Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done.

BACKGROUND: Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process. METHODS: Thirty Applied Cognitive Task Analysis interviews were conducted with clinical experts (>4 years' experience) including Ward Nurses (n = 7), Outreach or Sepsis Nurses (n = 8), Nurse Manager or Consultant (n = 6), Physiotherapists (n = 4), Advanced Practitioners (n = 4), and Doctor (n = 1) from two National Health Service hospitals and analysed using Framework Analysis. Task-related elements of care escalation were identified and represented in a Functional Resonance Analysis Model. FINDINGS: The NEWS2's clinical escalation response constitutes eight unique tasks and illustrates work-as-prescribed, but our interview data uncovered an additional 24 tasks (n = 32) pertaining to clinical judgement, decisions or processes reflecting work-as-done. Over a quarter of these tasks (9/32, 28 %) were identified by experts as cognitively challenging with a high likelihood of performance variability. Three out of the nine variable tasks were closely coupled and interdependent within the Functional Resonance Analysis Model ('synthesising data points', 'making critical decision to escalate' and 'identifying interim actions') so representing points of potential escalation failure. Data assimilation from different clinical information systems with poor usability was identified as a key cognitive challenge. CONCLUSION: Our data support the emphasis on the need to retain clinical judgement and suggest that future escalation protocols and audit guidance require in-built flexibility, supporting staff to incorporate their expertise of the patient condition and the clinical environment. Improved information systems to synthesise the required data surrounding an unwell patient to reduce staff cognitive load, facilitate decision-making, support the referral process and identify actions are required. Fundamentally, reducing the cognitive load when assimilating core escalation data allows staff to provide better and more creative care. Study registration (ISRCTN 38850) and ethical approval (REC Ref 20/HRA/3828; CAG-20CAG0106).

Commentary: Revisiting nanoparticle-assay interference: There's plenty of room at the bottom for misinterpretation.

Engineered nanomaterials (ENMs) are a diverse class of materials whose distinct properties make them desirable in a multitude of applications. The proliferation of nanotoxicology research has improved our understanding of ENM toxicity, but an under appreciation for their potential to interfere with biochemical assays has hampered progress in the field. The physicochemical properties of ENMs can promote their interaction with membranes or biomacromolecules (e.g. proteins, genomic material). This can influence the activity of enzymes used as biomarkers or as reagents in biochemical assay protocols, bind indicator dyes in cytotoxicity tests, and/or interfere with the cellular mechanisms controlling the uptake of such dyes. The spectral characteristics of some ENMs can cause interference with common assay chromophores, fluorophores, and radioisotope scintillation cocktails. Finally, the inherent chemical reactivity of some ENMs can short circuit assay mechanisms by directly oxidizing or reducing indicator dyes. These processes affect data quality and may lead to significant misinterpretations regarding ENM safety. We provide an overview of some ENM properties that facilitate assay interference, examples of interference and the erroneous conclusions that may result from it, and a number of general and specific recommendations for validating cellular and biochemical assay protocols in nanotoxicology studies.

Post-myomectomy intussusception: report of two cases.

BACKGROUND: Post-myomectomy intussusception is a very rare cause of post-operative intestinal obstruction in adult surgical practice. Preoperative diagnosis is usually missed or delayed because the symptoms are usually subacute and nonspecific. METHOD: The case notes of the patients were retrieved and relevant data extracted and summarized. An extensive literature search was done and results reviewed and compared with the present case. RESULTS: The two patients reported developed features of post operative intestinal obstructions which were thought to be due to adhesive bands and initial conservative managements instituted. Exploratory laparotomies later revealed ileo-ileal and jejuno-ileal intussusceptions which were reduced without resection with good outcome. CONCLUSION: Intussusception is a rare but serious complication of myomectomy. High index of suspicion with prompt intervention and early team management optimize outcomes.

The lithopedion - an unusual cause of an abdominal mass.

We report the rare case of a lithopedion in an asymptomatic 69-year-old woman with poor antenatal history. Diagnosis was confirmed by plain abdominal X-ray. In view of the patient's age and symptomatology, we opted for conservative management with regular abdominal examination and imaging.

Experience in the use of epidural anaesthesia.

BACKGROUND: Epidural anaesthesia is applicable for a wide range of surgical procedures and offers distinct advantages over general and spinal anaesthesia. It is however underutilised in our environment. We report a one year experience in the use of this technique. Our objective is to describe a one year experience in the use of epidural anaesthesia with emphasis on the scope and safety in our institution. METHOD: A retrospective study of all patients that had epidural anaesthesia over a one year period for different procedures. Case notes and anaesthetic records were studied and analysed using EPI info 3.2.1. software. RESULTS: Thirty two patients had epidural anaesthesia over the period. Majority (18 cases) were caesarean sections (56.3%). There were 9 general surgical cases (28.1%), four gynaecologic (12.0%) and one orthopaedic (3.1%) cases. Of the five complications observed (15.6%), only two could be traced to the technique of anaesthesia and the lone mortality (3.1%) was unconnected. CONCLUSION: We conclude that epidural anaesthesia is applicable to a wide range of procedures within and across disciplines in our practice and is both easy to perform and safe.

