causation connects the surrogate to the target tissue. It demonstrates the need to assess broader biomolecular impact of interventions to examine side effects.

Raman spectroscopy predicts the link between claw keratin and bone collagen structure in a rodent model of oestrogen deficiency.

Osteoporosis is a common disease characterised by reduced bone mass and an increased risk of fragility fractures. Low bone mineral density is known to significantly increase the risk of osteoporotic fractures, however, the majority of non-traumatic fractures occur in individuals with a bone mineral density too high to be classified as osteoporotic. Therefore, there is an urgent need to investigate aspects of bone health, other than bone mass, that can predict the risk of fracture. Here, we successfully predicted association between bone collagen and nail keratin in relation to bone loss due to oestrogen deficiency using Raman spectroscopy. Raman signal signature successfully discriminated between ovariectomised rats and their sham controls with a high degree of accuracy for the bone (sensitivity 89%, specificity 91%) and claw tissue (sensitivity 89%, specificity 82%). When tested in an independent set of claw samples the classifier gave 92% sensitivity and 85% specificity. Comparison of the spectral changes occurring in the bone tissue with the changes occurring in the keratin showed a number of common features that could be attributed to common changes in the structure of bone collagen and claw keratin. This study established that systemic oestrogen deficiency mediates parallel structural changes in both the claw (primarily keratin) and bone proteins (primarily collagen). This strengthens the hypothesis that nail keratin can act as a surrogate marker of bone protein status where systemic processes induce changes.

Confirmation of suboptimal protocols in spinal immobilisation?

BACKGROUND: Spinal immobilisation during extrication of patients in road traffic collisions is routinely used despite the lack of evidence for this practice. In a previous proof of concept study (n=1), we recorded up to four times more cervical spine movement during extrication using conventional techniques than self-controlled extrication. OBJECTIVE: The objective of this study was to establish, using biomechanical analysis which technique provides the minimal deviation of the cervical spine from the neutral in-line position during extrication from a vehicle in a larger sample of variable age, height and mass. METHODS: A crew of two paramedics and four fire-fighters extricated 16 immobilised participants from a vehicle using six techniques for each participant. Participants were marked with biomechanical sensors and relative movement between the sensors was captured via high-speed infrared motion analysis cameras. A three-dimensional mathematical model was developed and a repeated-measures analysis of variance was used to compare movement across extrication techniques. RESULTS: Controlled self-extrication without a collar resulted in a mean movement of 13.33° from the neutral in-line position of the cervical spine compared to a mean movement of 18.84° during one of the equipment-aided extrications. Two equipment-aided techniques had significantly higher movement (p<0.05) than other techniques. Both height (p=0.003) and mass (p=0.02) of the participants were significant independent predictors of movement. CONCLUSIONS: These data support the findings of the proof of concept study, for haemodynamically stable patients controlled self-extrication causes less movement of the cervical spine than extrications performed using traditional prehospital rescue equipment.

Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study.

BACKGROUND: In most countries, road traffic collisions (RTCs) are the main cause of cervical spine injuries. There are several techniques in use for spinal immobilisation during prehospital extrication; however, the evidence for these is currently poor. OBJECTIVE: The objective of this study is to establish which technique provides the minimal deviation of the cervical spine from the neutral inline position during the extrication of the RTC patient using biomechanical analysis techniques. METHODS: A crew of two paramedics and four fire-fighter first responders extricated a simulated patient from a prepared motor vehicle using nine different extrication techniques. The patient was marked with biomechanical sensors and relative movement between the sensors was captured via high speed infrared motion analysis cameras. A 3D mathematical model was developed from the recorded movement. RESULTS: Control measurements were taken from the patient during self-extrication and movement was recorded of 4.194° left of midline (LOM) to 2.408° right of midline (ROM) resulting in a total movement of 6.602°. The least deviation recorded during equipment aided extrication was movement of 3.365° LOM and 8.352° ROM resulting in a total movement of 11.717°. The most deviation recorded during equipment aided extrication was movement of 1.588° LOM and 24.498° ROM resulting in a total movement of 26.086°. CONCLUSIONS: Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication. This proof of concept study demonstrates the need for further evaluation of current rescue techniques and the requirement to investigate the clinical and operational significance of such movement.

A method for the design and development of medical or health care information websites to optimize search engine results page rankings on Google.

