Resuscitation Today Summer 2016

Volume 3 No. 2

Summer 2016

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

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Performance updates to award winning Brayden CPR manikin! ✓ Now Fully ERC & AHA (2015) Guideline Compliant

In this issue Resuscitation Today Conference Programme The Cube Approach to Resuscitation Audit The Face of Major Trauma is Changing

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We have listened

Performance updates to award winning Brayden CPR manikin!

CONTENTS

CONTENTS

Resuscitation Today

✓ Now Fully ERC & AHA (2015) Guideline Compliant 4 EDITORS COMMENT 7

EDUCATION

18

EVIDENCE

28

This issue edited by: Alan Batt c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com

NEWS

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COVER STORY

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Professor Andy Newton, Consultant Paramedic and Chief Clinical Officer, South East Coast Ambulance Service NHS Foundation Trust said: “I believe the Brayden manikin represents an important and innovative advance to help ensure effective CPR competence upon which all successful resuscitation is based”.

“This manikin is a refreshing change from traditional basic life support manikins. I have found my class more eager to practice with this new CPR feedback technique. Demonstrating blood flow and the concept of CPR in this unique way engages every class I teach. Over the last year the manikin has proved to be robust and reliable after being transported to a variety of locations for basic CPR teaching sessions”.

PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company.

Next Issue Autumn 2016 Subscription Information – Summer 2016 Resuscitation Today is a bi-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details.

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RESUSCITATION TODAY - SUMMER 2016

Rob Morrison, Resuscitation Officer, Dartford & Gravesham NHS Trust, Darent Valley Hospital said:

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3

EDITORS COMMENT

EDITORS COMMENT So now that we’ve had time to reflect on the introduction of the 2015 Guidelines, absorb the evidence and put it into practice, how have the changes worked for your organisation? Have you been measuring the implementation of the guidelines? Are the guidelines impacting on care, and ultimately outcomes?

The continued measurement of patient outcomes needs to be central to the development and refinement of our approach to resuscitation.

RESUSCITATION TODAY - SUMMER 2016

4

“Speaking directly to one of the issues we raised in the last issue, namely patient safety during resuscitation, this issue we take a look at suggested improvements in medication packaging and storage.”

We continue our pursuit of reviewing themes of education, evidence and equipment. Speaking directly to one of the issues we raised in the last issue, namely patient safety during resuscitation, this issue we take a look at suggested improvements in medication packaging and storage. Our colleagues from the US, Klint and Bruce take us through some of the steps we can take to reduce medication errors, including provider diligence, simulation, and they introduce us to the EZDrugID movement.

As we write we’re packing our bags for the NWAS Cardiac Alert Conference, smaccDUB, SPIRES and the EMS Gathering. Along with the team from the Academy of Professional Development, we’re holding workshops at the EMS Gathering on immersive simulation and high-risk personal protective equipment, along with demonstrations of equipment and strategies to improve the level of care provided. We hope to see some of you there too!

Until next time,

Alan Batt Editor

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EDUCATION

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EDUCATION

THE CUBE APPROACH TO RESUSCITATION AUDIT Angela Jones – Senior Nurse, Resuscitation Service; Andrew Morris - Resuscitation Practitioner; Dr Tony Turley – Assistant Medical Director (AMD) Quality and Safety; Kerry Ashmore – Head, Business Intelligence Service.

CARDIFF and VALE UNIVERSITY HEALTH BOARD

Introduction One of the core components of a Resuscitation Service is to collect data pertaining to Cardiac Arrests.

Cardiff and Vale University Health Board is a National Health Board in Wales. It came into being on 1 October 2009 through the amalgamation of three NHS organisations in the Cardiff and Vale of Glamorgan. The three organisations amalgamated were: Cardiff and Vale NHS Trust, employing 12,000 staff and previously responsibility for hospital services in the Cardiff and Vale of Glamorgan area; Cardiff Local Health Board; and Vale of Glamorgan Local Health Board both responsible for GP, Dental, Optical and pharmacy services.

The Resuscitation Service within the Health Board is comprised of a Senior Nurse and 4.1 Whole Time Equivalent (WTE) Resuscitation Practitioners – 3.6 WTE substantive for the UHB (including Primary Care) and 0.5 for the Velindre Cancer Centre (VCC) Service Level Agreement (SLA).

The Service is one of the few Services that has a University Health Board (UHB) wide, multi-disciplinary remit and it has a significant impact across the organisation. Resuscitation training and education includes advanced and basic training in adults, paediatrics and newborn resuscitation for all members of the multidisciplinary team in the acute hospitals, University Hospital Llandough (UHL) and University Hospital of Wales (UHW). The Service also has a remit to ensure that staff and

attendance at resuscitation calls and retrospective reviews of patient notes has led to the collection of over 6000 records. The Resuscitation Service clinical audit date has been highlighted as best practice by the Rapid Response to Acute Illness Learning Set (RRAILS) – an All Wales response to the recognition and management of acutely ill patients and the Welsh Resuscitation Forum – the forum for all Resuscitation Practitioners across Wales.

The Resuscitation Service collates data for all Resuscitation Team calls throughout the UHB. The UHB is the only Health Board in Wales that has a complete data set, this has been confirmed through the Welsh Resuscitation Forum. The information collated by the Resuscitation Service exceeds the universally accepted Utstein data set requirements for Resuscitation audit.

Information is obtained through the Resuscitation Practitioners attending Resuscitation Team calls, staff returning audit forms and also through retrospective reviews. The audit is a system of identifying issues with staff recognition of deterioration in patients physical condition or management of patients with NEWS>9, peri-arrest or in cardiorespiratory arrest.

The Resuscitation Practitioners complete the following audit form as a standard throughout the UHB. The front of this form is also the form that is completed and returned by ward/department staff or the Resuscitation Team.

departments are adequately trained and equipped to deal with cardiac arrests and acutely ill patients in the outlying community hospitals; St Davids, Cardiff Royal Infirmary, West Wing, Barry, Rookwood and Hafan Y Coed. This also includes community staff such as district nurses and health visitors and more recently through a Service Level Agreement External Defibrillation in GP surgeries throughout Cardiff and the Vale.

The Service has developed significantly over the years and has a major role in training and education in cardiac arrest management, recognition of the sick patient, and prevention of cardiac arrest and patient death across the UHB. Even though this dynamic service is small it has a significant impact throughout the UHB.

Background In 2008, the UHB began to undertake formalised resuscitation audits.

RESUSCITATION TODAY - SUMMER 2016

with Primary Care the provision of Basic Life Support and Automated

The universally accepted ‘Utstein’ template has been used to ensure data collection is accurate and of sufficient quality. Since this time,

7

EDUCATION

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EDUCATION The back aspect of the form is completed by the Resuscitation

the additional benefit of being able to drill through seamlessly to

Practitioners on retrospective review (or during attendance at a 2222

patient level information including call details and interventions.

call). If required, all members of the service have immediate access to flag any concerns to the Assistant Medical Director, this ensures that

Its introduction to the Resuscitation Service has allowed us to analyse

there is a robust process insitu to address concerns in a timely manner.

our extensive data set, collected over the last seven years.

Copies of Audit Forms:

Evaluation The Resuscitation Cube, since its inception in the April 2015 has

EVALUATION already improved the efficiency of data analysis by the Resuscitation Service. This has been achieved by streamlining the process for data

The Resuscitation Cube, sinceofits inception in the April 2015 has extraction such as automatic collation survival to discharge following

Cardiac Arrest. information wasby previously obtained throughService. a time efficiency of This data analysis the Resuscitation This ha consuming manual interrogation of several databases including PMS.

streamlining the process for data extraction such as automatic co This process involved two members of staff in the Resuscitation Service.

discharge following Cardiac Arrest.

This information was This information is regularly presented during meetings throughout thepreviously ob UHB and is also used tointerrogation provide wards of withseveral up to date figures related to consuming manual databases including PMS. the management of acutely ill/deteriorating patients and those patients

AIMS/PURPOSE

two members of staff in the Resuscitation Service. This information who have suffered Cardiac or Respiratory Arrest.

duringanalysis meetingsand throughout the UHB and is also used to provide w The aim of the project was to maximise collection, distribution of essential data Aims/Purpose figures related to the management of acutely ill/deteriorating patients a

related to Resuscitation and Emergency Care throughout the UHB. This data is utilised to

Outcome have suffered Cardiac or Respiratory Arrest.

The aim of the project was to maximise collection, analysis and

improve patient safety and address any clinical governance issues. Utilisation of this data distribution of essential data related to Resuscitation and Emergency

There have been a number of benefits to the Resuscitation Service and

OUTCOME and safety through resource planning, including

Care throughout theused UHB. This is utiliseddirect to improve patientcare safety will be to data improve patient

wider UHB.

and address any clinical governance issues. Utilisation of this data will

There havePolicies been a number of benefits toand the Resuscitation Service and requirements, with Organisational and Strategies also in be used toeducational improve direct patient care and safetyin-line through resource planning, including educational requirements, in-line with Organisational

What are the benefits for the Organisation?

compliance with National and International Guidelines recommendations.

What areand the benefits for the Organisation?

Policies and Strategies and also in compliance with National and International Guidelines and recommendations.

OUTLINE

OutlineAn

exciting opportunity for the Resuscitation Service to enhance the ability to provide time

efficient and resource efficient data across the UHB. This project developed the existing data

An exciting opportunity for the Resuscitation Service to enhance the

set held by the Service ability to provide time efficient and Resuscitation resource efficient data across

and through collaboration with the Business

the UHB. This project developed the existing data set held by the

Intelligence Warehouse an electronic “Resuscitation Cube” was created that directly imports

Resuscitation Service and through collaboration with the Business

Intelligence Warehouse an electronic Cube” wasPMS information from the “Resuscitation Resuscitation and created that directly imports information from the Resuscitation and

allowing all data to be interrogated, analysed

and utilised for patient care. This project was supported of the Assistant Medical Director.

PMS allowing all data to be interrogated, analysed and utilised for patient care. This project was supported of the Assistant Medical

The Cube is a software package that can be used to provide operational performance information and analytics. An opportunity arose for the Service to enhance the ability to

The Cube is a software package that can be used to provide

operational performance information and analytics.efficient An opportunity provide time and resource data. arose for the Service to enhance the ability to provide time and

Through collaboration with the Business

Warehouse an electronic “Resuscitation resource Intelligence efficient data. Through collaboration with the Business

Cube” was created.

Intelligence Warehouse an electronic “Resuscitation Cube” was created.

Data for reporting is presented using the IMB Cognos Business Intelligence System in the

form ofisapresented multi-dimensional cube and dashboard.