Experience in the Use of Epidural Anaesthesia

Background: Epidural anaesthesia is applicable for a wide range of surgical procedures and offers distinct advantages over general and spinal anaesthesia. It is however underutilised in our environment. We report a one year experience in the use of this technique. Our objective is to describe a one year experience in the use of epidural anaesthesia with emphasis on the scope and safety in our institution. Method: A retrospective study of all patients that had epidural anaesthesia over a one year period for different procedures. Case notes and anaesthetic records were studied and analysed using EPI info 3.2.1. software. Results: Thirty two patients had epidural anaesthesia over the period. Majority (18cases) were caesarean sections (56.3). There were 9 general surgical cases (28.1); four gynaecologic (12.0) and one orthopaedic (3.1) cases. Of the five complications observed (15.6); only two could be traced to the technique of anaesthesia and the lone mortality (3.1) was unconnected. Conclusion: We conclude that epidural anaesthesia is applicable to a wide range of procedures within and across disciplines in our practice and is both easy to performand safe

Early detection of psychosocial problems in adolescents: how useful is the Dutch short indicative questionnaire (KIVPA)?

BACKGROUND: Psychosocial problems, such as behavioural, emotional, and educational problems, are highly prevalent among children and adolescents. Early treatment may reduce these problems, if accurately identified. Validated questionnaires may support identification. The aim of this study is to assess the psychometric qualities of such a questionnaire, the Short Indicative Questionnaire for Psychosocial problems among Adolescents (KIVPA,) and to determine whether it is suitable for and adds to the early detection of psychosocial problems among adolescents. METHODS: Data came from a national sample of 1,440 Dutch adolescents, using the KIVPA, the Child Behavior Checklist (CBCL), and the Youth Self-Report (YSR). Of these, 1,248 provided data on all questionnaires (77.8%). The scale structure of the KIVPA was assessed; its sensitivity and specificity using CBCL, YSR and referral for psychosocial problems as criteria; and its contribution to detecting CBCL and YSR problems. RESULTS: The KIVPA is mostly uni-dimensional but the variance explained by its main factor is relatively low. The total KIVPA score discriminates between adolescents with and without problems on the three criteria. Using a clinical YSR total problem score as criterion, sensitivity and specificity are 0.82 and 0.85, respectively, at the proposed cut-off (area under the ROC curve: 0.92; 95% confidence interval (CI) 0.90-0.95). The odds ratio of a clinical YSR score for an elevated KIVPA score is 29.1 (95% CI: 14.4-59.1), although the KIVPA mainly covers internalizing problems. CONCLUSION: The KIVPA has added value in the early detection of internalizing psychosocial problems, but is not sufficiently efficient.

Evaluation of the basal and post-adrenocorticotrophic hormone serum concentrations of 17-hydroxyprogesterone for the diagnosis of hyperadrenocorticism in dogs.

Serum concentrations of 17-hydroxyprogesterone and cortisol were measured before and after the administration of exogenous adrenocorticotrophic hormone (ACTH) to three groups of dogs: 27 healthy dogs (group 1), 19 dogs with non-adrenal illness (group 2) and 46 dogs with hyperadrenocorticism (group 3). The median (range) post-ACTH concentrations of 17-hydroxyprogesterone were 5.0 (22.2 to 16.8), 6.9 (2.0 to 36.2) and 14.4 (1.7 to 71) nmol/litre in groups 1, 2 and 3, respectively. There were no significant differences in the basal or post-ACTH concentrations of cortisol or 17-hydroxyprogesterone between groups 1 and 2. The post-ACTH concentrations of 17-hydroxyprogesterone in group 3 were significantly (P<0.001) greater than those in groups 1 and 2 combined. The area under the receiver operating curve (ROC) for the post-ACTH concentration of cortisol (0.94) was significantly greater than that for the post-ACTH concentration of 17-hydroxyprogesterone (0.76). Using a two-graph ROC analysis, a cut-off of 8.5 nmol/litre was found to maximise both the sensitivity and specificity of the post-ACTH concentration of 17-hydroxyprogesterone for the diagnosis of hyperadrenocorticism at 71 per cent. With a cut-off of 4.5 nmol/litre the sensitivity increased to 90 per cent but the specificity decreased to 40 per cent; with a cut-off of 16.7 nmol/litre the specificity increased to 90 per cent but the sensitivity decreased to 47 per cent.

