Resus Today Summer 2018

Volume 5 No. 2

Summer 2018

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

Developing nicely!

Read cover story on page 3 for latest update

medical

CONTENTS

CONTENTS 4

EDITORS COMMENT

7

CLINICAL PAPER Management of upper gastrointestinal bleeding in emergency departments

21

CLINICAL PAPER Development of the major trauma case review tool

30

NEWS

Resuscitation Today This issue edited by: Paul Jones 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 PUBLISHED: Spring, Summer and Autumn

COVER STORY Dear Friends and Colleagues, Developing nicely!

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RESUSCITATION TODAY - SUMMER 2018

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3

EDITORS COMMENT

EDITORS COMMENT In a time where resuscitation can make such a difference in comparison to years gone by, we all need to begin focussing on wider and more challenging aspects of our roles in order to reduce the risk of patient deterioration and increase the chance of survivability from sudden cardiac arrest.

This edition has been geared around exactly this, there are a number of key conditions that can lead to cardiac arrest, if we begin to focus more on researching and discussing these things then we will start to see people in a different light. We will see the potential for deterioration and, whilst it is difficult to measure, we will start to save lives before needing to resuscitate them.

“Those performing resuscitation have always given everything they can and will always continue to RESUSCITATION TODAY - SUMMER 2018

4

do so.”

Whatever our clinical environment, from first aider to intensivist, we are in a position to recognise deterioration by many methods. Whether it is the simple recognition of an altering level of consciousness, changes within a scientific scoring system which brings together baseline observations (such as NEWS) or the use of haematological testing and interpretation. We all have the opportunity to prevent cardiac arrest instead of needing to successfully perform resuscitation – and this has to be better for patient outcome!

The UK Resus Council notably offer guidance on peri-arrest specifically for cardiac arrhythmias and anaphylaxis, and this sits very comfortably within the theme of cardiac arrest prevention.

From simple to complex, they continue to promote an understanding of the Chain of Survival whilst offering support to those wanting to fully consider deficiencies in acute care, ‘at risk’ patients, clinical response and the role that education can play in improving outcomes for all (https://www.resus.org.uk/resuscitation-guidelines/prevention-of-cardiac-arrest-and-decisionsabout-cpr/#).

Those performing resuscitation have always given everything they can and will always continue to do so. I’m not decrying this fact. The suggestion is that we develop our skill-set and prevent the patient needing this in the first place. If we continue to develop our skills of recognising the sickest of patients with the highest levels of risk of cardiac arrest, then we will successfully save lives – maybe without realising we did so and with minimal recognition or fuss.

Training and education, continuing professional development opportunities and research, conferences and conversations have started to move in this direction. So, let us do the same, let’s continue to identify the killers and keep the dialogue going – resuscitation isn’t just about chest compressions, ventilations and drug therapy; it’s about the hours of peri-arrest, the contact leading to the point of crisis, the actions of those who treat the sickest of patients and the studies which inform them and keep them ready for unglorified action.

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CLINICAL PAPER

MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING IN EMERGENCY DEPARTMENTS, FROM BLEEDING SYMPTOMS TO DIAGNOSIS: A PROSPECTIVE, MULTICENTER, OBSERVATIONAL STUDY Pierre-Clément Thiebaud1,2, Youri Yordanov1,3,4, Jacques-Emmanuel Galimard5, Pierre-Alexis Raynal1,3, Sébastien Beaune2,6, Laurent Jacquin2,7, François-Xavier Ageron2,8, Dominique Pateron1,3* and the Initiatives de Recherche aux Urgences Group Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Abstract Background

Results

Upper gastrointestinal bleeding (UGB) is common in emergency

In total, 110 EDs participated, including 194 patients with suspected

departments (EDs) and can be caused by many eso-gastro-duodenal

UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%)

lesions. Most available epidemiological data and data on the

had hematemesis and 75 (39%) melena. Endoscopy revealed lesions

management of UGB comes from specialized departments (intensive

in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or

care units or gastroenterology departments), but little is known from the

bleeding lesions due to portal hypertension (20%). The final diagnosis

ED perspective.

of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died

We aimed to determine the distribution of symptoms revealing UGB

(11%); 40 (21%) were hospitalized in intensive care units and 126 (65%)

in EDs and the hemorrhagic lesions identified by endoscopy. We

in medicine departments; 28 (14%) were outpatients. Mortality was

also describe the characteristics of patients consulting for UGB, UGB

higher among patients with clinical and biological severity signs.

management in the ED and patients outcomes.