BACKGROUND: The Internet is a widely used source of information for patients searching for medical/health care information. While many studies have assessed existing medical/health care information on the Internet, relatively few have examined methods for design and delivery of such websites, particularly those aimed at the general public. OBJECTIVE: This study describes a method of evaluating material for new medical/health care websites, or for assessing those already in existence, which is correlated with higher rankings on Google's Search Engine Results Pages (SERPs). METHODS: A website quality assessment (WQA) tool was developed using criteria related to the quality of the information to be contained in the website in addition to an assessment of the readability of the text. This was retrospectively applied to assess existing websites that provide information about generic medicines. The reproducibility of the WQA tool and its predictive validity were assessed in this study. RESULTS: The WQA tool demonstrated very high reproducibility (intraclass correlation coefficient=0.95) between 2 independent users. A moderate to strong correlation was found between WQA scores and rankings on Google SERPs. Analogous correlations were seen between rankings and readability of websites as determined by Flesch Reading Ease and Flesch-Kincaid Grade Level scores. CONCLUSIONS: The use of the WQA tool developed in this study is recommended as part of the design phase of a medical or health care information provision website, along with assessment of readability of the material to be used. This may ensure that the website performs better on Google searches. The tool can also be used retrospectively to make improvements to existing websites, thus, potentially enabling better Google search result positions without incurring the costs associated with Search Engine Optimization (SEO) professionals or paid promotion.

Generic medicines: an evaluation of the accuracy and accessibility of information available on the Internet.

BACKGROUND: Internationally, generic medicines are increasingly seen as a key strategy to reduce healthcare expenditure, therefore awareness and knowledge transfer regarding generic medicines are valid areas of research. Although the Internet is a frequently used source of medical information, the accuracy of material found online is variable. The aim of this study was to evaluate information provided on the Internet regarding generic medicines in terms of quality of information and readability. METHODS: Internet searches for information regarding generic medicine were completed, with a pre-defined search term, using the Google search engine, in five English-speaking geographical regions (US, UK, Ireland, Canada and Australia). Search results likely to be looked at by a searcher were collated and assessed for the quality of generic medicine-related information in the websites, using a novel customised Website Quality Assessment (WQA) tool; and for readability, using existing methods. The reproducibility of the tools between two independent reviewers was evaluated and correlations between WQA score, readability statistics and Google search engine results page ranking were assessed. RESULTS: Wikipedia was the highest-ranking search result in 100% of searches performed. Considerable variability of search results returned between different geographical regions was observed, including that websites identified in the Australian search generated the highest number of country specific websites; searches performed using computers with Irish, British, American and Canadian IP addresses appear to be more similar to each other than the google.com search performed in Australia; and the Canadian google.ca results show a notable difference from any of the other searches. Of the 24 websites assessed, none scored a perfect WQA score. Notably, strong correlation was seen between WQA and readability scores and ranking on google.com search results. CONCLUSIONS: This novel evaluation of websites providing information on generic medicines showed that, of the websites likely to be seen by a searcher, none demonstrated a combination of scoring highly on quality of information (as evinced by WQA score) and readability. Therefore, there is a gap in online knowledge provision on this topic which, if filled by a website designed using the WQA tool developed in this study, has an improved likelihood of ranking highly in google.com search results.

Can advanced paramedics in the field diagnose patients and predict hospital admission?

BACKGROUND: Accurate patient diagnosis in the prehospital environment is essential to initiate suitable care pathways. The advanced paramedic (AP) is a relatively recent role in Ireland, and refers to a prehospital practitioner with advanced life-support skills and training. OBJECTIVES: The objectives of this study were to compare the diagnostic decisions of APs with emergency medicine (EM) physicians, and to investigate if APs, as currently trained, can predict the requirement for hospital admission. METHODS: A prospective study was initiated, whereby each emergency ambulance call received via the statutory 999 system was recorded by the attending AP. The AP was asked to provide a clinical diagnosis for each patient, and to predict if hospital admission was required. The data was then cross-referenced with the working diagnosis of the receiving emergency physician and the hospital admission records. RESULTS: A total of 17 APs participated in the study, and 1369 emergency calls were recorded over a 6-month period. Cases where a general practitioner attended the scene were excluded from the concordance analysis. Concordance with the receiving emergency physician represents 70% (525/748) for all cases of AP diagnosis, and is mirrored with 70% (604/859) correct hospital admission predictions. CONCLUSIONS: AP diagnosis and admission prediction for emergency calls is similar to other emergency medical services systems despite the relative recency of the AP programme in Ireland. Recognition of non-concordance case types may identify priorities for AP education, and drive future AP practice in areas such as 'treat and refer'.

Developing novel prognostic biomarkers for multivariate fracture risk prediction algorithms.