Data for reporting using the IMB Cognos Business

This approach enables ‘headline’ figures to

Intelligence System in the form of a multi-dimensional cube

be presented immediately on logging in to the system. Online use of the cube enables users

and dashboard. This approach enables ‘headline’ figures to be

navigateontheir way presentedtoimmediately logging in tointuitively the system. through Online use pre-calculated of

statistics to find trends, patterns and

RESUSCITATION TODAY - SUMMER 2016

Director.

the cube enables users to navigate their way intuitively through

outliers, with the additional benefit of being able to drill through seamlessly to patient level

pre-calculated statistics to find trends, patterns and outliers, with

information including call details and interventions.

9

EDUCATION 350

The Resuscitation Cube, along with Electronic Mortality Audit

300

CARDIAC ARREST COLLAPSE / ? CAUSE

300

CARDIAC ARREST

250

MISTAKEN CALL COLLAPSE / ? CAUSE

200 150

Calls

Calls

250

200

100 150

MISTAKEN CALL NEWS 9 OR

50 100

NEWS 9 OR Not Defined GREATER

GREATER

050 2015

2013

20152014

Date

2014

2012

2013

2011

2012

2011

20102010

20092009

Not Defined 20082008

0

Tool (EMAT), has allowed the Resuscitation Service to utilise data which now minimises waste, and continue to strive to prevent harm

350

OUT OF HOSPITAL ARREST

OUT OF HOSPITAL ARREST

through using existing initiatives previously implemented by the Resuscitation Service eg National Early Warning Score (NEWS).

Also, the provision of timely and appropriate medical response to deteriorating patients. In 2012, the Resuscitation Service was tasked with the leading the implementation of NEWS across the UHB. It was recognised that alongside the recognition of the acutely ill patient, a structured response needed to be developed to ensure that patients were referred and reviewed in a timely manner.

Date

Gathering information for this graph would have previously taken 9 hours. It can now be produced in less than 2 minutes.

The Resuscitation Cube will also allow us to align 2222 episodes

The Service also implemented a SBAR (Situation, Background, Assessment and Recommendation) document for completion at the time of referral. The duplicate nature of this form would allow a

to Survival to Discharge – again a process that required manual

copy to be retained in the patient notes and a copy to be returned

interrogation and often repeated database interrogation to ensure that

back to the Resuscitation Service for audit purposes.

The Resuscitation Cube Cube will allow us to 2222 2222 episodes to Survival to Discharge – The Resuscitation willalso also allow usalign to align episodes to Survival to Discharge – data was accurate. again a process that required manual interrogation and often repeated database It wasdatabase also recognised that there was a need to highlight the again a process that required manual interrogation and often repeated interrogation to ensure that data was accurate.

interrogation to ensure that data was accurate.

Survival to Discharge (rolling 18 months).

Survival to Discharge (rolling 18 months).

Survival to Discharge (rolling 18 months).

importance of Sepsis Screening as part of NEWS implementation.

The Service developed an educational DVD to be part of the standardised teaching programme for staff to assist with implementation.

This project has been presented in a number of forums, including the Resuscitation Council (UK) Symposium 2015, the Chief Nursing Officer Conference, International Forum on Quality and Safety in Healthcare in Gothenburg and is due to be presented in the RCN International Centenary Conference. The project has also been submitted to the NHS Wales Awards 2016 and Patient Safety

This data is now updated following an upload and refreshing of patient data each night. Awards 2016.

This data is now updated following an upload and refreshing of patient data each night.

This report measures the percentage of patients who survive cardiac arrest and

This project is progressing into the next stage, whereby subsequently be discharged alive.

Patients whose resuscitation event occurred in This data is now updated following an went uploadon andto refreshing of patient data each night. data collection will be at the patient’s bedside and therefore This report measures the percentage of patients who survive cardiac Emergency Department then automatically admitted are excluded the survival to uploaded onto thefrom database.

Therefore negating the arrest and subsequently went on to be dischargedand alive. were Patientsnot whose resuscitation event occurred ininformation.

Emergency Department and were not discharge

then admitted are excluded from the survival to discharge information.

need to transfer the review manually, this will allow Resuscitation Practitioners have greater clinical presence.

RESUSCITATION TODAY - SUMMER 2016

10 The Resuscitation Cube, along with Electronic Mortality Audit Tool (EMAT), has allowed the

EDUCATION

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EDUCATION

THE FACE OF MAJOR TRAUMA IS CHANGING Major trauma is the commonest cause of death and disability in

In addition, the 5 principle mechanisms of injury were recorded as:

the under 40 age group1 where there is now misconception that in the UK this represents young males, frequently involved in road

• Road traffic collision (RTC)

traffic collisions (RTCs) .

• Falls from height greater than 2 metres

2

With improvements in medical care, including diagnostics, treatment and preventative strategies, the elderly are living longer where increasing years and enhanced quality of life increases their potential

• Falls from height less than 2 metres • Shootings and stabbings • All others

exposure to major trauma. Add to this any significant medical comorbidities, limited physiological reserve and rehabilitation potential

To determine further changes in trends in Major Trauma in recent times

and we have an emerging national crisis .

the Hospital Episode Statistics (HES) data was reviewed to determine

3,4

absolute number of patients recorded as suffering major trauma in UK It is important to have an agreed definition of “Major Trauma”.

hospitals.

Traditionally and put simply a major trauma patient can be regarded as anyone with “life threatening injuries”. To facilitate comparative

Kehoe and colleagues2 reviewed 116,467 cases from which the

outcomes and scientific publications it is important to have an agreed

following results were determined:

definition that has international recognition.

• In 1990 the mean age of patients suffering major trauma was The most widely used system is the Injury Severity Score (ISS) where

recorded as 36.1 years, with the largest single group being under 25

an ISS greater than 15 is the definition of major trauma. This number is

years of age (39.3%).

derived from knowledge of the Abbreviated Injury Scale (AIS); where a score of 1 is a minor injury, a score of 5 a critical injury and a score of 6 an unsurvivable injury. The ISS is the number derived from the sum of the square of the AIS scores taken from the 3 most severely injured body areas. A score in excess of 15 may be achieved from a single injury or a series of lesser injuries.

• The mean age for patients suffering major trauma has increased year on year during this study and in 2013 was 53.8 years.

• The percentage of major trauma patients in the over 75 year age group rose from 8.1% in 1990 to 26.9% in 2013.

• The proportion of male patients suffering major trauma fell slightly from a peak of 75.5% in 2001 to 68% in 2013.

In a landmark study Kehoe et al2 have reviewed cases submitted to the Trauma Audit Research Network (TARN) between 1990 and the end of 2013. To be TARN eligible patients need to be admitted for 72 hours or over, or have spent time in Critical Care, or died from their injuries in hospital. Simple pubic rami and patients over 65 years of age with fractures of the neck of femur are ineligible.

• In 1990 the predominant mechanism of injury was RTCs being responsible for almost 60% of TARN returns. By 2013 this had reduced to 39.1%.

• In 1990 the percentage of major trauma due to low falls (falls from a standing height) was 4.7%. By 2013 figures had risen to 39.1% - the most common cause.

The aim of this study was to review changes in the year on year RESUSCITATION TODAY - SUMMER 2016

demographics of patients suffering major trauma in England and Wales

Whilst the increase in the number of elderly trauma victims was

over 2 decades. Recorded data included:

anticipated5 over the last decade the average age of patients suffering major trauma has risen on average 1.43 years per year2.

• Age • Gender • Mechanism of injury • Percentage of patients undergoing CT examinations Patients were categorised by age into: • 0 - 24 years • 25 - 49 years • 50 - 74 years • > 75 years

12

Kehoe et al2 made a number of additional comments on their results: • The National Office of Statistics report a significant reduction in death and severe injuries from RTCs in the course of the last 20 years. This is attributed to better roads, car designs, accident prevention and clinical care.

• Review of HES data has shown the number of TARN submissions in patients under 50 years has remained stable between 2004-2010 whereas there was a 50% increase in the 50-75 year age group and a 75% increase in the over 75 year age group. This was reported to match the increase in the number of older people in the population.

EDUCATION • This increase in the elderly may reflect better reporting, better diagnoses and better investigations. • There has been a significant increase in CT scan usage with adaptation into National Guidelines for Head Injury or pan-CT for major trauma .

6

• Without the use of CT scans many patients with ISS over 15 missed detection.

Kehoe A et al2 quote as an example an elderly patient with an intracranial contusion, two fractured ribs and a wedge fracture of the first lumbar vertebrae which cored an ISS of 17 (32x22x22).

The challenge to pre-hospital practice is the development of better field triage tools.

Whilst the advent of Major Trauma Centres has led to major improvement in patient mortality annually to a figure of 30% more survivors in England in the first 3 years, a progressive decrease in the sensitivity of field triage tools with each decade beyond 60 years has been demonstrated.

However in one UK Major Trauma Centre the overall sensitivity of the local field triage tool was estimated to be only 52%7. This is not surprising as the pathophysiological responses are different in the elderly compared to the young4,8. This is particularly relevant when assessing shock by pulse and blood pressure and using the Glasgow Coma Scale (GCS) for head injuries where the elderly patient may be GCS 14 or 15 and have life threatening head injuries.

Paradoxically many Ambulance Services in England have recently decreased their field triage score from GCS 14 to 13 because of the percentage overtriage to MTCs. Certainly using 14 or less in the elderly produces better sensitivities for the recognition of major head injuries in the over 65 years old age group9.

Because the elderly frequently do not trigger the field triage tool either on mechanism of injury or altered physiology these patients do not

Once again it is a challenge to get the right patient with the right assessment, with the right level of pre-hospital care, by the right transport platform, to the right hospital, in the right time for prompt acute investigations and treatment irrespective of their age.

References: 1. Krug EG, Sharma GK, Lozano R. The global burden of injury. Am J Public Health 2000;90:523-6 2. Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in the elderly trauma patient.

Emerg Med J 2015;32:911-915 3. Grossman MD, Ofurum U, Stehly CD, et al. Long term survival after major trauma in geriatric trauma patients: the glass is half full. J Trauma Acute Care Surg 2012;72:1181-5 4. Bruijns SR, Guly HR, Bouamra O, et al. The value of traditional vital signs, shock index, and age based markers in predicting trauma mortality. J Trauma Acute Care Surg 2013;74:1432-7 5. MacKenzie EJ, Morris JA Jr, Smith GS, et al. Acute hospital costs of trauma in the United States: implications for regionalized systems of care. J Trauma 1990;30:1096-101; discussion 101-3 6. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of wholebody CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373:1455-61 7. Potter D, Kehoe A, Smith JE. The sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre. J R Nav Med Serv 2013; 99:16-9 8. Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma 2010;69:813-20 9. Caterino JM, Raubenolt A, Cudnik MT. Modification of Glasgow Coma Scale criteria in injured elders. Acad Emerg Med 2011;18:1014-21 10. Jenkins P, Rogers J, Kehoe A, et al. An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre. Emerg Med J 2015;32:364-7 11. Battle C, Hutchings H, Lovett S, et al. Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model. Crit Care 2014; 18:R98

generate trauma team activation.