Conclusion Method

Most of the UGB cases in EDs are revealed by hematemesis. The

This was a prospective, observational, multicenter study covering 4

emergency physician diagnosis of UGB is rarely challenged by the

consecutive days in November 2013. Participating EDs were part of

endoscopic findings.

the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected

Keywords: Gastrointestinal bleeding, Hematemesis, Melena,

UGB in these EDs were included.

Endoscopy, Emergency department

Background Upper gastrointestinal bleeding (UGB) is a common emergency, with

an endoscopy [10–13]. But these patients represent only a portion of

a variety of eso-gastro-duodenal symptoms as hematemesis, melena,

all those with UGB seen in emergency departments (EDs). Specifically

less often hematochezia or anemia. It can be caused by various

targeting UGB patients presenting in EDs could give us a more

potentially serious lesions, as peptic ulcers or varices [1]. UGB annual

comprehensive epidemiological description.

incidence tends to decrease, influenced by the latest therapeutical Therefore, we aimed at describing the distribution of symptoms

of portal hypertension complications [2]. But it remains relatively high

revealing UGB in EDs and the hemorrhagic lesions identified

because of the widespread use of non-steroidal anti-inflammatory

by endoscopy. Our secondary objectives were to describe the

drugs (NSAIDS) and anti-thrombotic agents [3, 4]. Current cases of

epidemiological characteristics and management of patients with UGB,

UGB occur in patients older than previously described [4–6]. Several

including outcomes.

recommendations regarding UGB management have been published, including therapeutic interventions initiated by the emergency physicians. The implementation of these recommendations could affect

Methods

patients’ prognosis [2, 7, 8].

This prospective, observational, multicenter study was conducted over Very few studies have been conducted in the emergency setting

4 consecutive days in November 2013. We included the 110 EDs, 17

(hospital and pre-hospital settings) to describe UGB epidemiology and

with a prehospital medical unit, that were part of a network of clinical

management [9]. Existing epidemiological data usually concern UGB

research (Initiatives de Recherche aux Urgences [IRU]) coordinated by

in patients hospitalized in gastroenterology, intensive care units or after

the French Society of Emergency Medicine [SFMU].

* 1 3

Correspondence: Dominique.pateron@aphp.fr; dominique.pateron@sat.aphp.fr Service des Urgences - Hôpital Saint Antoine, Assistance Publique–Hôpitaux de Paris (APHP), Paris, France Sorbonne Universités, UPMC Paris Univ-06, Paris, France Full list of author information is available at the end of the article

RESUSCITATION TODAY - SUMMER 2018

developments in the management of peptic ulcers or the prevention

7

CLINICAL PAPER Table 1 General characteristics and treatments of patients presenting an upper gastrointestinal bleeding (UGB)

Age (median [Q1–Q3])a Sex (men; n, %)

Arrival at the ED n = 170

Pre-hospital management n = 24

Total n = 194

P value

66 [49–82]

71 [57.5–75.5]

66 [51–81]

0.71

88 (52)

17 (71)

105 (54)

0.085

Hematemesis

87 (51)

17 (71)

104 (54)

0.096

Melena

70 (41)

5 (21)

75 (39)

Hematochezia

6 (4)

2 (8)

8 (4)

Other

7 (4)

0 (0)

7 (4)

n = 143

n = 20

n = 163

Known cirrhosis

31 (22)

4 (20)

35 (21)

1.

Known ulcer

33 (23)

5 (25)

38 (23)

0.78

Initial symptoms suggesting UGB, n (%)

Medical history and medication, n (%)b

Non-steroid anti-inflammatory drugs

10 (7)

2 (10)

12 (7)

0.64

Antithrombotic agents

54 (38)

8 (40)

62 (38)

1.