Multivariate prediction algorithms such as FRAX® and QFractureScores provide an opportunity for new prognostic biomarkers to be developed and incorporated, potentially leading to better fracture prediction. As more research is conducted into these novel biomarkers, a number of factors need to be considered for their successful development for inclusion in these algorithms. In this review, we describe two well-known multivariate prediction algorithms for osteoporosis fracture risk applicable to the UK population, FRAX and QFractureScores, and comment on the current prognostic tools available for fracture risk; dual X-ray assessment, quantitative ultrasonography, and genomic/biochemical markers. We also highlight the factors that need to be considered in the development of new biomarkers. These factors include the requirement for prospective data, collected in new cohort studies or using archived samples; the need for adequate stability data to be provided; and the need for appropriate storage methods to be used when retrospective data are required. Area under the receiver operating characteristic curve measures have been found to have limited utility in assessing the impact of the addition of new risk factors on the predictive performance of multivariate algorithms. New performance evaluation measures, such as net reclassification index and integrated discrimination improvement, are increasingly important in the evaluation of the impact of the addition of new markers to multivariate algorithms, and these are also discussed.

The impact of frailty Screening of Older adults with muLtidisciplinary assessment of those At Risk during emergency hospital attendance on the quality, safety and cost-effectiveness of care (SOLAR): a randomised controlled trial.

BACKGROUND: Older people account for 25% of all Emergency Department (ED) admissions. This is expected to rise with an ageing demographic. Older people often present to the ED with complex medical needs in the setting of multiple comorbidities. Comprehensive Geriatric Assessment (CGA) has been shown to improve outcomes in an inpatient setting but clear evidence of benefit in the ED setting has not been established. It is not feasible to offer this resource-intensive assessment to all older adults in a timely fashion. Screening tools for frailty have been used to identify those at most risk for adverse outcomes following ED visit. The overall aim of this study is to examine the impact of CGA on the quality, safety and cost-effectiveness of care in an undifferentiated population of frail older people with medical complaints who present to the ED and Acute Medical Assessment Unit. METHODS: This will be a parallel 1:1 allocation randomised control trial. All patients who are ≥ 75 years will be screened for frailty using the Identification of Seniors At Risk (ISAR) tool. Those with a score of ≥ 2 on the ISAR will be randomised. The treatment arm will undergo geriatric medicine team-led CGA in the ED or Acute Medical Assessment Unit whereas the non-treatment arm will undergo usual patient care. A dedicated multidisciplinary team of a specialist geriatric medicine doctor, senior physiotherapist, specialist nurse, pharmacist, senior occupational therapist and senior medical social worker will carry out the assessment, as well as interventions that arise from that assessment. Primary outcomes will be the length of stay in the ED or Acute Medical Assessment Unit. Secondary outcomes will include ED re-attendance, re-hospitalisation, functional decline, quality of life and mortality at 30 days and 180 days. These will be determined by telephone consultation and electronic records by a research nurse blinded to group allocation. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Health Service Executive (HSE) Mid-Western Regional Hospital Research Ethics Committee (088/2020). Our lay dissemination strategy will be developed in collaboration with our Patient and Public Involvement stakeholder panel of older people at the Ageing Research Centre and we will present our findings in peer-reviewed journals and national and international conferences. TRIAL REGISTRATION: ClinicalTrials.gov NCT04629690 . Registered on November 16, 2020.

Raman Spectroscopic Analysis of Fingernail Clippings Can Help Differentiate Between Postmenopausal Women Who Have and Have Not Suffered a Fracture.

Raman spectroscopy was applied to nail clippings from 633 postmenopausal British and Irish women, from six clinical sites, of whom 42% had experienced a fragility fracture. The objective was to build a prediction algorithm for fracture using data from four sites (known as the calibration set) and test its performance using data from the other two sites (known as the validation set). Results from the validation set showed that a novel algorithm, combining spectroscopy data with clinical data, provided area under the curve (AUC) of 74% compared to an AUC of 60% from a reduced QFracture score (a clinically accepted risk calculator) and 61% from the dual-energy X-ray absorptiometry T-score, which is in current use for the diagnosis of osteoporosis. Raman spectroscopy should be investigated further as a noninvasive tool for the early detection of enhanced risk of fragility fracture.

Biological evaluation of nano-hydroxyapatite-zirconia (HA-ZrO2) composites and strontium-hydroxyapatite (Sr-HA) for load-bearing applications.

The biological response of strontium (Sr) doped hydroxyapatite (HA) and hydroxyapatite-zirconia (HA-ZrO2) composites produced by employing sol-gel technology, minimal ZrO2 loadings, and novel microwave-sintering regimes thereby retarding decomposition, is reported. In vitro evaluations indicate that all materials induce a favorable response from rat osteosarcoma cells. In vivo evaluations show osteoconductivity and biocompatibility for both the Sr-HA and HA-ZrO2. The materials did not cause any inflammatory response in bone. The Sr-HA displays better biocompatibility which may be due to the incorporation of Sr and the formation of a surface apatite layer.