Whilst a full trauma team response for all elderly patients would generate a non-achievable workload, a tiered trauma response to generate senior clinical assessment of elderly patients and rapid access for elderly patients with head injury trauma11.

In conclusion the study by Kehoe et al2 has shown that the average age of patients suffering major trauma is now getting progressively greater and the predominant mechanism of injury is falls from less than 2 metres which equates to falling from a standing height.

It falls within clinical colleagues, including the Ambulance Service, College of Paramedics and researchers to work towards better field triage tools for our elderly trauma patients and for colleagues in the Emergency Department to give appropriate priority to this group of patients where better assessment, timely investigations and aggressive

RESUSCITATION TODAY - SUMMER 2016

to CT scans is workable10. Some centres now have a tiered activation

management will reduce both the morbidity and mortality of major trauma in our elderly patients.

13

EDUCATION Fentanyl” to put the kid back to sleep. You

identification or administration error.

reach down to the floor next to you and grab

In adequate summation, it may be best to

Paramedics don’t make the medication bag. You reach for the Fentanyl ampule – finding exactly where it should be medication errors…right?

Paramedics don’t make medication errors…right?

turn to Dave Grossman’s book ‘On Combat’ where we are told, “to err is human” (3).

– and drawing it near to your face you read

This succinct and impactful statement duly

the label. As the blurriness fades, you can

supports the fact that “the human factor plays

clearly see the word FLUmazenil printed on

a significant role” (3) in stressful situations,

the side of the ampule. “FLUmazenil”, you

such as during war time. One can draw a

mutter to yourself - that’s where the Fentanyl is

similar parallel when comparing such to the

supposed to be…” You see your partner give

critical care environment.

you a thumbs up and you show him the vial.

His happy face becomes a sad face; and he

Many of these same principles and concepts

throws his hands up in the air in disgust. You

are directly applicable to both the ground

put the ampule of FLUmazenil back, and start

and air critical care setting. For example,

rummaging around the medication bag for

some of the factors that are associated with

Fentanyl. Still sleepy, and now irritated, you

medication errors include “medications

think “there has to be a better way”…

with similar names or similar packaging,

(1)

Hoffman1 pping1, Bruce (1)

Klint DistanceCME PA, Hoffman USA. 1 Bruce Kloepping1L, LC,

e is reproduced from Canadian Paramedicine with the permission of the editor and 1. DistanceCME LLC, PA, USA. ctive authors.

Discussion

This article is reproduced from Canadian

on

Paramedicine with the permission of the editor

mechanisms that exist so this process he following known scenario: happens easily and safely. Despite the many

combined with ground or air transport in the critical care setting can lead directly to a medication identification and administration error. The question seems to ask itself: “can and how do we prevent and mitigate these errors?”

To be clear, lets answer the first part of the

rehearse and teach many of the safety

question: “can we prevent these errors” - the

mechanisms associated with medication

short answer is YES – wen can prevent these

administration. These include the rights of

errors. The second question of “how” is a

e Flight Paramedic on resources, a 24 hour sthere hift for a fixed wan ing critical care transport sadministration ervice. available continues medication and checking, urrently in flight w ith a

s even-­‐year-­‐old m ale, p ost c ardiac a rrest.

I t h as a lready been a checking. We unsettling increase of medication identification rechecking and double nd you are on hour number 13 out of 24. You have already completed two successful and administration errors. Several factors rehearse these with near perfect cadence, nd understandably, are very tired. Your partner informs you that the kid is have been revealed as consistent culprits identical to the way we were taught c in the 130’s and slightly hypertensive, 150 / 90 and seems to boften e getting agitated. allow for these tokoccur. our initial training and education. As ou to get out “that some Fentanyl” to errors put the id back There to sleep. You rduring each down to the are tseveral best practices known tofthe prepractice would have us believe that to you and grab he medication bag. You reach or the Fentanyl best ampule – finding here it should hospital be – and drawing near worlds to your face you read the these label. allow As the and criticalit care that support for near perfect practice, actual fades, you can clearly see the administration. word FLUmazenil printed on the sdata ide otells f the us ampule.

safe medication These include otherwise; precisely that they nil”, you mutter to yourself -­‐ that’s where the Fentanyl is supposed to be…” You see the many rights of medication administration, are not fail proof. ner give you a thumbs up and you show him the vial. His happy face becomes a sad the process of checking and double checking,

RESUSCITATION TODAY - SUMMER 2016

14

look-alike / sound-alike medication names” (4). Understandably, these factors when

Sound familiar? Unfortunately, this is

n identification dministration is a regular and anticipated esomething xpectation that of pre-­‐ andand thearespective authors. happens all too frequently. nd critical care transport clinicians and providers. There are several known As critical care providers we do all we can ms that exist so this process happens easily and safely. Despite the many available Introduction for the safety of the team and the patient. there continues an unsettling increase of medication identification and However, ation errors. Several factors have been revealed as consistent culprits that sometimes allow for a simple task, like identification and administration medication can become rs to occur. TMedication here are several best practices known to the pre-­‐hospital and administration, critical ds that support medication administration.

These include the many rprecarious. ights of is asafe regular and anticipated expectation uniquely As paramedics and n administration, the process of ccritical hecking and double checking, tcritical he facilitation of high of pre-hospital and care transport care practitioners we consistently mulation training and lastly, the promulgation and use of the EZ Drug ID system. clinicians and providers. There are several

medications that are not commonly used and

bit more involved, but absolutely achievable and doable. It can be suggested that we, as critical care providers, take measures to reduce medication errors. These include stocking medications in the same place, every time, without exception. Additionally, we might also consider passing along medication information changes in a timely manner such as during a safety huddle or at change of shift. This is supported by a

the facilitation of high fidelity simulation training

The time to take stock in this situation has

statement from the National Institute of Health

and lastly, the promulgation and use of the EZ

come; here and now. Critical care providers

which stated “five studies and one literature

Drug ID system.

and paramedics work in an austere and

review assessed the relationship between

typically sleepless environment; answering

communication failures and medication

calls for help that are flogged with extreme

errors” (4).

Consider the following scenario:

intensity, significant stress and high acuity.

You are the Flight Paramedic on a 24 hour shift

This occurs at all hours, day and night. An

Lastly, conducting a double check with

for a fixed wing critical care transport service.

understanding mind would realize that the

another provider, prior to medication

You are currently in flight with a seven-year-

environment alone predisposes us to making

administration will allow for another layer of

old male, post cardiac arrest. It has already

errors. Additionally, a fifteen-year literature

safety. A recent publication reported that

been a long day and you are on hour number

review showed that “insufficient sleep has

“double checking policies are commonly

13 out of 24. You have already completed

been associated with cognitive problems,

used as a strategy to ensure medication

two successful missions and understandably,

mood alterations, reduced job performance,

safety” (4). These practices are a standard

are very tired. Your partner informs you that

reduced motivation, increased safety risks,

of care that should be regularly implemented

the kid is tachycardic in the 130’s and slightly

and physiological changes” (2). It is fair to

by critical care crews. Rationale for these

hypertensive, 150 / 90 and seems to be getting

say that no one individual is without the risk

practices can be found in a clinically

agitated. He asks you to get out “some

of unintentionally committing a medication

applicable case scenario as described above.

EDUCATION But is there more?

The short answer is YES! Simulation training has been an increasingly valuable resource among educators all over the world.

Simulated training helps to minimize the human factor during real world medication administration by keeping in both patient and provider safeties in check. Assuring that critical care providers do not make medication identification and administration mistakes in real world practice, they must be pushed to their limits during intense, high fidelity, real world simulation training. This is supported by a statement from Issenberg et al. which states that “These principles concern the learner’s engagement in deliberate practice of desired educational outcomes [which] involves (a) repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with (b) rigorous skills assessment, that provides learners with (c) specific, informative feedback, that results in increasingly (d) better skills performance, in a controlled setting” (5). We should be clinically practicing consistent and reliable behaviors – the same way, every single time. This includes medication identification and administration.

There is a growing culture within the critical care transport system that unnecessarily pressures providers to “never” make a mistake. This is unrealistic. At its most basic understanding perfect practice is rarely achieved in the critical care transport environment. High fidelity simulation provides us the medium to progressively improve the imperfect. Debriefing, as you would after every mission in real world practice, should be seen and understood as equally beneficial during a simulation training.

Internationally, there is a campaign to standardize medication packaging to provide an additional safety layer to medication identification and administration. This campaign is called EZ Drug ID. The core concept and central purpose behind this mission is to make all drugs packaging standard, worldwide. For example, these recommendations include “colour coding the packaging for [a specific] class of medication”

Conclusion

Medication identification and administration is prone to errors. As discussed in this article there are number of factors that contribute to this, both human and systems based. There are evidence based solutions in how to assure the limitation of these errors. Some of the solutions EZ Drug ID was the brain child of Dr. Nicholas include the appropriate use of the rights Chrimes, an Anaesthetist in Sydney, Australia. of medications, checking and double It should be noted that there were “numerous checking, the use of high fidelity simulation reports in the literature that labelling issues and lastly, the promulgation and use of the [with medications] are a significant contributor EZ Drug ID system. solution you supports c urrent b est p ractices a nd s eeks to codify the kWhichever nown essentials of medicatio to medicine errors” (6). This momentous elect to choose, all of them or one of them, campaign has caught industrial eye identification and the administration. there is an increased chance of mitigating of healthcare delivery systems all over the medication errors. world. Specifically, it has made a lasting and

EZ Drug ID was the brain child of Dr. Nicholas Chrimes, an Anaesthetist in Sydney, Au impactful mark in the critical care transport should be noted that there were “numerous reports in the literature that labelling iss Disclaimer setting. It is important to note that there is medications] a re a

s ignificant c ontributor t o m edicine errors” (6). This momentous c no set goal for the EZ Drug ID corporation or has caught the over industrial eye of hItealthcare delivery systems all over inthe campaign to take current practices.

The views and opinions expressed thisworld. Spec simply seeksato improveacurrent practices. mark iarticle those c ofare the tauthors andsdo has made lasting nd impactful n the are critical ransport etting. It is impo As such, thethere EZ Drug campaign works necessarily reflect the o official policy orto take ove note that is IDno set goal for the EZ not Drug ID corporation r campaign to reduce and ultimately prevent any and all position of their employers or organizations. practices. It simply seeks to improve current practices. As such, the EZ Drug ID camp medication identification and administration to reduce ultimately prevent any and all medication identification and administr errors.

