Minimum data set harmonization in the management of cross-border Multi Casualty Incidents. Modified Delphi (VALKYRIES-H2020 project).

INTRODUCTION: There is a need to develop harmonized procedures and a Minimum Data Set (MDS) for cross-border Multi Casualty Incidents (MCI) in medical emergency scenarios to ensure appropriate management of such incidents, regardless of place, language and internal processes of the institutions involved. That information should be capable of real-time communication to the command-and-control chain. It is crucial that the models adopted are interoperable between countries so that the rights of patients to cross-border healthcare are fully respected. OBJECTIVE: To optimize management of cross-border Multi Casualty Incidents through a Minimum Data Set collected and communicated in real time to the chain of command and control for each incident. To determine the degree of agreement among experts. METHOD: We used the modified Delphi method supplemented with the Utstein technique to reach consensus among experts. In the first phase, the minimum requirements of the project, the profile of the experts who were to participate, the basic requirements of each variable chosen and the way of collecting the data were defined by providing bibliography on the subject. In the second phase, the preliminary variables were grouped into 6 clusters, the objectives, the characteristics of the variables and the logistics of the work were approved. Several meetings were held to reach a consensus to choose the MDS variables using a Modified Delphi technique. Each expert had to score each variable from 1 to 10. Non-voting variables were eliminated, and the round of voting ended. In the third phase, the Utstein Style was applied to discuss each group of variables and choose the ones with the highest consensus. After several rounds of discussion, it was agreed to eliminate the variables with a score of less than 5 points. In phase four, the researchers submitted the variables to the external experts for final assessment and validation before their use in the simulations. Data were analysed with SPSS Statistics (IBM, version 2) software. RESULTS: Six data entities with 31 sub-entities were defined, generating 127 items representing the final MDS regarded as essential for incident management. The level of consensus for the choice of items was very high and was highest for the category 'Incident' with an overall kappa of 0.7401 (95% CI 0.1265-0.5812, p 0.000), a good level of consensus in the Landis and Koch model. The items with the greatest degree of consensus at ten were those relating to location, type of incident, date, time and identification of the incident. All items met the criteria set, such as digital collection and real-time transmission to the chain of command and control. CONCLUSIONS: This study documents the development of a MDS through consensus with a high degree of agreement among a group of experts of different nationalities working in different fields. All items in the MDS were digitally collected and forwarded in real time to the chain of command and control. This tool has demonstrated its validity in four large cross-border simulations involving more than eight countries and their emergency services.

Digitalisation of information and management optimisation in Multiple Victim Incidents. Analytical study.

INTRODUCTION: Triage is a crucial tool for managing a Multiple Victim Incident (MVI). One particularly problematic issue is the communication of results to the chain of command and control. Favourable data exists to suggest that digital triage can improve some features of analogue triage. Within this context we have witnessed the emergence of the Valkyries Project, which is working to develop strategies to respond to MVIs, and especially cross-border incidents. To that end, an IT platform called "SIGRUN" has been created which distributes, in real time, all the information to optimise MVI management. A full-scale simulation, held on the Spain-Portugal border and featuring contributions from different institutions on both sides of the border, put to the test the role of information digitalisation in this type of incidents. OBJECTIVE: To evaluate the impact of the synchronous digitalisation of information on the optimal management of Multiple Victim Incidents. METHOD: Clinical evaluation study carried out on a cross-border simulation between Spain and Portugal. A Minimum Data Set (MDS) was established by means of a modified Delphi by a group of experts. The digital platform "SIGRUN" integrated all the information, relaying it in real time to the chain of command and control. Each country assigned two teams that would carry out digital and analogue triage synchronously. Analogue triage variables were gathered by observers accompanying the first responders. Digital triage times were recorded automatically. Each case was evaluated and classified simultaneously by the two participating teams, to carry out a reliability study in a real time scenario. RESULTS: The total duration of the managing of the incident in the A group of countries involved compared to the B group was 72.5 minutes as opposed to 73 minutes. The total digital assistance triage (AT) time was 37.5 seconds in the digital group, as opposed to 32 minutes in the analogue group. Total evacuation (ET) time was 28 minutes in the digital group compared with 65 minutes in the analogue group. The average differences in total times between the analogue and the digital system, both for primary and secondary evaluation, were statistically significant: p = 0.048 and p = 0.000 respectively. For the "red" category, AT obtained a sensitivity of 100%, also for ET, while with regard to AT safety it obtained a PPV of 61.54% and an NPV of 100%, and for ET it obtained a PPV of 83.33% and an NPV of 100%. For the analogue group, for AT it obtained a sensitivity of 62.50%, for ET, 70%, for AT safety it obtained a PPV of 45.45% and an NPV of 92.31%, while for ET it obtained a PPV of 70% and an NPV of 92.50%. The gap analysis obtained a Kappa index of 0.7674. CONCLUSION: The triage system using the developed digital tool demonstrated its validity compared to the analogue tool, as a result of which its use is recommended.

