Coping with uncertainty in clinical practice: a narrative review.

Clinicians must make decisions amid the uncertainty that is ubiquitous to clinical practice. Uncertainty in clinical practice can assume many forms depending on its source, such as insufficient personal knowledge or scientific evidence, limited practical understanding or competence, challenging interpersonal relationships, and complexity and ambiguity in clinical encounters. The level and experience of uncertainty varies according to personal traits, clinical context, affective factors and sociocultural norms. Clinicians vary in their tolerance of uncertainty, and maladaptive responses may adversely affect patient care and clinician wellbeing. Various strategies can be used to minimise and manage, but not eliminate, uncertainty and to share uncertainty with patients without compromising the clinician-patient relationship or clinician credibility.

Pediatric Erythema Multiforme in the Emergency Department: More Than "Just a Rash".

OBJECTIVES: Erythema multiforme (EM) is characterized by symmetrical acrally distributed target lesions; however, other conditions can mimic the clinical features of EM. Although it is typically self-limiting, alternative diagnoses may be life-threatening and require immediate identification and treatment. This study aimed to investigate the clinical spectrum and accuracy of diagnosis of pediatric EM in the emergency department (ED). METHODS: A retrospective, descriptive study of all pediatric patients with an ED information system diagnosis of EM at 2 EDs in Southeast Queensland between January 2010 and July 2013. Cases were evaluated using previously established EM classification criteria. RESULTS: Seventy patients (34 males and 36 females) with a diagnosis of EM were identified. From 57 cases where a diagnosis could be established, 9 cases fulfilled the classification criteria for EM. No patients had mucosal involvement, and therefore, all 9 cases were classified as EM minor, with the majority (89%) attributed to viral infection. Of the 48 cases that did not fit the criteria, the most common condition misdiagnosed as EM was urticaria multiforme (n = 20). CONCLUSIONS: In the ED setting, EM in children is frequently misdiagnosed. Greater awareness of diagnostic factors for EM may improve diagnostic accuracy. Teledermatology and incentives to include clinical pictures in the (electronic) medical record may be useful adjuncts for patients with suspected EM and other dermatological conditions.

Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial.

OBJECTIVE: To assess the effect of a single dose of intravenous dexamethasone in addition to routine treatment on visual analogue scale (VAS) pain scores at 24 h in emergency department (ED) patients with low back pain with radiculopathy (LBPR). METHODS: Double-blind randomised controlled trial of 58 adult ED patients with LBPR, conducted in one tertiary and one urban ED. The intervention was 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. The primary outcome was the change in VAS pain scores between presentation and 24 h. Secondary outcomes included VAS pain scores at 6 weeks, ED length of stay (EDLOS), straight leg raise (SLR) angles and Oswestry functional scores. RESULTS: Patients treated with dexamethasone had a 1.86 point (95% CI 0.31 to 3.42, p=0.019) greater reduction in VAS pain scores at 24 h than placebo (dexamethasone: -2.63 (95% CI -3.63 to -1.63) versus placebo: -0.77 (95% CI -2.04 to 0.51)). At 6 weeks, both groups had similar significant and sustained decrease in VAS scores compared with baseline. Patients receiving dexamethasone had a significantly shorter EDLOS (median: 3.5 h vs 18.8 h, p=0.049) and improved SLR angle at discharge (14.7°, p=0.040). There was no difference in functional scores. CONCLUSIONS: In patients with LBPR, a single dose of intravenous dexamethasone in addition to routine management improved VAS pain scores at 24 h, but this effect was not statistically significant at 6 weeks. Dexamethasone may reduce EDLOS and can be considered as a safe adjunct to standard treatment. TRIAL REGISTRATION NUMBER: ACTRN12611001020976.

A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey.