This a isnd accomplished through a References errors.

This is acolor ccomplished hrough a process of regular, color coding and consisten process of regular, coding and tconsistent packaging among drugs worldwide.

Color packaging among drugs worldwide.

Color coding a6246376_orig nd consistent packaging would cle 1. EZDrugID. [Internet]. coding and consistent packaging would clearly 2015 [cited 1 November 2015]. “improve the distinctiveness of [many] high risk [drug groups]” (7).

Available from: http://ezdrugid.org/ “improve the distinctiveness of [many] high uploads/3/5/5/2/3552206/6246376_orig.jpg risk [drug groups]” (7).

RESUSCITATION TODAY - SUMMER 2016

So, we have double checked our medications, packed them in our bags the same way (every time), and have successfully completed simulation training. Our patients are completely safe now, right? Not quite! There is always more that can be done to improve patient safety, especially during medication administration.

(7) such as muscle relaxants. Although progress has been made in the effort to mitigate such errors, there are still regularly occurring medication identification and administration errors. The EZ Drug ID campaign additionally supports current best practices and seeks to codify the known essentials of medication identification and administration.

Figure recommended and consistent color sfor chemes high risk medication profil Figure 11- -­‐recommended and consistent color schemes high riskfor medication profiles 15 (EZDrugID) (EZDrugID)

EDUCATION 2. Rogers, AE (2008) Chapter 40: The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety in Hughes RG (Ed.) Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Rockville (MD): Agency for Healthcare Research and Quality (US) 3. Grossman, D and Christensen, LW. (2007) On Combat: The Psychology and Physiology of Deadly Conflict in War and Peace. 2nd ed.

PPCT Research Publications.

4. Hughes, RG, Blegen, MA. (2008) Chapter 37: Medication Administration Safety in Hughes RG (Ed.) Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US)

RESUSCITATION TODAY - SUMMER 2016

16

5. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005 Jan;27(1):10-28.

6. Department of Health Australia. (2014).

Regulation impact statement - General requirements for labels for medicines.

Retrieved from http://ezdrugid.org/EZDrugID/ Strategies_files/GenReqsforMedLabels.pdf 01 November 2015.

Bruce Hoffman is a critical care nurse, paramedic and current graduate student.

He works as both a clinician and educator in Connecticut, Massachusetts and Maryland, with a background in the division of critical care (ICU, ER, Cardiology, and Flight).

Email: bruce.e.hoffman@gmail.com Twitter: @bruceEhoffman Klint Kloepping is a US trained Critical Care Paramedic and Flight Paramedic. He is

7. EZDrugID (2015) Strategies For Minimising Medication Error. Retrieved from http:// ezdrugid.org/strategies.html 01 November 2015.

currently pursuing a Baccalaureate degree in

Keywords – paramedic, simulation, education, medication, administration, clinician

Email: klint.kloepping@flightbridgeed.com

EMS management. Klint works full time as a Flight Paramedic in the Midwest, USA. Klint is also an EMS Instructor with DistanceCME. Twitter @NoDesat

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EVIDENCE

CLINICAL SCORES FOR PREDICTING RECURRENCE AFTER TRANSIENT ISCHEMIC ATTACK OR STROKE HOW GOOD ARE THEY? Robin Lemmens MD, PhD; Stephanie Smet MD; Vincent N. Thijs MD, PhD

Risk scores are commonly used in the prediction of disease outcome. In the context of cerebrovascular diseases, risk scores have been created to identify stroke risk after transient ischemic attack (TIA) and (minor) stroke, to identify subgroups of patients with high risk of stroke (for instance, correlated with grade of carotid stenosis), or to predict functional outcome after stroke.

Identifying high-risk patients after TIA is important because early assessment and management of these patients is pivotal.

Confident detection of the low-risk patient, however, is of similar importance. Performing multiple acute diagnostic investigations for all suspected TIA and stroke patients might overwhelm the medical system and might not be feasible because of resource limitations. Simple and reliable risk estimation of recurrence might be beneficial to high-risk patients to be admitted and investigated

Results We identified 17 risk scores that were derived from TIA or stroke cohorts (Table 1) to predict short-term or long-term recurrence and one that was derived from a prospective population-based study in the general population but was validated in a TIA/stroke cohort. The characteristics and quality criteria for the risk scores are shown in Tables II and III in the online-only Data Supplement. The studies were performed in heterogeneous study populations with various designs and inclusion/ exclusion criteria. Qualification of these reports was, therefore, not always possible according to the criteria presented in Table I in the online-only Data Supplement. Ten of the predictive models were derived in cohorts that used TIA as an index event, 5 models included both TIA and (minor) stroke, whereas 2 scales were developed in a population that only included stroke patients. In general, cardiovascular risk profiles were adequately collected in the majority of the study populations.

early. Additionally, the medical health system might benefit as well, because lowrisk patients can be seen in less expensive outpatient

The diagnostic work-up after the incident event varied largely between

clinics.

studies, which might have indirectly influenced recurrence rates; for instance, performing ECG or holter monitoring to identify atrial

We performed a systematic review of published risk scores that

fibrillation likely has an effect on the treatment of patients and the

predict recurrence risk after stroke or TIA. We checked the quality

frequency of recurrence. Primary end points were rarely adjudicated

of the risk scores based on the characteristics of the various

by 2 independent persons and were often not determined by a patient

derivation and replication studies.

visit, but by patient file review. Different studies used various clinical end points: recurrence of stroke, vascular disease, (vascular) death,

RESUSCITATION TODAY - SUMMER 2016

18

Methods One investigator (S.S.) performed a PubMed search with the search terms prognostic models stroke and prognostic scores

or combined end points. The nature of the recurrent stroke (ischemic vs hemorrhagic) was frequently not specified. Race characteristics were rarely provided, which is of relevance because recurrence rates could differ between races.4-6 The various risk scores and their clinical applicability will be discussed.

stroke for the period 1992 to 2011, and additionally explored the reference lists of the identified articles. We excluded specific risk scores for stroke risk in atrial fibrillation, for instance, CHADS2,1

Californian Risk Score

CHADS2VASC2, or global vascular estimates, such as the QRISK2 and SCORE.3 The other exclusion criteria, internal and external

A simple 5-point score using age, diabetes mellitus, symptom duration,

validity, statistical methodology, validation of the models, and

the presence of weakness, and speech impairment was found predictive

clinical applicability were evaluated (for details, see Methods and

of stroke within 90 days in a retrospective study of 1000 patients admitted

Table I in the online-only Data Supplement) by 3 independent

with TIA to an emergency department.7 This risk score was externally

researchers (R.L., S.S., and V.T.). All results were compared

validated in large cohorts and population-based studies, although

between researchers and inconsistencies were resolved by

c-statistics did not reach 0.8.8,9 Whether addition of brain imaging to the

reevaluation of the original article.

score might be of additive value has not been determined.10

EVIDENCE Table 1.

Study Design of Index Event, Follow-up in Derivation Cohorts, and Performance in Validation Cohorts of Predictive Models Risk Score

TIA

Minor Stroke

Stroke

Short-term Recurrence (≤90 d)

Long-term Recurrence (≥1 y)

Validated in Replication Study*

California risk score

X

X

3/3

ABCD

X

X

9/12

ABCD2

X

X

19/23

ABCDI

X

X

1/1

AB2CD(2) (3)

X

X

1/1

ABCD2I

X

X

0/0

ABCD2 and DWI (including CIP)

X

X

2/2

ABCD2+MRI

X

X

0/0

ABCD3

X

X

1/1

ABCD3I

X

X

1/1

ABCD +

X

Oxford TIA (Hankey score)

X

Stroke Prognostic Instrument (SPI)

X

X

X

1/2

X

SPI-II

X

X

2/2

X

3/4

Dutch TIA

X

LiLAC

X

X

X

0/2

X

X

0/1

X

3/4

X

Essen Stroke Risk Score

X

Recurrence risk estimator at 90 d

X

X

1/1

AB2CD(2)(3) indicates AB2CD/AB2CD2/AB2CD3CIP; clinical- and imaging-based predictive algorithm; DWI, diffusion-weighted imaging; LiLAC, Life long after cerebral ischemia trial; and TIA, transient ischemic attack. *Risk score model used for replication needed to be similar as initially reported by the authors of the original article, based on stratification of patients or c-statistics. Numbers are studies validating the score over total replication studies (original studies on derivation of the risk score, which included an external validation cohort, are also included).

ABCD, ABCD2, and Additional Variables The 7-day risk for stroke after TIA was estimated based on clinical characteristics within the OXVASC study. The following significant predictors were included in calculation of the score (with different weights, as indicated in parentheses): age >60 years (1); blood pressure ≥140/90 mm Hg (1); unilateral weakness (2); speech impairment without weakness (1); duration ≥60 minutes (2); or 10 to 59 minutes (1).11 Since publication, this ABCD score has been replicated in most studies, which included >200 patients, with some of these also extending the prediction horizon to 90 days after the incident TIA (or minor stroke).8,9,12–20 In none of the replication cohorts, c-statistics reached 0.8, with the exception of one validation cohort8 (Table III in the

Pooling of the studies deriving the Californian and the ABCD scores led to the ABCD2 score, which includes the following 5 factors (with different weights, as indicated in parentheses): age ≥60 years (1); blood

a dichotomization was analyzed and proposed that could be used for individual patients. Based on the data in the original article, which divided the values of the ABCD2 score into 3 categories (0–3, 4–5, and 6–7), a score ≥4 would urge medical doctors to initiate adequate medical attention (eg, admission).

Two observational studies and 1 prospective study, all with large sample sizes, however, failed to convincingly validate the ABCD2 score, which was reflected in observed higher recurrence rates in the low-risk groups.25,33,34 In summary, the ABCD2 has rather low specificity and positive predictive value but good sensitivity and negative predictive value. C-statistics in none of the publication reached 0.8, with the exception of one validation cohort8 (Table III in the online-only Data Supplement). The score can be used to identify those patients at increased risk who need admission, but caution is warranted because several studies identified recurrence in patients with low scores25,33,34 and high-risk disease has

pressure ≥140/90 mm Hg (1); clinical features: unilateral weakness (2)

been shown to be present in patients in the low-risk group.39 This

and speech impairment without weakness (1); duration ≥60 minutes (2)

was underscored by additional data from the discovery cohort of the

or 10 to 59 minutes (1); and diabetes mellitus (1).8 The ABCD2 score

ABCD/ABCD2 score, which showed the ABCD2 score to be predictive

was validated in 2 independent cohorts8 and has been the subject of

for severity of recurrence rather than risk.27 Potentially adding other

replication and modification in various other populations.9,16,19–38 In a

characteristics, such as hyperglycemia, history of hypertension (AB2CD/

reasonable percentage (9/23 or 39%) of study protocols, imaging data

AB2CD2/AB2CD3),19 or dual TIA (ABCD3),31 might increase the negative

were required for additional analysis. This inclusion criterion enabled

predictive value, but validation is lacking.

researchers to refine the score by including imaging (MRI or computed tomography) data. Risk stratification seemed to be independent of

Additionally, several groups have explored whether adding imaging

follow-up duration (7, 28, or 90 days). In clinical practice, a trend

findings to the ABCD/ABCD2 scores might improve their performance.

