Frailty is a better predictor than age for shockable rhythm and survival in Out-of-Hospital cardiac arrest in over 16-year-olds.

Objective: To determine if the Clinical Frailty Scale (CFS) predicts out-of-hospital cardiac arrest (OHCA) outcomes better than age?Design: The analysed data was collected as part of a larger study run by NCEPOD on hospital admissions for OHCA in 2018. Study selection was OHCA in over 16-year-olds with restoration of spontaneous circulation (ROSC) for >20 mins and who were admitted to hospital, or who died in the emergency department. Patients from hospitals in England, Wales and Northern Ireland were identified using standard coding for cardiac arrest. CFS, age and gender were examined against two binary outcomes (non-shockable rhythm and survival). Results: 304 patients with a known CFS, known original rhythm, and known outcome were included. Younger patients had lower CFSs, as a continuous variable (Pearson correlation coefficient 0.44, p-value < 0.001) and in CFS groupings of 1-3, 4-6, 7-9 (p-value < 0.001). CFSs were higher (p-values < 0.001) for both non-shockable rhythm and death (median CFS was 4 for death and 2 for survivors). Logistic regression analysis of continuous scale CFS showed the association with non-shockable rhythm remained when adjusted for age and sex (odds ratio [95% CI]; age adjustment 1.46 [1.28, 1.68] p-value < 0.001) and remained for survival when adjusted for age alone (odds ratio [95% CI]; 1.60 [1.36, 1.88] p-value < 0.001) and when adjusted for age, sex and initial rhythm combined (1.45 [1.21, 1.73] p-value < 0.001). 3.2% of patients had resuscitation against their advanced-care-directives. 12.9% (23/178) of hospitals had electronic systems which shared advance-care-directives with ambulance services and primary care. Conclusion: A higher CFS is a prognostic indicator in adult OHCA independent of age. Frail individuals have a lower likelihood of a shockable rhythm and poorer survival. Sensitive sharing of this information with patients when discussing advance-care-directives may enhance shared decision-making.

Trends in Long-Term Ventilation Care in U.K. Children and Young People-Further Consideration Required for Pediatric Critical Care Services.

OBJECTIVES: The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. DESIGN: A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. SETTING: Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. PATIENTS: Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). CONCLUSIONS: The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.

NEWS2, patient safety and hypercapnic respiratory failure.

The National Early Warning Score (NEWS) has been widely adopted for use in clinical practice in the UK since its introduction in 2012. It is designed to improve patient safety. The original score was adapted in 2017 to improve patient safety further by introducing a separate score for oxygen saturation to be used in selected patients with respiratory diseases. In this article, evidence for the effectiveness of the improved score is reviewed.

Time matters: reviewing the care provided to patients admitted to hospital following an out-of-hospital cardiac arrest.

The National Confidential Enquiry into Patient Outcome and Death reviewed the organisation of services and the quality of clinical care provided to patients who were admitted to hospital following an out-of-hospital cardiac arrest. The report looked at all four links in the 'chain of survival', covering the last link, in-hospital advanced life support and post-resuscitation care, in most detail.

Prognostic value of National Early Warning Scores (NEWS2) and component physiology in hospitalised patients with COVID-19: a multicentre study.

BACKGROUND: National Early Warning Scores (NEWS2) are used to detect all-cause deterioration. While studies have looked at NEWS2, the use of virtual consultation and remote monitoring of patients with COVID-19 mean there is a need to know which physiological observations are important. AIM: To investigate the relationship between outcome and NEWS2, change in NEWS2 and component physiology in COVID-19 inpatients. METHODS: A multi-centre retrospective study of electronically recorded, routinely collected physiological measurements between March and June 2020. First and maximum NEWS2, component scores and outcomes were recorded. Areas under the curve (AUCs) for 2-day, 7-day and 30-day mortality were calculated. RESULTS: Of 1263 patients, 26% died, 7% were admitted to intensive care units (ICUs) before discharge and 67% were discharged without ICU. Of 1071 patients with initial NEWS2, most values were low: 50% NEWS2=0-2, 27% NEWS2=3-4, 14% NEWS2=5-6 and 9% NEWS2=7+. Maximum scores were: 14% NEWS2=0-2, 22% NEWS2=3-4, 17% NEWS2=5-6 and 47% NEWS2=7+. Higher first and maximum scores were predictive of mortality, ICU admission and longer length of stay. AUCs based on 2-day, 7-day, 30-day and any hospital mortality were 0.77 (95% CI 0.70 to 0.84), 0.70 (0.65 to 0.74), 0.65 (0.61 to 0.68) and 0.65 (0.61 to 0.68), respectively. The AUCs for 2-day mortality were 0.71 (0.65 to 0.77) for supplemental oxygen, 0.65 (0.56 to 0.73) oxygen saturation and 0.64 (0.56 to 0.73) respiratory rate. CONCLUSION: While respiratory parameters were most predictive, no individual parameter was as good as a full NEWS2, which is an acceptable predictor of short-term mortality in patients with COVID-19. This supports recommendation to use NEWS2 alongside clinical judgement to assess patients with COVID-19.

Balancing the pressures: a review of the quality of care provided to children and young people aged 0-24 years who were receiving long-term ventilation.

Assessing the quality of care for patients receiving long-term ventilation is complex given the diversity of this population (0-24 years in this case) and their differing requirements for treatment. This article details how and why such reviews are necessary.

"SHOUT" to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital.

Acute kidney injury (AKI) affects up to 20% of all patients admitted to hospital, and is associated with a higher risk of adverse clinical outcomes, increased healthcare costs, as well as long term risks of chronic kidney disease and end stage renal failure. The aim of this project was to improve the quality of care for patients with AKI admitted to the acute medical unit (AMU) at the Great Western Hospital (GWH). We assessed awareness and self reported confidence among physicians in our Trust, in addition to basic aspects of care relevant to AKI on our AMU. A multifaceted quality improvement strategy was developed, which included measures to improve awareness such as a Trust wide AKI awareness day, and reconfiguring the admission proforma on our AMU in order to enhance risk assessment, staging, and early response to AKI. Ancillary measures such as the dissemination of flashcards for lanyards containing core information were also used. Follow up assessments showed that foundation year one (FY1) doctors' self reported confidence in managing AKI increased from 2.8 to 4.2, as measured on a five point Likert scale (P=0.0003). AKI risk assessment increased from 13% to 57% (P=0.07) following a change in the admission proforma. Documentation of the diagnosis of AKI increased from 66% to 95% (P=0.038) among flagged patients. Documentation of urine dip results increased from 33% to 73% (P=0.01), in addition to a rise in appropriate referral for specialist input, although this was not statistically significant. Our results suggest that using the twin approaches of improving awareness, and small changes to systemic factors such as modification of the admission proforma, can lead to significant enhancements in the quality of care of patients with AKI.