Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis.

OBJECTIVE: Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. DESIGN: Systematic mapping review and narrative synthesis. DATA SOURCES: Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. ELIGIBILITY CRITERIA: Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. DATA EXTRACTION AND SYNTHESIS: We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. RESULTS: Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. CONCLUSION: Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

The UK's dysfunctional relationship with medical migrants: the Daniel Ubani case and reform of out-of-hours services.

In 2008, a patient died in the UK after being given an excessive dose of diamorphine by an overseas-trained doctor working in out-of-hours (OOH) primary care. This incident led to a debate on the recourse to international medical graduates and on the shortcomings of the OOH system. It is argued here that a historical reflection on the ways in which the NHS uses migrant labour can serve to reframe these discussions. The British Medical Association, the General Medical Council, and the House of Commons Health Committee have emphasised the need for more regulation of overseas graduates. Such arguments fit into a well-established pattern of dependency on and denigration of overseas graduates. They give insufficient weight to the multiple systemic failings identified in reports on OOH provision by the Department of Health and the Care Quality Commission. Medical migrants are often found in under-resourced and unpopular parts of healthcare systems, in the UK and elsewhere. Their presence provides an additional dimension to Julian Tudor Hart's inverse care law: the resources are fewer where the need is greatest, and the practitioner dealing with the consequences is more likely to be a migrant. The failings of the UK OOH system need to be understood in this context. Efforts to improve OOH care should be focused on controlling quality rather than the movement of doctors. A wider reflection on the nature of the roles that international medical graduates are asked to play in healthcare systems is also required.