RESUSCITATION TODAY - SUMMER 2016

online-only Data Supplement).

across scores has less direct implications; therefore, in most studies,

19

EVIDENCE Computed tomography, diffusion-weighted imaging (DWI), and vessel

In 3 additional large cohort studies, the SPI-II was evaluated. 36,38,42,45

occlusion status data were analyzed.18,21–24,28,31,35 Initially, imaging data

The results were disparate, with both confirming the risk score as well as

on any evidence of infarction and leukoaraiosis were joined to the ABCD

showing poor predictive power.

score to create the ABCDI, which resulted in similar accuracy compared with ABCD.18,35 The ABCD2I score, which included the presence of brain infarction on computed tomography or DWI, has been extensively studied in a multicentric approach.28 Three studies included acute DWI lesions on MRI in the prediction of stroke model, which clearly improved the accuracy to c-statistics >0.8 in all cohorts.22–24 Moreover, the ABCD3I, which includes carotid stenosis in addition to abnormal DWI, also showed a superior prediction and was validated in a separate sample set, although c-statistics were less convincing in the validation set.31 Adding data regarding intracranial vessel stenosis to DWI lesions led to similar higher accuracy (c-statistics of 0.88), although no validation population was included in this study.21 These findings clearly support a role for imaging data, in particular DWI lesions, to increase the reliability.

Dutch TIA Trial and Life Long After Cerebral Ischemia Trial Data from >3000 patients enrolled in the Dutch TIA trial were analyzed for their prognostic value for a 2-year risk analysis.46,47 Based on the hazard ratios in the initial publication, the predictive value of 13 parameters (Table IV in the online-only Data Supplement) was calculated in the same population but showed no strong discriminative value.47 This was confirmed in another cohort comparing 7 models in which this score was found to overestimate risk.36 The original Dutch TIA cohort was followed-up during a mean period of 10 years, and the data were reanalyzed (Life long after cerebral ischemia trial [LiLAC]). Three

Oxford TIA (Hankey Score) In a population-based cohort from Oxford, several vascular risk rates were calculated, and prognostic factors were determined for stroke, myocardial infarction, and combined end points, and they were translated into a 5-year risk percentage.

The model for stroke was established by using the following 8 clinical factors: age, sex, affected region (amaurosis fugax as well as carotid and

different models were designed based on subcategories of variables: demographics (sex and age) and medical history (myocardial infarction, intermittent claudication, diabetes mellitus, peripheral vascular surgery, and hypertension) in model 1; addition of event characteristics (TIA vs stroke, Rankin grade, and vertigo) in model 2; and addition of brain imaging (white matter lesions and any infarct) and ECG data (Q wave on ECG and negative T wave) in model 3. Areas under the curve were clearly improved and reached values >0.8 for all 3 models48; however, this could not be confirmed in a validation cohort.42

vertebrobasilar), frequency of TIA, residual neurological deficits, peripheral vascular disease, and left ventricular hypertrophy.40 Although the risk score was able to discriminate high-risk patients from low-risk patients

Framingham: Stroke-Specific

(depending on the cut-off), a clear cut-off that was able to divide patients in high-risk vs low-risk groups could not be confidently recommended.41

A stroke risk score was derived based on 472 stroke events occurring

In 2 other studies, the Hankey score was found to overestimate the

within the initially stroke-free subjects from the Framingham study.

risk; although the model could be used for prediction of recurrence, the

A sex-specific risk model was developed that included age, systolic blood

accuracy seemed relatively weak

36,42

(Table III in the online-only Data

pressure, use of antihypertensive therapy, diabetes mellitus, smoking,

Supplement). Additionally, the risk prediction did not simply involve the

previous cardiovascular disease, atrial fibrillation, and left ventricular

collection of several clinical data set, but also a calculation of these

hypertrophy (on ECG). There is only 1 publication that evaluated the

variables in a formula probably reducing its clinical applicability.

Framingham stroke risk score in a cohort of patients with previous TIA and stroke. The score was not validated and had poor c-statistics.36

Stroke Prognosis Instrument

Essen Stroke Risk Score

The Stroke Prognosis Instrument (SPI-I) was developed in patients RESUSCITATION TODAY - SUMMER 2016

20

with suspected carotid TIA or minor stroke. In a small patient

The Essen Stroke Risk Score (ESRS) was derived from the stroke

sample of 142 patients, 5 predictors (age, diabetes mellitus,

subgroup of the CAPRIE (clopidogrel vs aspirin in patients at risk of

hypertension, coronary heart disease, and distinction between TIA

ischemic events) trial, which compared the effect of clopidogrel over

and stroke) were included to define 3 risk groups for recurrence

aspirin in patients with vascular disease during a mean follow-up of 1.9

in a 2-year follow-up.43 Ten years later, this score was externally

years. This model used 8 clinical parameters: age, hypertension, diabetes

validated in 4 cohorts, and although the risk score was validated,

mellitus, myocardial infarction, other cardiovascular disease, peripheral

even in the lowrisk group, the recurrence rate was 10%.44

artery disease, smoking status, and history of TIA or stroke.49 Patients

A modified SPI-II was created that included the additional variables

with indications for oral anticoagulants were not enrolled in CAPRIE.

previous stroke and congestive heart failure. The patients were

In a validation cohort, this score was unable to significantly distinguish

more evenly distributed, and the c-statistics improved moderately,

between high-risk and low-risk patients.50 Thereafter, the ESRS was

although they remained <0.8. Still, the recurrence rate remained

calculated in various study populations in which the dichotomization

10% in the lowest-risk group. Furthermore, application of this score

cut-off between high risk and low risk was either confirmed42,51 or

was restricted to patients with carotid territory TIA or minor stroke

refuted.38 However, even in the replication cohorts, which confirmed the

based on clinical characteristics, impeding the clinical utility for

predictability, the positive predictive values were low, questioning the

primary care physicians.

usefulness of these risk scores in daily clinical practice.

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We are delighted once again to be hosting a resuscitation conference which this year will contain a number of topical presentations including: Human Factors in End of Life Care - Implications for Education & Training, Medical Command...The Future and Paediatric Retrieval/Resuscitation, presented by Ken Spearpoint, Stuart Blatston and Amy Chan-Dominy. Early Bird Offer - Book by July 29 to secure a delegate rate of £36.00 or pay £60.00 to also attend the Paramedic Practice Conference taking place the previous day.

First Aid Conference supported by AoFA

This year's programme is again made up of presentations that will be of great interest to first aiders and first aid trainers, including: Sepsis Guidelines - Early Recognition is the Key, Minor Injury Management, How Safe is Your Home?, and Practical Management of Paediatric Emergencies.

Early Bird Offer - Book by July 29 to secure a delegate rate of £60.00

21

EVIDENCE Recurrence Risk Estimator at 90 Days

Studies replicating only 1 risk score occasionally evaluated risk in patients with a dissimilar preceding event compared with the derivation

A Web-based prognostic 6-point score (the recurrence risk estimator at 90 days) was derived from a sample of 1500 stroke patients to estimate the 90-day risk of recurrence.45 Recurrent stroke was confirmed by MRI. Two models, either with or without baseline imaging data, were validated in derivation and validation cohorts. The area under the curve for the 90-day risk of recurrence was 0.80 for the derivation cohort, which was

population or used longer or shorter duration of follow-up to determine recurrence. Additionally, patient characteristics varied between studies because patients with atrial fibrillation were sometimes excluded or imaging was used as an inclusion criteria. Many studies lacked a clear clinical confirmation of a recurrent event by a physician because patient files were used to obtain end points. This was illustrated by the

reasonably well-replicated in the validation cohort (0.76).

fact that a difference between hemorrhagic and ischemic stroke was

The models include the following factors: presence of multiple infarcts

added in the study design to validate recurrent stroke.

rarely reported. Furthermore, it is only recently that imaging has been

of different ages, simultaneous infarcts in different circulations, multiple acute infarcts, isolated cortical infarcts, history of stroke or TIA, and stroke subtype based on the Causative Classification of Stroke System.

Stroke attributable to other causes, as typed by Classification of

When designing a predictive model, high event rates are desirable, with occurrence of at least 10 events per studied prediction variable; in several derivations and in half of the validation cohorts, this criterion

Stroke System, was identified as the highest-risk subtype. Interestingly,

was not met. Almost all models suffer from low c-statistics (<0.8) and,

conventional risk factors identified by scores estimating the risk after

therefore, cannot be confidently used in the clinic, because this implies

TIA (such as hypertension and diabetes mellitus) were not identified as

that cutoffs cannot be reliably introduced to make decisions regarding

short-term (90 days) risk factors for recurrence after ischemic stroke.

individual patients. This is reflected by the relatively high event rates in low-risk patients in some studies. Individual treatment decisions based on the current prognostic models cannot be justified.

Discussion

In efforts to improve the precision of the predictive models, researchers have increased the number of variables into risk models.

Several prediction models have been developed to evaluate the stroke

Although adding more factors to a model can increase accuracy and

recurrence risk after TIA and (minor) stroke (Table IV in the online-only Data Supplement). Ideally, one would like to know which is the best score.

However, comparison of risk scores is hampered by the different study paradigms, particularly inclusion criteria of the index event (TIA vs stroke) and duration of follow-up to determine recurrence (Table 1). Therefore,

Including imaging findings, such as diffusion lesions and the presence of vessel stenoses, increases accuracy. However, the initial purpose of risk stratification scores was to support emergency doctors and primary care doctors to identify patients at high risk for recurrence

studies that directly compare various scores need to be interpreted

with limited resources. Therefore, the addition of costly imaging will

with some caution. In an independent Dutch cohort, the 2-year risk was

face resistance by emergency doctors and primary care physicians.

obtained in patients after TIA or minor stroke, and the SPI-II, Hankey,

One can wonder whether the addition of MRI data interferes with the

Dutch TIA, and ABCD2 scores were validated. However, the ABCD2 36

was not developed to estimate the long-term risk of recurrence, and both the ABCD2 and Hankey derivation cohorts only included TIA patients.

Another prospective study assessed the prognostic value of the ABCD2, ESRS, and SPI-II in patients presenting with minor stroke. The accuracy of all 3 models was poor in predicting recurrence rate at 7 and 90 days.