Engaging the community served: a U.S. Cancer Center's Facebook live cancer awareness campaign for Spanish-speaking Latinos during COVID-19.

Cancer is the leading cause of mortality in U.S. Latino adults, a group with limited access to screening, higher rates of advanced disease, and prone to online misinformation. Our project created a Facebook Live social media video campaign on general cancer prevention, screening, risk, information, and resources, targeting Spanish-monolingual Latinos during the COVID-19 pandemic. Content was delivered in Spanish by fluent, ethnically concordant topic experts and cancer center staff. Four prerecorded and three livestream interview videos were produced, amassing over 161 shares, 1,000 engagements, 12,000 views, 19,000 people reached, and 34,000 impressions in a span of four months. Strengths of this project included developing community partnerships and collaborations, providing evidence-based cancer information in a culturally responsive manner to often-excluded community members during COVID-19 pandemic, and presenting our cancer center as an accessible resource to the wider community. Future directions include formalizing evaluation strategies to capture medical engagement via cancer screening and detection rates, delivering focused cancer discussions by disease sites, and further expanding audience base through mixed media formats.

Acute Poisoning Readmissions to an Emergency Department of a Tertiary Hospital: Evaluation through an Active Toxicovigilance Program.

The aim of this study is to investigate hospital readmissions during 1 year after acute poisoning cases (APC), analyze the temporal behavior of early readmissions (ER) (in the month after the index episode) and predict possible ER. A descriptive analysis of the patients with APC assisted between 2011 and 2016 in the Emergency Department of Hospital La Paz is presented, and various methods of inferential statistics were applied and confirmed by Bayesian analysis in order to evaluate factors associated with total and early readmissions. Out of the 4693 cases of APC included, 968 (20.6%) presented, at least one readmission and 476 (10.1%) of them were ER. The mean age of APC with readmission was 41 years (12.7 SD), 78.9% had previous psychiatric pathology and 44.7% had a clinical history of alcohol addiction. Accidental poisoning has been a protective factor for readmission (OR 0.50; 0.26-0.96). Type of toxin ("drug of abuse" OR 8.88; 1.17-67.25), history of addiction (OR 1.93; 1.18-3.10) and psychiatric history (OR 3.30; 2.53-4.30) are risk factors for readmissions during the first year. Women showed three or more readmissions in a year. The results of the study allow for identification of the predictors for the different numbers of readmissions in the year after the index APC, as well as for ERs.

Eficiencia en el diagnóstico y tratamiento de la intoxicación aguda por paracetamol: análisis de costeefectividad a través de un programa de toxicovigilancia activa hospitalario / Efficient diagnosis and treatment of acute paracetamol poisoning: cost-effectiveness analysis of approaches based on a hospital toxicovigilance program