Comorbidity

57 (40)

5 (25)

62 (38)

0.25

86 (51)

16 (67)

102 (53)

0.19

Exteriorized bleeding in the ED, n (%)c d

Clinical features of severity, n (%) Heart rate > 100 bpm

n = 166

n = 22

n = 188

36 (22)

12 (55)

48 (26)

0.003

Systolic arterial pressure < 90 mmHg

27 (16)

8 (36)

35 (19)

0.037

Marbling

5 (3)

3 (14)

8 (4)

0.053

Altered mental status Hemoglobin level, n (%)e

< 7 g/dL

Treatments in ED, n (%)

5 (3)

4 (18)

9 (5)

0.012

34 (20)

5 (24)

39 (21)

0.77

n = 170

n = 24

n = 194

Nasogastric tube

15 (9)

4 (17)

19 (10)

0.26

Fluid administration

55 (32)

12 (50)

67 (35)

0.11

Transfusion

71 (42)

1 (4)

72 (37)

0.0002

Proton pump inhibitors

132 (78)

8 (33)

140 (72)

< 0.0001

Vasopressors

33 (19)

3 (13)

36 (19)

0.58

Catecholamines

2 (1)

2 (8)

4 (2)

0.075

Antibioticsf (excluding erythromycin)

8 (5)

—

—

—

Vitamin K antagonist reversal

18 (11)

1 (4)

19 (10)

0.048

Erythromycin

16 (9)

1 (4)

17 (9)

0.70

a

for 193 of 194 patients for 163 of 194 patients for 192 of 194 patients d for 188 of 194 patients e for 189 of 194 patients f for 170 of 194 patients b c

RESUSCITATION TODAY - SUMMER 2018

8

The IRU correspondent for each ED was responsible for patients’

(hematemesis, melena, other), medical history (cirrhosis, ulcer and other

inclusion and data extraction. The STROBE recommendations for

comorbidities), and NSAIDS and/or antithrombotic treatment. In light

reporting of observational studies were followed [14].

of existing epidemiological data, showing an annual incidence of high digestive bleeding of 100 to 150/100,000 inhabitants [5], the number of

Patients

centres in the IRU network and the duration of the study of 4 days, we

All patients with suspected UGB, hematemesis with or without melena,

expected to include 150 to 300 cases of UGB. We estimated the prevalence

melena without hematemesis, hematochezia or other symptoms (acute

of UGB with 2013 data from the French Emergency Survey (FES) and the

anemia, hemorrhagic shock or syncope) suggestive of hemorrhage, who

National Institute of Statistics and Economic Studies (INSEE) data.

were seen in one of the participating pre-hospital or hospital EDs were included by the emergency physicians of the participating departments.

Assessment of disease severity

Exclusion criteria were patients aged less than 18 years old, refusal to

Data for the initial clinical items related to severity were collected,

participate or already included in the study once. For each patient, the

including signs related to blood loss (heart rate > 100 bpm, systolic

following data were collected: type of first contact with an emergency

blood pressure < 90 mmHg, marbling, altered mental status) and

medicine structure (hospital or pre-hospital), age, sex, first symptoms

haemoglobinemia (> 10, 7–10 and <7 g/dL hemoglobin level).

CLINICAL PAPER

Fig. 1 Flow of patients from the first symptoms of suspected upper gastrointestinal bleeding (UGB) to endoscopy diagnosis. N = total number of patients. n1 = patients arriving to the emergency department. n2 = patients initially assessed by a pre-hospital medical team

The following therapeutic measures, done in the ED, were collected:

Categorical variables are expressed as number and percentage. They

placement of a nasogastric tube; fluid administration; transfusion; and

were compared using Fisherâ&#x20AC;&#x2122;s exact test. Statistical analyses were

use of proton pump inhibitors, vasopressors (somatostatin, octreotide,

two-tailed, and a p value less than 0.05 was considered significant.

terlipressin), catecholamines (adrenaline, norepinephrine), anticoagulation

Analyses were performed using R statistical software, version 3.1.3

reversal and antibiotics. The use of erythromycin before endoscopy was

(www.r-project.org).

also noted. Endoscopy data concerning bleeding lesions and hemostasis procedures were noted, as were the performance of any imaging test

Ethics

(ultrasonography, CT). Patients outcome (hospitalised or outpatient), final

The study was approved by the institutional review board (IRB) (ComitĂŠ

diagnosis and hospital deaths were also collected.

de protection des personnes, Ile de France XI, Paris, France) and the Advisory Committee on Information Processing in Material Research in

Statistical analysis

the Field of Health (CCTIRS). Patients, or their next of kin, were informed

Continuous variables are presented as median, first and third quartile

that a study was being led and that their data might be used. They

(Q1-Q3) and were compared using the Wilcoxon rank sum test.

could refuse being included.