38

However, the ESRS and SPI-II were developed in stroke, not TIA, patients to predict long-term recurrence. It can be assumed that risk factors of a second cerebrovascular event differ between early and late recurrence,

RESUSCITATION TODAY - SUMMER 2016

22

reliability, this often compromises its utility in daily clinical practice.

purpose of these models. Therefore, adjusted models with increased accuracy might be more useful in epidemiological studies or clinical trials rather than in aiding clinicians in therapeutic decision-making.

Additionally, requirement of neuroimaging may result in selection bias. For instance, one of the first studies to report on imaging data and ABCD score in TIA patients identified a substantial age difference between patient with and without MRI.12 Furthermore, in the assessment of recurrence risks of TIA, the yield of diffusion in addition

as well as between TIA and stroke as the index event. This is underscored

to the ABCD2 versus the yield of commonly recommended diagnostic

by the recurrence risk estimator at 90 days, a model predicting recurrence

tests, such as ECG and carotid ultrasound, has not been specifically

after stroke in a period of 90 days, which includes other prognostic

assessed.

factors compared with the ABCD2 score (which evaluates recurrence at 90 days after TIA). Only a large prospective study in German stroke

Direct comparison studies evaluating various predictive models can

centers evaluated the risk in patients after TIA or minor stroke (with a

be criticized for the reasons mentioned above; however, the existence

median follow-up of 1 year) with scores that were derived to estimate the

of multiple models, including different index events for the evaluation

recurrence rate after follow-up of at least 1 year in patients with TIA or

of short-term as well as long-term recurrence, does reflect the real-life

minor stroke: the ESRS, SPI-II, Oxford TIA, and LiLAC scores.

clinical experience. It is not likely that 1 model will be developed to

42

evaluate short-term and long-term risk after stroke or TIA. Moreover, None of these models could convincingly reproduce the prediction

given the various causes of stroke, a one-size-fits-all prediction

models. The finding that risk factors might differ in patients, based on

risk model is unlikely to be perfect under all circumstances. The

either TIA or stroke as index event, might explain the difficulty in replicating

heterogeneity of predictive models can be helpful to evaluate diverse

the accuracy of a scale, especially in the 5 models that were derived from

patients in various scenarios. Therefore, it may be less relevant to

cohorts that included both TIA and stroke patients. Potentially, variations

directly compare the models, but more important to validate each

in proportions of TIA and stroke patients could have resulted in different

model in the population cohort for which it was designed and for the

findings in the replication cohorts compared with the derivation sample.

end point that was chosen in the derivation study.

EVIDENCE

Resuscitation Today Conference Programme

Wednesday 19th October 2016

Kettering Conference Centre, Kettering, Northants NN15 6PB Early Bird Delegate Rate – book by 29th July for only £36 including VAT. Special Offer – Book Now for a combined rate of £60 including VAT should you wish to also attend our Paramedic Conference taking place the previous day.

Time

Presentation

Speaker

Position

Stuart Blatston

Consultant

Professor Sir Keith Porter

Professor in Clinical Traumatology

Dr Simon Le Clerc

Consultant

Registration

09.30 – 09.45

Introduction

09.45 – 10.30

Medical Command…The Future

10.30 – 11.15

The Changing Face of Major Trauma

11.15 – 12.00

Tea/Coffee, Exhibition

12.00 – 12.30

Are We Finally Going to Get to the Bleeding Point?

12.30 – 13.00

Human Factor in End of Life Care – Implications for Education & Training

Ken Spearpoint

Consultant

13.00 – 13.30

How Resuscitation Works

David Halliwell

MSc Paramedic Flfl

13.30 – 15.00

Lunch and Exhibition

15.00 – 15.30

Paediatric Retrieval / Resuscitation

Amy Chan-Dominy

Consultant

15.30 – 16.00

TBA

16.00 – 16.30

Damage Control Resuscitation: Fluids in Trauma

Professor Richard Lyons

Consultant in Emergency Medicine

16.30 - Close

Q&A

Amy Chan-Dominy

Consultant

Topics & Speakers correct at the time of press but may be subject to change.

www.lifeconnections.uk.com

RESUSCITATION TODAY - SUMMER 2016

08.30 – 09.30

23

EVIDENCE Table 2.

Key Points

Predictive models for recurrent stroke ultimately should be able to guide physicians in early decision-making after TIA and stroke A variety of models have been developed in various populations with different index events and methodology, complicating direct comparison, but probably mimicking the real-life experience Risk factors for recurrence differ between TIA and stroke as initial event The majority of predictive scales have been derived from cohorts that include patients with TIA as the index event Adding neuroimaging to predictive models increases accuracy but reduces simplicity High event rates have been reported in predicted low-risk categories The ABCD2 with diffusion imaging data seems most reliable to estimate the early risk of recurrence after TIA; RRE-90 might be an interesting tool to establish the early risk of recurrence after stroke by stroke specialists Validation in large sample sizes with adequate and similar inclusion criteria of the index event and end points as in the derivation study is of importance to confidently use these tools in daily clinical practice Stratification of the best therapeutic and diagnostic pathway for an individual patient based on simple predictive scales might be difficult to achieve When evaluating risk models, changes in diagnostic and therapeutic avenues need to be investigated to identify a correlation with improved patient care; thus far, this has not been clearly determined RRE-90 indicates recurrence risk estimator at 90 days; and TIA, transient ischemic attack.

At present, the early risk of stroke after TIA, the issue that has been

3. Conroy RM, Pyörälä K, Fitzgerald AP, Sans S, Menotti A, De Backer

most extensively studied, seems to be predicted best by the ABCD2

G, et al; SCORE project group. Estimation of ten-year risk of fatal

combined with DWI data. For early recurrence risk after stroke in

cardiovascular disease in Europe: the SCORE project. Eur Heart J.

the 2 models developed, the recurrence risk estimator at 90 days

2003;24:987–1003.

is optimally suited, but it requires both very accurate subtyping and neuroradiological assessment (Table 2). Long-term risk after TIA and

4. Kono Y, Yamada S, Kamisaka K, Araki A, Fujioka Y, Yasui K, et al.

stroke cannot be reliably assessed based on the current knowledge.

Recurrence risk after noncardioembolic mild ischemic stroke in a

Whether these models can be used for decision-making on an

Japanese population. Cerebrovasc Dis. 2011;31:365–372.

individualpatient level remains speculative. Further large prospective studies involving TIA and stroke patients using various models are still necessary to strongly validate the predictive models and, even more importantly, to evaluate the added value regarding improving care.

5. Levine DA, Neidecker MV, Kiefe CI, Karve S, Williams LS, Allison JJ. Racial/ethnic disparities in access to physician care and medications among US stroke survivors. Neurology. 2011;76:53–61.

6. Waddy SP, Cotsonis G, Lynn MJ, Frankel MR, Chaturvedi S, Williams

Sources of funding Drs Lemmens and Thijs are Senior Clinical Investigators for FWO Flanders.

JE, et al. Racial differences in vascular risk factors and outcomes of patients with intracranial atherosclerotic arterial stenosis. Stroke.

2009;40:719–725.

7. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA.

Disclosures Dr Thijs has declared to have received modest support from Boehringer Ingelheim (Speakers’ Bureau) and from Boehringer Ingelheim, Sygnis, RESUSCITATION TODAY - SUMMER 2016

24

Bayer, and Pfizer (Consultant/Advisory Board). The other authors have no conflicts to report.

2000;284:2901–2906.

8. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet.

2007;369:283–292.

9. Nguyen H, Kerr D, Kelly AM. Comparison of prognostic performance

References 1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford

of scores to predict risk of stroke in ED patients with transient ischaemic attack. Eur J Emerg Med. 2010;17:346–348.

10. Purroy F, Begué R, Quílez A, Piñol-Ripoll G, Sanahuja J, Brieva L,

MJ. Validation of clinical classification schemes for predicting

et al. The California, ABCD, and unified ABCD2 risk scores and the

stroke: results from the National Registry of Atrial Fibrillation. JAMA.

presence of acute ischemic lesions on diffusion-weighted imaging

2001;285:2864–2870.

in TIA patients. Stroke. 2009;40:2229–2232.

2. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M,

11. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN,

Brindle P. Derivation and validation of QRISK, a new cardiovascular

Warlow CP, et al. A simple score (ABCD) to identify individuals at

disease risk score for the United Kingdom: prospective open cohort

high early risk of stroke after transient ischaemic attack. Lancet.

study. BMJ. 2007;335:136.

2005;366:29–36.

Specialist Paramedic Critical Care Conference Programme

EVIDENCE

Wednesday 19th October 2016

Kettering Conference Centre, Kettering, Northants NN15 6PB Early Bird Delegate Rate…£36 including VAT. Book by 29th July 2016.

Normal Delegate Rate £48 including VAT. Special Offer…Book Now to also secure a delegate place on our Paramedic Conference taking place the previous day for a combined rate of £60 including VAT Time

Presentation

Speaker

Position

Mark Hodkinson

Specialist Paramedic Critical Care

Ian Wilmer

Advanced Paramedic Practitioner

08.30 – 09.30

Registration

09.30 – 09.45

Welcome and Introduction

09.45 – 10.15

Fit for Purpose? Advanced Seizure Management

10.15 – 10.45

Intra-Arrest Thrombolysis

10.45 – 11.30

Tea, Coffee, Exhibition

11.30 – 12.00

Management of Life-Threatening Asthma and Anaphylaxis

Dr Felicity Clark

Consultant in Anaesthetics and Intensive Care

12.00 – 12.30

Sedation in Acute Behavioural Disorder

Dr Neil Thompson

Assistant Medical Director

12.30 – 13.00

Cutting Up Rough…Surgical Skills for Specialist Paramedics

Tim Edwards

Advanced Paramedic Practitioner

13.00 – 14.30

Lunch and Exhibition

14.30 – 15.00

Retrieval Medicine…Developing the Welsh System

Dr Mike Greenway

EMRTS Wales

15.00 – 15.30

Damage Control Resuscitation…Fluids in Trauma

Prof Richard Lyon

Consultant in Emergency Medicine

15.30 – 16.00

Developing Paramedic Specialist Practice

16.00 – Close

Closing Address

TBA

Associate Clinical Director Magpas Helimedix

Prof Julia Williams

Professor of Paramedic Science

Topics & Speakers correct at the time of press but may be subject to change

www.lifeconnections.uk.com

RESUSCITATION TODAY - SUMMER 2016

Dan Cody

25

EVIDENCE 12. Cucchiara BL, Messe SR, Taylor RA, Pacelli J, Maus D, Shah Q, et

26. Asimos AW, Johnson AM, Rosamond WD, Price MF, Rose KM,

al. Is the ABCD score useful for risk stratification of patients with

Catellier D, et al. A multicenter evaluation of the ABCD2 score’s

acute transient ischemic attack? Stroke. 2006;37:1710–1714.

accuracy for predicting early ischemic stroke in admitted patients with

13. Tsivgoulis G, Spengos K, Manta P, Karandreas N, Zambelis T, Zakopoulos N, et al. Validation of the ABCD score in identifying

transient ischemic attack. Ann Emerg Med. 2010;55:201–210.e5.