OBJECTIVE: This study prospectively evaluated in-hospital and postdischarge missed injury rates in admitted trauma patients, before and after the formalisation of a trauma tertiary survey (TTS) procedure. METHODS: Prospective before-and-after cohort study. TTS were formalised in a single regional level II trauma hospital in November 2009. All multitrauma patients admitted between March-October 2009 (preformalisation of TTS) and December 2009-September 2010 (post-) were assessed for missed injury, classified into three types: Type I, in-hospital, (injury missed at initial assessment, detected within 24 h); Type II, in-hospital (detected in hospital after 24 h, missed at initial assessment and by TTS); Type III, postdischarge (detected after hospital discharge). Secondary outcome measures included TTS performance rates and functional outcomes at 1 and 6 months. RESULTS: A total of 487 trauma patients were included (pre-: n = 235; post-: n = 252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8 vs. 4.8 %, P = 0.61), as were postdischarge missed injury rates (Type III) at 1 month (13.7 vs. 11.5 %, P = 0.43), and 6 months (3.8 vs. 3.3 %, P = 0.84) after discharge. TTS performance was substantially higher in the post-group (27 vs. 42 %, P < 0.001). Functional outcomes for both cohorts were similar at 1 and 6 months follow-up. CONCLUSIONS: This is the first study to evaluate missed injury rates after hospital discharge and demonstrated cumulative missed injury rates >15 %. Some of these injuries were clinically relevant. Although TTS performance was significantly improved by formalising the process (from 27 to 42 %), this did not decrease missed injury rates.

Expanding emergency department capacity: a multisite study.

OBJECTIVES: The aims of the present study were to identify predictors of admission and describe outcomes for patients who arrived via ambulance to three Australian public emergency departments (EDs), before and after the opening of 41 additional ED beds within the area. METHODS: The present study was a retrospective comparative cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (LOS), admission requirement, access block, hospital LOS and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission. RESULTS: Almost one-third of all 286037 ED presentations were via ambulance (n=79196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED LOS, admission requirement, access block and hospital LOS did not improve. Strong predictors of admission before and after increased capacity included age >65 years, Australian Triage Scale (ATS) Category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS >4h. With additional capacity, the odds ratios for these predictors increased for age >65 years and ED LOS >4h, and decreased for ATS category and ED diagnoses. CONCLUSIONS: Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes, but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing or decreasing) ED bed numbers, the whole healthcare system needs to be considered.

Prediction and surveillance of influenza epidemics.

OBJECTIVE: To describe the use of surveillance and forecasting models to predict and track epidemics (and, potentially, pandemics) of influenza. METHODS: We collected 5 years of historical data (2005-2009) on emergency department presentations and hospital admissions for influenza-like illnesses (International Classification of Diseases [ICD-10-AM] coding) from the Emergency Department Information System (EDIS) database of 27 Queensland public hospitals. The historical data were used to generate prediction and surveillance models, which were assessed across the 2009 southern hemisphere influenza season (June-September) for their potential usefulness in informing response policy. Three models are described: (i) surveillance monitoring of influenza presentations using adaptive cumulative sum (CUSUM) plan analysis to signal unusual activity; (ii) generating forecasts of expected numbers of presentations for influenza, based on historical data; and (iii) using Google search data as outbreak notification among a population. RESULTS: All hospitals, apart from one, had more than the expected number of presentations for influenza starting in late 2008 and continuing into 2009. (i) The CUSUM plan signalled an unusual outbreak in December 2008, which continued in early 2009 before the winter influenza season commenced. (ii) Predictions based on historical data alone underestimated the actual influenza presentations, with 2009 differing significantly from previous years, but represent a baseline for normal ED influenza presentations. (iii) The correlation coefficients between internet search data for Queensland and statewide ED influenza presentations indicated an increase in correlation since 2006 when weekly influenza search data became available. CONCLUSION: This analysis highlights the value of health departments performing surveillance monitoring to forewarn of disease outbreaks. The best system among the three assessed was a combination of routine forecasting methods coupled with an adaptive CUSUM method.

Linking ambulance, emergency department and hospital admissions data: understanding the emergency journey.

OBJECTIVE: To assess the accuracy of data linkage across the spectrum of emergency care in the absence of a unique patient identifier, and to use the linked data to examine service delivery outcomes in an emergency department (ED) setting. DESIGN: Automated data linkage and manual data linkage were compared to determine their relative accuracy. Data were extracted from three separate health information systems: ambulance, ED and hospital inpatients, then linked to provide information about the emergency journey of each patient. The linking was done manually through physical review of records and automatically using a data linking tool (Health Data Integration) developed by the CSIRO (Commonwealth Scientific and Industrial Research Organisation). Match rate and quality of the linking were compared. SETTING: 10,835 patient presentations to a large, regional teaching hospital ED over a 2-month period (August - September 2007). RESULTS: Comparison of the manual and automated linkage outcomes for each pair of linked datasets demonstrated a sensitivity of between 95% and 99%; a specificity of between 75% and 99%; and a positive predictive value of between 88% and 95%. CONCLUSIONS: Our results indicate that automated linking provides a sound basis for health service analysis, even in the absence of a unique patient identifier. The use of an automated linking tool yields accurate data suitable for planning and service delivery purposes and enables the data to be linked regularly to examine service delivery outcomes.