Dieting in children referred to the paediatric outpatient clinic.

UNLABELLED: Dietary interventions are sometimes necessary, even in young children; however, adhering to a diet can cause medical and psychosocial problems. Therefore, insight into frequency, reasons, and effectiveness is important. To establish the prevalence of dieting in children referred to a general paediatric outpatient clinic, parents of newly referred patients were given a structured questionnaire. Excluded were children whose parents did not speak Dutch, those younger than 3 months and emergency cases. Of 1826 patients, 907 (511 boys, 56%; median age 5 years, range 0-18 years) were included; 124 (13.7%, 95% CI 11.5%-15.9%) were or had been on a diet, more boys than girls (82/511 versus 42/396, P=0.02). In 60% of patients, the diet was started before the age of 2 years, 50% had been dieting longer than a year. Diets most used were: cow's milk free (62%), egg-free (20%), lactose-free (14%), no sugar (20%) and no colouring additives (20%). Reasons for dieting were gastrointestinal (51%), dermal (51%) and behavioural (27%) symptoms or complaints. Dieting was considered effective by the parents in 65% of cases and 61% reported no problems. CONCLUSION: One in eight children, referred to a general paediatric outpatient clinic is or has been dieting. Most parents reported positive effects with no problems. Some children were on a difficult-to-keep diet with serious medical and psychosocial implications, without being tested. Scientific evidence for dieting should be sought and the results discussed with the parents.

Questions raised by artificial prolongation of life of the aged patient.

The existence of treatments which now make it possible to prolong life beyond the point when it would previously have ended, gives rise to particular questions in the context of the care of aged patients: the distinction between curative and palliative treatment, the evaluation of incurability, the right to refuse treatment, competence to make such a decision and the use of the limited objective and pure objective tests in the event of incompetence. The natural role of the physician as protector adds a further ethical dimension to what is also a medicolegal question.

Comparison of detergents for extraction and ion-exchange high-performance liquid chromatography of Sendai virus membrane proteins.

The integral membrane proteins of Sendai virus, haemagglutinin-neuraminidase (HN) and fusion protein (F) were extracted from purified virions with a non-ionic and two zwitterionic detergents, i.e., pentaethylene glycol monolauryl ether (C12E5), lauryldimethylamine oxide (LDAO) and dodecyldimethylammoniopropane-1-sulphonate (SB12), respectively. The extracts were subjected to ion-exchange high-performance liquid chromatography (HPIEC) using 0.1% of the detergent in the eluent on four different columns (MA7Q, Zorbax BioSeries SAX, Mono Q and PL-SAX) with a quaternary amine as interacting ligand and with different pore sizes: non-porous and 30, 80 nm and 400 nm, respectively. The relative recoveries of protein were similar for all the columns. The highest recovery of HN and F protein and the best separation were obtained with C12E5. Analysis of HPIEC fractions with monoclonal antibodies directed against conformational epitopes showed that C12E5 had less effect on the conformation than the other two detergents.

Comparison of non-ionic detergents for extraction and ion-exchange high-performance liquid chromatography of Sendai virus integral membrane proteins.

The integral membrane proteins of Sendai virus haemagglutinin-neuraminidase (HN) and fusion protein (F) were extracted from purified virions with 2% of a non-ionic detergent, i.e., polyoxyethylene alkyl ethers varying by 8-14 hydrocarbon units in the alkyl chain and by 4-8 ethylene glycol units in the oxyethylene chain. Triton X-100 and octyl glucoside were included as reference detergents. The hydrophile-lipophile balance (HLB) and the critical micelle concentration (CMC) of the detergents were determined. A decrease in length of the oxyethylate by 8-5 ethylene glycol units and an increase in the alkylate by 8-12 hydrocarbon units resulted in higher yields of extracted proteins. The highest yields were obtained for C12E5 with an HLB of 11.7. Yields of extracted protein could be correlated with the HLB values of the polyoxyethylene alkyl ethers. The structural integrity of HN and F was not affected during extraction by either detergent as measured by their reactivity with monoclonal antibodies directed against native HN and F. Extracts were subjected to anion-exchange high-performance liquid chromatography (HPLC) on a Mono Q column in the presence of 0.1% of the detergent used for extraction. Eluate fractions were analysed by sodium dodecyl polyacrylamide gel electrophoresis and recoveries of HN and F protein were determined by size-exclusion HPLC. The immunological activity of HN and F was tested in an enzyme-linked immunosorbent assay. The highest recoveries of HN and F (80%) were obtained with C10E5 in the elution buffer. HN and F were partially purified and the immunological activity was well preserved.