RESUSCITATION TODAY - SUMMER 2018

Management and treatment

9

CLINICAL PAPER Results

Table 2 Final diagnosis Final diagnosis

n (%)

Ulcers

44 (30)

Gastritis

16 (11)

not included in the study. The participating EDs received 46.190 visits

Variceal bleeding

30 (20)

during the study period and UGB was suspected in 0.42% of the

Esophagitis

12 (8)

situations. Thus, the estimated incidence of UGB in France, in 2013,

Mallory-Weiss tear

7 (5)

Cancer

12 (8)

Lower gastrointestinal bleeding

5 (3)

None

22 (15)a

Lower gastrointestinal bleeding

4 (9)

None

42 (91)b

During the study, we have included 194 patients with suspected UGB, No patients declined participation, no patients were excluded due to multiple inclusions, and two patients younger than 18 years old were

Endoscopy performed, n = 148 (76%)

was 122/100,000 inhabitants. Out of the 194 included patients, 24 received initial prehospital medical care (12%), median age was 66 years [Q1-Q3 51-81] and 105 (54%) were male. Overall, 104 (54%) had hematemesis and 75 melena (39%). For 15 patients (8%), the suspicion was based on other symptoms (Table 1). Bleeding externalization was observed during the ED stay of a 102 patients (53%). The flow from first

No endoscopy performed, n = 46 (24%)

symptoms to endoscopy diagnosis is reported in Fig. 1. In total, 148

a

patients (76%) underwent endoscopy during their hospital stay, out of

b

5 outpatients included 23 outpatients included

which 44 (23%) during the ED stay: 9/44 (20%) received erythromycin and 12/44 (27%) a hemostatic procedure. Endoscopy confirmed the diagnosis and revealed lesion explaining UGB in 121/148 patients (82%) (Table 2). Gastroduodenal ulcer (44/148 patients, 30%) was the most frequent lesion followed by variceal bleeding (30/148, 20%) and gastritis (16/148, 11%). In 22/148 patients (15%), no lesion was found. In 5/148 (3%) the diagnosis of UGB was overturned, with lower gastrointestinal

than one third of patients had at least one severity sign; about 20% had hypotension, < 7 g/dL hemoglobin level, and a known cirrhosis. In all, 11% of patients died; initial hypotension, marbling or altered mental status were significantly linked to mortality.

bleeding finally diagnosed.

Our proportion of patients presenting with hematemesis (54%) is close

Overall, 67/194 patients (35%) had at least one severity sign: 48 (26%)

departments, intensive care units or by emergency endoscopy [3, 9, 17,

tachycardia, 35 (19%) hypotension, some could present several severity sign (Table 1). Thirty-nine patients (21%) had a hemoglobin level < 7 g/

to literature data (42â&#x20AC;&#x201C;61%) for UGB managed in gastroenterology 18]. In a study of 1140 emergency and ambulatory care patients with UGB of ulcerative origin, the proportion of melena was higher than in

dL and 72 (37%) underwent transfusion. Data regarding type of UGB

our study (52 vs 39%), with 40% of patients having hematemesis and

management are presented in Table 1. Thirty-five patients (21%) had

8% anemia without exteriorized bleeding [19]. In our study, bleeding

a known cirrhosis. Clinical characteristics and outcomes depending

lesions were diagnosed by endoscopy in 80% of cases. One quarter

on presence or not of cirrhosis are presented in Table 3. Patients with

of patients had no endoscopy during hospitalization, often because of

a history of cirrhosis were more often younger and males than those

the low severity among outpatients and more rarely (4 cases) because

without cirrhosis. They presented with a significantly higher proportion

the patient died before endoscopy could be performed. This might

of severity signs, as heart rate > 100 bpm (p = 0.006), marbling (p =

have an impact on the distribution of the causes of UGB. In about 15%

0.031) or an altered mental status (p = 0.015). A total of 21 patients

of patients, endoscopic diagnosis was missing, which is comparable

(11%) died, of which 3 during the pre-hospital phase; 40 (21%) were

to previously published studies [5, 20, 21]. The prevalence of 41%

hospitalized in intensive care units, 126 (65%) in medicine departments

of lesions with an ulcerative origin (ulcer disease or complicated

and 28 (14%) were outpatients.