Tertiary survey performance in a regional trauma hospital without a dedicated trauma service.

BACKGROUND: Initial management of trauma patients is focused on identifying life- and limb-threatening injuries and may lead to missed injuries. A tertiary survey can minimise the number and effect of missed injuries and involves a physical re-examination and review of all investigations within 24 h of admission. There is little information on current practice of tertiary survey performance in hospitals without a dedicated trauma service. We aimed to determine the rate of tertiary survey performance and the detail of documentation as well as the baseline rate of missed injuries. METHODS: We performed a retrospective, descriptive study of all multitrauma patients who presented to an Australian level II regional trauma centre without a dedicated trauma service between May 2008 and February 2009. A medical records review was conducted to determine tertiary survey performance and missed injury rate. RESULTS: Of 252 included trauma patients, 20% (n = 51) had a tertiary survey performed. A total of nine missed injuries were detected in eight patients (3.2%). Of the multiple components of the tertiary survey, most were poorly documented. Documentation was more comprehensive in the subgroup of patients who did have a formal tertiary survey. CONCLUSIONS: Tertiary survey performance was poor, as indicated by low documentation rates. The baseline missed injury rate was comparable to previous that of retrospective studies, although in this study an underestimation of true missed injury rates is likely. Implementing a formal, institutional tertiary survey may lead to improved tertiary survey performance and documentation and therefore improved trauma care in hospitals without a dedicated trauma service.

Predicting influenza A and 2009 H1N1 influenza in patients admitted to hospital with acute respiratory illness.

OBJECTIVE: To create a clinical decision tool for suspected influenza A (including 2009 H1N1) to facilitate treatment and isolation decisions for patients admitted to hospital with an acute respiratory illness from the emergency department (ED) during a 2009 H1N1 pandemic. METHODS: Cross-sectional study conducted in two hospitals in Queensland, Australia. All patients admitted to hospital from the ED between 24 May and 16 August 2009 with an acute respiratory illness were included. All had nasal and throat swabs taken. Data were collected from clinical chart review regarding clinical symptoms, co-morbidities, examination findings, pathology and radiology results. Influenza A status was detected by reverse transcription-PCR assay. Univariate and multivariate regression analyses were performed to identify independent predictors of influenza A status. RESULTS: 346 consecutive patients were identified, of which 106 were positive for 2009 H1N1 influenza; an additional 11 patients were positive for other influenza A viruses. Independent clinical predictors (with points allocated using weighted scoring) for all types of influenza A in patients admitted with acute respiratory illness were: age 18-64 years (2 points); history of fever (2); cough (1); normal level of consciousness (2); C-reactive protein >5 and ≤ 100 mg/l (2) and normal leucocyte count (1). A clinical score of 5 (presence of two or three predictors) gave a sensitivity of 93% (95% CI 87% to 96%), specificity of 36% (95% CI 30% to 42%), resulting in a negative-predictive value of 91% (95% CI 83% to 95%). CONCLUSION: A clinical prediction tool was developed that may be able to assist in making appropriate isolation decisions during future 2009 H1N1 outbreaks.

Caffeine can decrease insulin sensitivity in humans.