27. Chandratheva A, Geraghty OC, Luengo-Fernandez R, Rothwell PM;

individuals at high early risk of stroke after a transient ischemic attack:

Oxford Vascular Study. ABCD2 score predicts severity rather than

a hospital-based case series study. Stroke. 2006;37:2892–2897.

risk of early recurrent events after transient ischemic attack. Stroke.

14. Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department? Emerg Med J. 2007;24:92–95.

15. Calvet D, Lamy C, Touzé E, Oppenheim C, Meder JF, Mas JL. Management and outcome of patients with transient ischemic attack admitted to a stroke unit. Cerebrovasc Dis. 2007;24:80–85.

16. Koton S, Rothwell PM. Performance of the ABCD and ABCD2 scores in TIA patients with carotid stenosis and atrial fibrillation.

Cerebrovasc Dis. 2007;24:231–235.

2010;41:851–856.

28. Giles MF, Albers GW, Amarenco P, Arsava MM, Asimos A, Ay H, et al. Addition of brain infarction to the ABCD2 Score (ABCD2I): a collaborative analysis of unpublished data on 4574 patients. Stroke.

2010;41:1907–1913.

29. Holzer K, Feurer R, Sadikovic S, Esposito L, Bockelbrink A, Sander D, et al. Prognostic value of the ABCD2 score beyond short-term follow-up after transient ischemic attack (TIA)–a cohort study. BMC Neurol. 2010;10:50.

30. Lou M, Safdar A, Edlow JA, Caplan L, Kumar S, Schlaug G, et

17. Purroy García F, Molina Cateriano CA, Montaner Villalonga J, Delgado

al. Can ABCD score predict the need for in-hospital intervention

Martínez P, Santmarina Pérez E, Toledo M, et al. [Lack of usefulness of

in patients with transient ischemic attacks? Int J Emerg Med.

ABCD score in the early risk of recurrent stroke in transient ischemic

2010;3:75–80.

attack patients]. Med Clin (Barc). 2007;128:201–203.

31. Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet 18. Sciolla R, Melis F; SINPAC Group. Rapid identification of high-risk

D, et al. Addition of brain and carotid imaging to the ABCD2

transient ischemic attacks: prospective validation of the ABCD

score to identify patients at early risk of stroke after transient

score. Stroke. 2008;39:297–302.

ischaemic attack: a multicentre observational study. Lancet Neurol.

19. Fothergill A, Christianson TJ, Brown RD Jr, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis.

Stroke. 2009;40:2669–2673.

20. Harrison JK, Sloan B, Dawson J, Lees KR, Morrison DS. The ABCD and ABCD2 as predictors of stroke in transient ischemic attack

32. Ong ME, Chan YH, Lin WP, Chung WL. Validating the ABCD(2) Score for predicting stroke risk after transient ischemic attack in the ED. Am J Emerg Med. 2010;28:44–48.

33. Sheehan OC, Kyne L, Kelly LA, Hannon N, Marnane M, Merwick A,

clinic outpatients: a retrospective cohort study over 14 years. QJM.

et al. Population-based study of ABCD2 score, carotid stenosis, and

2010;103:679–685.

atrial fibrillation for early stroke prediction after transient ischemic

21. Coutts SB, Eliasziw M, Hill MD, Scott JN, Subramaniam S, Buchan AM, et al; VISION study group. An improved scoring system for

attack: the North Dublin TIA study. Stroke. 2010;41:844–850.

34. Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein A, Gilmore

identifying patients at high early risk of stroke and functional

RM, et al. An assessment of the incremental value of the ABCD2

impairment after an acute transient ischemic attack or minor stroke.

score in the emergency department evaluation of transient ischemic

Int J Stroke. 2008;3:3–10.

attack. Ann Emerg Med. 2011;57:46–51.

22. Ay H, Arsava EM, Johnston SC, Vangel M, Schwamm LH, Furie RESUSCITATION TODAY - SUMMER 2016

26

2010;9:1060–1069.

35. Tsivgoulis G, Stamboulis E, Sharma VK, Heliopoulos I, Voumvourakis

KL, et al. Clinical- and imaging-based prediction of stroke risk after

K, Teoh HL, et al. Multicenter external validation of the ABCD2 score

transient ischemic attack: the CIP model. Stroke. 2009;40:181–186.

in triaging TIA patients. Neurology. 2010;74:1351–1357.

23. Calvet D, Touzé E, Oppenheim C, Turc G, Meder JF, Mas JL. DWI

36. Wijnhoud AD, Maasland L, Lingsma HF, Steyerberg EW, Koudstaal

lesions and TIA etiology improve the prediction of stroke after TIA.

PJ, Dippel DW. Prediction of major vascular events in patients with

Stroke. 2009;40:187–192.

transient ischemic attack or ischemic stroke: a comparison of 7

24. Cucchiara BL, Messe SR, Sansing L, MacKenzie L, Taylor RA, Pacelli J, et al. D-dimer, magnetic resonance imaging diffusion-

models. Stroke. 2010;41:2178–2185.

37. Yang J, Fu JH, Chen XY, Chen YK, Leung TW, Mok V, et al. Validation

weighted imaging, and ABCD2 score for transient ischemic attack

of the ABCD2 score to identify the patients with high risk of late

risk stratification. J Stroke Cerebrovasc Dis. 2009;18:367–373.

stroke after a transient ischemic attack or minor ischemic stroke.

25. Weimar C, Benemann J, Huber R, Mieck T, Kaendler S, Grieshammer S, et al; German Stroke Study Collaboration. Long-

Stroke. 2010;41:1298–1300.

38. Chandratheva A, Geraghty OC, Rothwell PM. Poor performance

term mortality and risk of stroke after transient ischemic attack: a

of current prognostic scores for early risk of recurrence after minor

hospital-based cohort study. J Neurol. 2009;256:639–644.

stroke. Stroke. 2011;42:632–637.

EVIDENCE 39. Amarenco P, Labreuche J, Lavallée PC, Meseguer E, Cabrejo L, Slaoui T, et al. Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack? Stroke.

2009;40:3091–3095.

40. Hankey GJ, Slattery JM, Warlow CP. Transient ischaemic attacks: which patients are at high (and low) risk of serious vascular events?

J Neurol Neurosurg Psychiatr. 1992;55:640–652.

41. Hankey GJ, Slattery JM, Warlow CP. Can the long term outcome of individual patients with transient ischaemic attacks be predicted accurately? J Neurol Neurosurg Psychiatr. 1993;56:752–759.

42. Weimar C, Benemann J, Michalski D, Müller M, Luckner K, Katsarava Z, et al; German Stroke Study Collaboration. Prediction of recurrent stroke and vascular death in patients with transient ischemic attack or nondisabling stroke: a prospective comparison of validated prognostic scores. Stroke. 2010;41:487–493.

43. Kernan WN, Horwitz RI, Brass LM, Viscoli CM, Taylor KJ. A prognostic system for transient ischemia or minor stroke. Ann Intern Med. 1991;114:552–557.

44. Kernan WN, Viscoli CM, Brass LM, Makuch RW, Sarrel PM, Roberts RS, et al. The stroke prognosis instrument II (SPI-II): a clinical prediction instrument for patients with transient ischemia and nondisabling ischemic stroke. Stroke. 2000;31:456–462.

45. Ay H, Gungor L, Arsava EM, Rosand J, Vangel M, Benner T, et al.

A score to predict early risk of recurrence after ischemic stroke.

Neurology. 2010;74:128–135.

46. Predictors of major vascular events in patients with a transient ischemic attack or nondisabling stroke. The dutch tia trial study group. Stroke. 1993;24:527–531 47. Dippel DW, Koudstaal PJ. We need stronger predictors of major vascular events in patients with a recent transient ischemic attack or nondisabling stroke. Dutch TIA Trial Study Group. Stroke.

1997;28:774–776.

48. van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen M, et al; LiLAC study group. Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study. Lancet. 2005;365:2098–2104.

49. Diener HC, Ringleb PA, Savi P. Clopidogrel for the secondary prevention of stroke. Expert Opin Pharmacother. 2005;6:755–764.

50. Weimar C, Goertler M, Röther J, Ringelstein EB, Darius H, Nabavi DG, et al; SCALA Study Group. Predictive value of the Essen Stroke Risk Score and Ankle Brachial Index in acute ischaemic stroke patients from 85 German stroke units. J Neurol Neurosurg Psychiatr.

2008;79:1339–1343.

51. Weimar C, Diener HC, Alberts MJ, Steg PG, Bhatt DL, Wilson PW, et al; REduction of Atherothrombosis for Continued Health Registry Investigators. The Essen stroke risk score predicts recurrent cardiovascular events: a validation within the REduction of Atherothrombosis for Continued Health (REACH) registry. Stroke.

2009;40:350–354.

Key Words: clinical score • predictive model • recurrence risk • review

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enterprise

27

NEWS Understanding groups: working in teams

adopted, there is more likely to be significant

potential impact and save even more lives,”

changes in orientation towards all people, not

continued Bob.

just the “team” that individuals find themselves to be members of. I would be interested in the

“They now have most of the essential

views of this community about the desirability

equipment, so we just need to equip them with

Dr Mike Davis FAcadMEd

of such a development.

the skills to use it.”

Much effort and energy is now going into

Teaching to save lives in Kenya

A mix of surgeons, medical officers and

encouraging people to acknowledge the nature of the team in effective management of patients, particularly in acute settings. Among the justifications is the need to reduce the capacity for error. It is, however, acknowledged that error is inevitable: as a consequence of latent conditions (policies, equipment failures,

anaesthetists are taught during the course, who will then go on to teach more medical professionals throughout the country.

A leading consultant in critical care and major trauma has visited Kenya to teach the country’s people vital lifesaving skills following major trauma incidents.

“This is the fifth country where our group has done this type of work and Kenya is now half way through the process,” said Bob.

environment etc) and active failures (cognitive error, training deficiency, fatigue etc). If enough

Medical Director at East Midlands Ambulance

“We will fully complete the teaching and

of these align within a given context, error, and

Service, Dr Bob Winter, is a member of the

training process next summer when we come

possible fatal damage, is the outcome.

Advanced Trauma Life Support (ATLS) steering

back and run a course together rather than just

group which aims to create a uniformed way to

presenting it to them.