ulcerations) is close to data (28-67%) from studies including UGB cases from endoscopy examination [5, 21]. The 20% of bleeding lesions

RESUSCITATION TODAY - SUMMER 2018

10

Mortality was significantly higher for hypotensive patients (p = 0.004),

due to portal hypertension was associated to the high prevalence of

with marbling (p = 0.042) or altered mental status (p = 0.0008).

cirrhosis in our population [22]. More than a quarter of patients with

Exteriorized bleeding in the ED was also associated to a higher

cirrhosis presented bleeding from other causes than cirrhosis. This

mortality rate (p = 0.035). Deceased patients received more frequently

can be a strong argument in favor of the use of proton pump inhibitors

vasopressors (p = 0.0009) or catecholamines (p = 0.004). Although not

before endoscopy in this subset of patients, as itâ&#x20AC;&#x2122;s recommended [7],.

significant, there seem to be a trend between mortality and cirrhosis (p

In our study, the diagnosis of UGB in the ED was rarely challenged by

= 0.071) and transfusion (p = 0.057) (Table 4).

subsequent explorations (3% of cases).

Discussion

The UGB incidence estimated from our study favours the completeness of data for our included patients. Epidemiological reviews show an annual incidence of UGB of 50 to 150/100,000 inhabitants [5] and

The distribution of symptoms for suspected UGB is poorly known,

the main French study showed an annual incidence of 146/100,000

especially in EDs, even though most cases of UGB (80â&#x20AC;&#x201C;90%) are

[1]. The median age of UGB and proportion of patients older than 80

managed in EDs [11, 15, 16]. Our multicentric, prospective study

years is similar to that observed in the most recent studies and seems

performed over a short period (4 days) in French EDs found that

higher than that observed 10 years ago, with a significant proportion

for more than half of the patients (54%), the UGB was revealed by

of patients on anti-thrombotic therapy [3, 4]. The proportion of patients

hematemesis. Endoscopy revealed a lesion in about 80% of patients.

with UGB who were older than 75 years was 27% in 1996 [23] but 37%

The final diagnosis of UGB was reversed for only 3% of patients. More

in our study.

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RESUSCITATION TODAY - SUMMER 2018

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11

CLINICAL PAPER Table 3 Patients characteristics depending on their cirrhosis history

Age (median [Q1–Q3]) Sex (men; n, %) Initial symptoms suggesting UGB, n (%)

With cirrhosis n = 35

Without cirrhosis n = 128

P value

56 [50–67.5]

73 [56–83]

0.0006

26 (74%)

69 (54%)

0.034

Hematemesis

24 (69)

60 (47)

0.005

Melena

7 (20)

60 (47)

Hematochezia

1 (3)

6 (5)

Other

2 (2)

3 (9)

21 (62)

69 (54)

Exteriorized bleeding in the ED, n (%)a b

Clinical features of severity, n (%)

0.56

n = 32

n = 127

Heart rate > 100 bpm

17 (53)

26 (20)

0.0006

Systolic arterial pressure < 90 mmHg

9 (28)

22 (17)

0.21

Marbling

4 (13)

3 (2)

0.031

Altered mental status Hemoglobin level, n (%)b

< 7 g/dL c

Upper endoscopy in ED, n (%) Hemostatic procedured Treatments in ED, n (%)

4 (13)

2 (2)

0.015

10 (29)

26 (21)

0.35

29 (26)

9 (29)

0.82

5 (17)

5 (5)

0.036

n = 35

n = 128

Nasogastric tube

5 (14)

12 (9)

0.37

Fluid administration

20 (57)

38 (30)

0.005

Transfusion

16 (46)

50 (39)

0.56

Proton pump inhibitors

28 (80)

93 (73)

0.51

Vasopressors

23 (66)

10 (8)

<0.0001

Catecholamines

2 (6)

1 (1)