OBJETIVO: Evaluar la eficiencia de cinco estrategias diagnóstico-terapéuticas posibles ante la sospecha de intoxicación aguda (IA) por paracetamol (PCT) a través de un análisis coste-efectividad, según la perspectiva del financiador en un hospital universitario terciario dotado de un programa de toxicovigilancia activa validado (SAT-HULP). MÉTODO: Estudio de análisis de coste-efectividad (ACE) de cinco alternativas diagnóstico-terapéuticas consideradas en el abordaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con intoxicación por PCT mediante un modelo de árbol de decisión. La población estudiada fueron los pacientes atendidos en un SUH detectados por el SAT-HULP, entre el 1/04/2011 y el 31/01/2015. Las alternativas diagnóstico-terapéuticas consideradas fueron: 1) administración sistemática de Nacetilcisteína; 2) administración del tratamiento según la dosis confirmada; 3) tratamiento según el nomograma de Rümack Matthew; 4) tratamiento según test de orina confirmado con posterior test en sangre; y 5) tratamiento según el cálculo de la semivida. Los datos correspondientes a probabilidades fueron obtenidos del programa SAT-HULP y publicaciones sobre la validación de las pruebas diagnósticas. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: Las opciones "Tratar según dosis comunicada" y "Tratar según el nomograma" son las que muestran mejor coste-efectividad. Al compararlas, la razón coste-efectividad incremental es de 5.985,37 Euros para la primera. El análisis de sensibilidad mostró una importante dependencia del modelo a la variación de las variables principales. En el análisis de sensibilidad probabilístico la estrategia "Tratar a todos los casos" respecto a "Cálculo de semivida" obtuvo una razón coste-efectividad incremental de unos 25.111,06 Euros (DE: 1.534.420,16; intervalo: -42.136,03 a 92.358,75), resultando esta última la más eficiente. CONCLUSIONES: La estrategia "Tratar según el nomograma" es la alternativa más eficiente en el diagnóstico y tratamiento de la intoxicacióna aguda por Paracetamol en nuestro medio, no así para un escenario de mayor prevalencia e incertidumbre, donde la opción "Cálculo de semivida" se muestra como la más eficiente

OBJECTIVE: To evaluate 5 diagnostic-therapeutic strategies for suspected acute paracetamol poisoning in terms of cost-effectiveness in a tertiary university hospital with an active, validated poisoning surveillance program (SAT-HULP). METHODS: Cost-effectiveness analysis of the 5 diagnostic-therapeutic alternatives considered when attending patients with suspected paracetamol poisoning. The alternatives were chosen by means of a decision tree. We studied patients detected by the SAT-HULP program between April 1, 2011, and January 31, 2015. The diagnostic-therapeutic alternatives were as follows: 1) systematic treatment of all patients with N-acetylcysteine (NAC), 2) NAC treatment according to the reported dose; 3) NAC treatment according to a Rümack-Matthew nomogram; 4) NAC treatment according to urine test results confirmed by a blood test, and 5) treatment according to elimination half-life calculation. Probability data were obtained from the SAT-HULP program and validation studies corresponding to the diagnostic tests. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The approaches that were most cost-effective were those guided by reported doses and nomograms. The incremental cost-effectiveness of treatment according to reported dose was Euros 5985.37. The sensitivity analysis showed that the model was highly dependent on variations in the main variables; the probabilistic sensitivity analysis indicated an incremental cost-effectiveness of Euros 25 111.06 (SD, Euros 1 534 420.16; range, Euros 42 136.03-Euros 92 358.75) between the first approach (treat all cases) and last (calculate elimination half-life); half-life calculation was the more efficient. CONCLUSIONS: Treating according to nomogram was the most efficient diagnostic-therapeutic approach to treating paracetamol poisoning in our hospital. However, when the prevalence of paracetamol poisoning is higher and uncertainty is greater, it would be more efficient to treat based on calculating the half-life

Efficient diagnosis and treatment of acute paracetamol poisoning: cost-effectiveness analysis of approaches based on a hospital toxicovigilance program. / Eficiencia en el diagnóstico y tratamiento de la intoxicación aguda por paracetamol: análisis de costeefectividad a través de un programa de toxicovigilancia activa hospitalario.

OBJECTIVES: To evaluate 5 diagnostic-therapeutic strategies for suspected acute paracetamol poisoning in terms of cost-effectiveness in a tertiary university hospital with an active, validated poisoning surveillance program (SAT-HULP). MATERIAL AND METHODS: Cost-effectiveness analysis of the 5 diagnostic-therapeutic alternatives considered when attending patients with suspected paracetamol poisoning. The alternatives were chosen by means of a decision tree. We studied patients detected by the SAT-HULP program between April 1, 2011, and January 31, 2015. The diagnostic-therapeutic alternatives were as follows: 1) systematic treatment of all patients with N-acetylcysteine (NAC), 2) NAC treatment according to the reported dose; 3) NAC treatment according to a Rümack-Matthew nomogram; 4) NAC treatment according to urine test results confirmed by a blood test, and 5) treatment according to elimination half-life calculation. Probability data were obtained from the SAT-HULP program and validation studies corresponding to the diagnostic tests. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The approaches that were most cost-effective were those guided by reported doses and nomograms. The incremental cost-effectiveness of treatment according to reported dose was €5985.37. The sensitivity analysis showed that the model was highly dependent on variations in the main variables; the probabilistic sensitivity analysis indicated an incremental cost-effectiveness of €25 111.06 (SD, €1 534 420.16; range, €42 136.03-€92 358.75) between the first approach (treat all cases) and last (calculate elimination half-life); half-life calculation was the more efficient. CONCLUSION: Treating according to nomogram was the most efficient diagnostic-therapeutic approach to treating paracetamol poisoning in our hospital. However, when the prevalence of paracetamol poisoning is higher and uncertainty is greater, it would be more efficient to treat based on calculating the half-life.