Among the reactions to this analysis has

treat trauma patients around the world.

“It’s pleasing to think we’re making a

been the emergence of human factor or nontechnical skills training, with a focus on team

“I do it because I can probably save more

difference in other countries but it also makes

attributes such as:

people through education than I ever will

me really appreciate the advanced standard of

individually,” said Bob.

emergency medical and trauma care we have here at home.

• leadership • followership

“The skills we focus on teaching include lifesaving techniques during the first hour

“Between the highly skilled ambulance

of a patient suffering major trauma, which

paramedics who treat patients at an incident

• decision making

means an injury that has the potential to cause

and the expert clinicians who take over at

• situation awareness

prolonged disability or death.”

hospital, we can be reassured that we will

and many of these have now been

Alongside John Garnham Davis, Clinical Skills

incorporated into life support and other training

Centre Manager for Nottingham University

The team that worked with Bob to provide the

activities.

Hospital, Bob visited the Kenyan Red Cross

training was made up of medical professionals

training school in Nairobi during the first stage

from around the world including South Africa,

of establishing the ATLS program in the country.

Italy, Norway, Denmark and America.

(i.e. issues that emerge from collections

“Bringing this course to a developing country

The project is funded by the Kenyan Red

of individuals) rather than individual

like Kenya means we can make the biggest

Cross and Innovative Canadians for Change.

• communication

always receive the best possible care.”

My belief is that many of these programmes miss an opportunity to explore group issues

characteristics that people bring to membership of a team. Group phenomena, therefore, are more likely to address issues of: RESUSCITATION TODAY - SUMMER 2016

• sharing goals • enabling productive norms (trust, safety, cohesion, honesty, openness) • giving constructive feedback • sharing information and experiences • democratic (as opposed to authoritarian or laissez-faire) leadership • accepting conflict (including conflicts of interest) and disagreement • communication flowing in multiple directions I would argue that these require a different approach to training and that if this were

28

NEWS Northants and, until July 29, an ‘early bird’ rate of just £36 to include lunch, tea/coffee, etc., is on offer!

For those wishing to make the most of Life Connections 2016, further conferences/ workshops are taking place on Tuesday 18 October, to view these and, to register, please visit our dedicated website: www.lifeconnecitons.uk.com

iSimulate Update iSimulate provides world class simulation systems that are a realistic and cost effective solution to organisations across the world.

Our mantra is simple – use the best of current mobile technology to create products that are more advanced, simpler to use and more cost effective than traditional simulation solutions.

The ALSi system – Using just two iPads, the lightness and simplicity of ALSi makes it ideal for in-situ training. ALSi gives facilitators a great tool for training and students an incredibly realistic platform to learn from. ALSi offers medical simulation as you’ve never seen it before, built with technology you use every day.

Used by most Uk Paramedic Education Centres the ALSi tool provides a safe training system, which has the realism of waveform, technology and simplicity of operation.

Above - Facilitator (Instructor)

Giving you the best experience possible If you own or use a smartphone or tablet, you already know how to use ALSi. Our gesture based control panel is built to provide advanced functionality without the complexity of traditional systems, providing a seamless user experience from start to finish.

ALSi provides a highly advanced simulation platform, monitor, defibrillator and AED for far less than the cost of traditional systems.

We are able to do this by utilising current technology, enabling you to have access to highly advanced simulation technology without having to worry about the costs that are usually associated with this level of simulation.

For further information – please contact Philballett@mdtglobalsolutions.com http://www.isimulate.com/uk

Resuscitation Today Conference Date Announced We are pleased to advise that this year’s Resuscitation Today Conference will be taking place on Wednesday 19 October with Ken Spearpoint, Dr Simon Le Clerc, Professor Sir Keith Porter being amongst our line up of speakers who will be giving presentations on: Human Factor in End of Life Care - Implications for Education & Training’, ‘Are We Finally Going To Get To The Bleeding Point?’, ‘The Changing Face of Major Trauma’, etc. The full programme can be viewed on www.lifeconnections.uk.com

Syrian relief effort - SP helping those on the front line In the five years since protestors in Syria first demonstrated against the four-decade rule of the Assad family, hundreds of thousands of Syrians have been killed in the subsequent violence and some twelve million people have been displaced. The country has descended into an ever-more-complex civil war.

SP have been contacted by One Nation, a UK based charity for support with a relief effort to Syria. The charity supports local, national and international relief projects and distributes food packs, clothes and medical supplies to communities within Syria and displaced people along the Turkish border. SP’s donation of medical supplies forms part of a container that is on its way to Aleppo, Syria’s largest city. To date 30 containers of aid have been sent to Syria organised through One Nation with more planned.

Steve Bray, SP Services Managing Director said: “We are pleased to have helped out with the donation of urgently needed medical supplies to those people in Syria who have been caught up in the conflict. SP Services have been providing support for major disaster and relief projects for a number of years and will continue to assist where it can in the future”.

Rebecca Smith, Project Manager for One Nation said ”It is wonderful news that SP Services have helped out and provided essential medical supplies. The donation will make a large difference to the relief effort”.

RESUSCITATION TODAY - SUMMER 2016

Phil Ballett MSc – Paramedic – the UK technical lead - explains - Our aim was to make the device as real as possible - “The team enhanced the simulation even further with the latest version of our Neann bag. This custom designed bag secures the iPad inside its own compartment, giving it the look and feel of a real monitor/defibrillator.

Access to all the normal iPad controls are catered for and you can store and charge your facilitator iPad when not in use. There are compartments to store all your leads and power supplies to make the unit ultra portable.”

We look forward to welcoming you to this year’s event.

The Conference is again taking place at The Kettering Conference Centre, Kettering,

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NEWS Life Connections 2016 We are delighted to announce that Life Connections 2016 will again be taking place at the Kettering Conference Centre, Kettering, Northants on Tuesday 18th and Wednesday 19th October and that those interested in attending will again have a number of conferences / workshops to choose from.

On Tuesday 18th October a Paramedic Conference is in place which includes speakers including Professor Sir Keith Porter, David Halliwell, John Talbot, Tim Edwards etc who once again will be giving excellent presentations on The Changing Face of Major Trauma, How Resuscitation Works, Novel Psychoactives in the Pre-Hospital setting and Airway Management in Cardiac Arrest.

We are also hosting an Emergency First Responder conference which will provide

hosting three conferences which include a

Asthma and Anaphylaxis, Advanced Seizure

delegates with an insight into Enhancing the

Resuscitation Conference incorporating

Management, and Developing Specialist

Scope of Practice for CFR’s; Public Access

presentations by Professor Richard Lyons

Paramedic Practice which are all being given

Defibrillators, Governance versus Vigilance

on “Damage Control Resuscitation: Fluids in

by keynote speakers including Dr Felicity

and Observing and Observations of Children

Trauma”, Ken Spearpoint presenting “ Human

Clark, Dr Neil Thompson, Dr Mike Greenway

in the pre-hospital phase.

Factor in end of life care - implications for

etc.

education and training” and Amy ChanJamie Todd of Pre-Hospital Care Consultancy

Dominy presenting “Paediatric Retrieval /

And a First Aid Conference which includes

Ltd is also running an “Essentials of

Resuscitation”.

presentations on Minor Injury Management

Advanced Airway Management” Course.

and Sepsis Guidelines - Early Recognition is A Critical Care Conference which includes

On Wednesday 19th October we are

presentations on Intra-Arrest Thrombolysis,

the Key. Two further workshops are also be taking place these being a Motorsport Medicine Workshop run by Meditech Global and a PHTLS Course for First Responders.

For those able to book their

RESUSCITATION TODAY - SUMMER 2016

places in advance a discounted early bird rate is available until Friday 29th July and there are discounted rates on offer for those wishing to attend more than one conference. To view all conference programmes please visit our dedicated website www.lifeconnections.uk.com where you can also register to secure your place. Alternatively you can also register by calling the organiser’s office on 01322 660434

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NEWS iSimulate launch amazing new “Training Stethoscope”

ALSG using ‘Fold away Ambulances’ to enhance Safer Transfer education

The latest offering for the iSimulate team is a stethoscope

The Advanced Life Support

which allows the instructor to

Group have been using the

control (Via an ipad and wifi)

“Fold Away” Ambulance to

exactly what the student is able

enhance the teaching on their

to hear.

NAPSTaR course

Known as AURIS Neonatal, Adult and Paediatric Safe Transfer and Retrieval All patients are vulnerable when it comes to transfer; and the time spent transferring presents increased risk to the patient in that it’s time not spent treating.

Furthermore, the challenges posed in transferring are substantial, both clinical and non-clinical.

The product is being launched at the SMACC (Social Media and

To minimise these risks and

Critical Care) conference – and

respond successfully to these

will be a standard offering of the

challenges, the NAPSTaR

UK iSimulate team.

course presents ACCEPT, a structured approach to

Simulation with Standardised

neonatal, adult and paediatric

Patients (Actors) will never be the

transfers, and the knowledge of the processes involved in the transportation of the sick neonate, child or adult, emphasising the preparation required prior to transfer.

Retailing for between £3500

For Further info:

and £4000 (depending on the

Classroom – davehalliwell@

artwork design) the fold away

mdtglobalsolutions.com

classroom has become a

same – because now the reliance on learning heart, breath or bowel sounds is not reliant upon manikins.

Beam the noise you want

fantastic addition to Paramedic

NAPSTaR COURSE - Please

the student to Hear into the

and Transfer Courses.

contact - contactus@alsg.org

Stethoscope!

The ACCEPT methodology consists of the following: Assessment, Control, Preparation and Packaging and Transportation.

Using this approach substantially improves patient care and outcomes, both inter– and intra-hospital.

The Fold away ambulance creates the feeling of the confinements of an ambulance,

RESUSCITATION TODAY - SUMMER 2016

Communication, Evaluation,

but can be used in any classroom setting.

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EMMA® Waveform Capnograph All Patient use Adult/Paediatric Infant/Neonate

EtC02 & Respiratory rate End-tidal C02 and Respiratory Rate values + Waveform

Tube Placement & ROSC Ensures efficacy of intubation Early detection of ROSC

Effectiveness of CPR Feedback > effectiveness of chest compressions & CPR

Optimised Power 8 hrs. continuous use 2 x AAA batteries

Configurable Alarms High & Low EtC02, Apnoea Blocked airway, Battery status

when every breath counts  Application proven: pre-hospital, emergency, critical care & resuscitation  Provides compliance to 2015 ERC/UK ALS waveform capnography guidelines

MEDACX LIMITED • FREDERICK HOUSE • 58 STATION ROAD • HAYLING ISLAND • HAMPSHIRE • PO11 0EL

02392 469737 info@medacx.co.uk www.medacx.co.uk