OBJECTIVE: Caffeine is a central stimulant that increases the release of catecholamines. As a component of popular beverages, caffeine is widely used around the world. Its pharmacological effects are predominantly due to adenosine receptor antagonism and include release of catecholamines. We hypothesized that caffeine reduces insulin sensitivity, either due to catecholamines and/or as a result of blocking adenosine-mediated stimulation of peripheral glucose uptake. RESEARCH DESIGN AND METHODS: Hyperinsulinemic-euglycemic glucose clamps were used to assess insulin sensitivity. Caffeine or placebo was administered intravenously to 12 healthy volunteers in a randomized, double-blind, crossover design. Measurements included plasma levels of insulin, catecholamines, free fatty acids (FFAs), and hemodynamic parameters. Insulin sensitivity was calculated as whole-body glucose uptake corrected for the insulin concentration. In a second study, the adenosine reuptake inhibitor dipyridamole was tested using an identical protocol in 10 healthy subjects. RESULTS: Caffeine decreased insulin sensitivity by 15% (P < 0.05 vs. placebo). After caffeine administration, plasma FFAs increased (P < 0.05) and remained higher than during placebo. Plasma epinephrine increased fivefold (P < 0.0005), and smaller increases were recorded in plasma norepinephrine (P < 0.02) and blood pressure (P < 0.001). Dipyridamole did not alter insulin sensitivity and only increased plasma norepinephrine (P < 0.01). CONCLUSIONS: Caffeine can decrease insulin sensitivity in healthy humans, possibly as a result of elevated plasma epinephrine levels. Because dipyridamole did not affect glucose uptake, peripheral adenosine receptor antagonism does not appear to contribute to this effect.

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial.

BACKGROUND: Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge. METHODS/DESIGN: We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality. DISCUSSION: The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders. TRIAL REGISTRATION: ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013.

The effect of tertiary surveys on missed injuries in trauma: a systematic review.

BACKGROUND: Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes. METHODS: A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. 'Missed injury' was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale. RESULTS: Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01). CONCLUSIONS: Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.

Doctors' knowledge of patient radiation exposure from diagnostic imaging requested in the emergency department.

OBJECTIVE: To assess emergency department (ED) doctors' knowledge of radiation doses associated with diagnostic imaging and to describe their practice with regard to informing patients of risk. DESIGN, PARTICIPANTS AND SETTING: Prospective, questionnaire-based observational study in May 2009 among all 110 doctors in the EDs of a 570-bed teaching hospital and a 200-bed district hospital. MAIN OUTCOME MEASURES: Percentage knowledge score; and frequency of discussing radiation risk with patients, based on responses to three scenarios rated on a visual analogue scale (VAS), where a score of 100 indicates doctors would always discuss it. RESULTS: 96 doctors (87%) completed the questionnaire. The overall mean knowledge score was 40% (95% CI, 38%-43%). Senior doctors scored somewhat higher than junior doctors, but not significantly (42% v 39%; P = 0.75). Over three-quarters of doctors (78%) underestimated the lifetime risk of fatal cancer attributable to a single computed tomography scan of the abdomen. Most doctors (76%) reported never having had any formal training on risks to patients from radiation exposure. The frequency at which doctors would inform patients of the risk of radiation varied greatly depending on the clinical scenario (mean VAS scores, between 38 and 90). CONCLUSION: Emergency doctors in our sample had a varied knowledge of the risks from radiation exposure, but overall knowledge was poor. Staff should receive education, and the diagnostic imaging request process may need to include information on radiation doses and risks.

A survey of drug-dose calculation skills of Australian tertiary hospital doctors.

OBJECTIVE: To assess the ability of doctors to calculate drug doses and their workplace prescribing and calculation habits. DESIGN AND SETTING: Prospective, questionnaire-based observational study conducted at a 570-bed teaching hospital in February 2007. PARTICIPANTS: Convenience sample of 190 doctors, representing all acute medical and surgical disciplines and diverse levels of experience. MAIN OUTCOME MEASURES: Demographic data, self-reported prescribing habits, predicted score on a 12-item test of ability to calculate drug doses, score considered adequate for peers, and actual score. RESULTS: 141 doctors (74%) completed the questionnaire. The mean actual score on the test was 72.5% (95% CI, 67.8%-77.3%), which was similar to the group's mean predicted score (74.7%; 95% CI, 71.0%-78.5%) but significantly lower than the mean of the score they considered adequate (91.6%; 95% CI, 89.5%-93.8%) (P < 0.001). Subgroup analyses showed that senior doctors and those in critical care specialties (intensive care, emergency medicine and anaesthesia) achieved significantly higher actual scores than junior doctors and those in non-critical care specialties, respectively. CONCLUSIONS: Doctors expect their colleagues to perform significantly better in a drug-dose calculation test than they expect to, or can achieve, themselves. Junior staff and those in non-critical care specialties should be targeted for education in the skill of drug-dose calculation to reduce the risk of medication error and its consequences.