OBJETIVO: Evaluar la eficiencia de cinco estrategias diagnóstico-terapéuticas posibles ante la sospecha de intoxicación aguda (IA) por paracetamol (PCT) a través de un análisis coste-efectividad, según la perspectiva del financiador en un hospital universitario terciario dotado de un programa de toxicovigilancia activa validado (SAT-HULP). METODO: Estudio de análisis de coste-efectividad (ACE) de cinco alternativas diagnóstico-terapéuticas consideradas en el abordaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con intoxicación por PCT mediante un modelo de árbol de decisión. La población estudiada fueron los pacientes atendidos en un SUH detectados por el SAT-HULP, entre el 1/04/2011 y el 31/01/2015. Las alternativas diagnóstico-terapéuticas consideradas fueron: 1) administración sistemática de Nacetilcisteína; 2) administración del tratamiento según la dosis confirmada; 3) tratamiento según el nomograma de Rümack- Matthew; 4) tratamiento según test de orina confirmado con posterior test en sangre; y 5) tratamiento según el cálculo de la semivida. Los datos correspondientes a probabilidades fueron obtenidos del programa SAT-HULP y publicaciones sobre la validación de las pruebas diagnósticas. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: Las opciones "Tratar según dosis comunicada" y "Tratar según el nomograma" son las que muestran mejor coste-efectividad. Al compararlas, la razón coste-efectividad incremental es de 5.985,37 € para la primera. El análisis de sensibilidad mostró una importante dependencia del modelo a la variación de las variables principales. En el análisis de sensibilidad probabilístico la estrategia "Tratar a todos los casos" respecto a "Cálculo de semivida" obtuvo una razón coste-efectividad incremental de unos 25.111,06 € (DE: 1.534.420,16; intervalo: ­42.136,03 a 92.358,75), resultando esta última la más eficiente. CONCLUSIONES: La estrategia "Tratar según el nomograma" es la alternativa más eficiente en el diagnóstico y tratamiento de la intoxicacióna aguda por Paracetamol en nuestro medio, no así para un escenario de mayor prevalencia e incertidumbre, donde la opción "Cálculo de semivida" se muestra como la más eficiente.

A fast-track anaemia clinic in the Emergency Department: cost-analysis of intravenous iron administration for treating iron-deficiency anaemia.

BACKGROUND: A fast-track anaemia clinic (FTAC) for the management of moderate-to-severe iron-deficiency anaemia (IDA) was established in our Emergency Department in 2010. In this FTAC, the replacement of packed red cell transfusion by ferric carboxymaltose administration was proven to be safe and effective. The aim of this study was a cost-analysis of IDA management in the FTAC, comparing this management with the previous standard care pathway consisting of packed red cell transfusion, if needed, and referral to outpatient specialised care. MATERIALS AND METHODS: A cost study was performed for patients with IDA who were at risk of requiring transfusion (haemoglobin <9 g/dL) but did not require hospitalisation. Total IDA treatment costs in the FTAC were compared to those theoretically incurred if these patients had been managed using the standard care pathway. In addition, a sensitivity analysis considering variations of up to ±30% in ferric carboxymaltose and packed red cell acquisition costs was performed (49 possible scenarios). RESULTS: Between 2012 and 2015, 238 IDA patients were treated in the FTAC. The average treatment cost was € 594±337/patient in the FTAC group and € 672±301/patient in the standard care pathway group, with a saving of € 78±28/patient (95% CI, 22-133; p<0.001). The sensitivity analysis showed that IDA treatment costs in the FTAC (€ 480-722/patient), compared with those of the standard care pathway (€ 550-794/patient), resulted in significant cost-savings for all studied scenarios (€ 51-104/patient; p<0.005). DISCUSSION: The administration of ferric carboxymaltose for IDA management in a FTAC may be cost-saving compared with the standard care pathway.

An acenocoumarol dosing algorithm using clinical and pharmacogenetic data in Spanish patients with thromboembolic disease.

Appropriate dosing of coumarins is difficult to establish, due to significant inter-individual variability in the dose required to obtain stable anticoagulation. Several genetic and other clinical factors have been associated with the coumarins dose, and some pharmacogenetic-guided dosing algorithms for warfarin and acenocoumarol have been developed for mixed populations. We recruited 147 patients with thromboembolic disease who were on stable doses and with an international normalized ratio (INR) between 2 and 3. We ascertained the influence of clinical and genetic variables on the stable acenocoumarol dose by multiple linear regression analysis in a derivation cohort (DC; n = 117) and developed an algorithm for dosing that included clinical factors (age, body mass index and concomitant drugs) and genetic variations of VKORC1, CYP2C9, CYP4F2 and APOE. For purposes of comparison, a model including only clinical data was created. The clinical factors explained 22% of the dose variability, which increased to 60.6% when pharmacogenetic information was included (p<0.001); CYP4F2 and APOE variants explained 4.9% of this variability. The mean absolute error of the predicted acenocoumarol dose (mg/week) obtained with the pharmacogenetic algorithm was 3.63 vs. 5.08 mg/week with the clinical algorithm (95% CI: 0.88 to 2.04). In the testing cohort (n = 30), clinical factors explained a mere 7% of the dose variability, compared to 39% explained by the pharmacogenetic algorithm. Considering a more clinically relevant parameter, the pharmacogenetic algorithm correctly predicted the real stable dose in 59.8% of the cases (DC) vs. only 37.6% predicted by the clinical algorithm (95% CI: 10 to 35). Therefore the number of patients needed to genotype to avoid one over- or under-dosing was estimated to be 5.

Estrategias para el diseño sistematico de un PACS institucional / Strategies for the sistematic design of institutional PACS

Cuando se encara el diseño de un PACS (Picture Archiving and Communications Systems - Sistemas de Almacenamiento y Comunicacion de Imagenes Medicas), se debe tener claro que se trata de un sistema donde las especificaciones estan relacionados directamente con el lugar en donde sera instalado. Por este motivo es dificil encontrar plantillas o modelos que se puedan adaptar a distintas soluciones. Este trabajo intenta desarrollar un metodo sistematico de evaluacion de PACS instalados con el fin de asimilar y utilizar los logros de otros centros. Por otro lado, establece una forma estructurada de trabajo, para el dimensionamiento y descripcion de los requerimientos de un sistema. El metodo mencionado hace uso de relaciones de productividad y eficiencia adimensionales, caracteristica que le permite analizar los PACS, independizandose de la envergadura de este. Entre sus etapas contempla, el relevamiento de la institucion donde se implementara dicho sistema, el formulario de encuesta para la evaluacion de sistemas existentes, la investigacion de la tecnologia disponible en el mercado y un procedimiento de seleccion de dispositivos para obtener la mejor relacion costo / beneficio

Estrategias para el diseño sistematico de un PACS institucional / Strategies for the sistematic design of institutional PACS

Cuando se encara el diseño de un PACS (Picture Archiving and Communications Systems - Sistemas de Almacenamiento y Comunicacion de Imagenes Medicas), se debe tener claro que se trata de un sistema donde las especificaciones estan relacionados directamente con el lugar en donde sera instalado. Por este motivo es dificil encontrar plantillas o modelos que se puedan adaptar a distintas soluciones. Este trabajo intenta desarrollar un metodo sistematico de evaluacion de PACS instalados con el fin de asimilar y utilizar los logros de otros centros. Por otro lado, establece una forma estructurada de trabajo, para el dimensionamiento y descripcion de los requerimientos de un sistema. El metodo mencionado hace uso de relaciones de productividad y eficiencia adimensionales, caracteristica que le permite analizar los PACS, independizandose de la envergadura de este. Entre sus etapas contempla, el relevamiento de la institucion donde se implementara dicho sistema, el formulario de encuesta para la evaluacion de sistemas existentes, la investigacion de la tecnologia disponible en el mercado y un procedimiento de seleccion de dispositivos para obtener la mejor relacion costo / beneficio (AU)