0.12

Antibioticsc (excluding erythromycin)

4 (13)

2 (2)

0.020

Vitamin K antagonist reversal

0

19 (15)

0.027

Erythromycin

6 (17)

9 (7)

0.09 <0.0001

e

Final diagnosis (hospitalized patients), n (%)

Ulcer

2 (6)

38 (37)

Gastritis

3 (9)

12 (12)

Variceal bleeding

25 (74)

1 (1)

Esophagitis

2 (6)

9 (9)

Mallory-Weiss tear

0

6 (6)

Cancer

0

12 (12)

Lower GI bleeding

0

6 (6)

None

2 (6)

19 (18)

a

for 161 of 163 patients for 159 of 163 patients for 143 of 163 patients d for 141 of 163 patients e for 137 of 163 patients b

RESUSCITATION TODAY - SUMMER 2018

12

c

Two studies [4, 6] confirmed an increase in the ageing of the population

bleeding, including those with a history of cirrhosis that appeared more

with UGB, with average age 57, 59, 63 and 66 years in 1986-1987, 1995,

severe, and critically ill patients that were initially managed in the pre-

2000-2001, and 2005, respectively. As in our study, the literature shows

hospital setting. The main factors associated with mortality found in the

a male predominance, with a sex ratio between 1.3 and 2 [1, 20, 23],

literature are ageing, co-morbidities (including cirrhosis), signs of severity,

but the proportion of women with UGB is increasing [24].

an initial low blood pressure, hematemesis and low hemoglobin level [4, 5, 20, 21]. We found a significant association between mortality and

The observed severity of disease in our patients was similar to

signs of severity (low blood pressure, marbling, altered mental status),

epidemiological studies, finding mortality between 3 and 14% [4, 5, 17,

exteriorized bleeding in the ED or therapeutical interventions as the use of

21]. Our level of mortality (11%) might seem relatively high for patients with

catecholamines or vasoactive agents. There appear to be a trend toward

UGB in EDs [5], possibly because we included all patients with suspected

an association with history of cirrhosis and need to transfusion, although

CLINICAL PAPER Table 4 Patients characteristics depending on their survival status Age (median [Q1–Q3])

b

Sex (men; n, %)

Survivors n = 172a

Dead n = 21a

P value

66.5 [49–81]

66 [57–83]

0.46

91 (53)

13 (62)

0.49

Hematemesis

90 (52)

13 (62)

0.87

Melena

67 (39)

8 (38)

Hematochezia

8 (5)

0 (0)

Other

7 (4)

0 (0)

n = 144

n = 18

Known cirrhosis

28 (19)

7 (39)

Known ulcer

35 (24)

3 (17)

0.57

Non-steroid anti-inflammatory drugs

54 (38)

8 (44)

0.61

Antithrombotic agents

58 (40)

4 (22)

0.20

Initial symptoms suggesting UGB, n (%)

Medical history and medication, n (%)c

Comorbidity

0.071

12 (8)

0 (0)

0.36

Exteriorized bleeding in the ED, n (%)d

85 (50)

16 (76)

0.035

Clinical features of severity, n (%)e

n = 167

n = 20

Heart rate > 100 bpm

39 (23)

8 (40)

0.11

Systolic arterial pressure < 90 mmHg

26 (16)

9 (45)

0.004

Marbling

5 (3)

3 (15)

0.042

Altered mental status

4 (2)

5 (25)

0.0008

34 (20)

5 (24)

0.55

39 (25)

5 (31)

0.57

11 (7)

1 (7)

1.00

n = 172

n = 21

18 (10)

1 (5)

0.70

Fluid administration

58 (34)

8 (38)

0.81

Transfusion

60 (35)

12 (57)

0.057

Proton pump inhibitors

125 (73)

14 (67)

0.61

Vasopressors

25 (15)

10 (48)

0.0009

Hemoglobin level n (%)f Upper endoscopy in ED, n (%)

< 7 g/dL g

Hemostatic procedureh Treatments in ED, n (%) Nasogastric tube

1 (1)

3 (14)

0.004

7 (5)

1 (6)

0.56

Vitamin K antagonist reversal

16 (9)

3 (14)

0.44

Erythromycin

15 (9)

2 (10)

1.00

Ulcer

41 (29)

3 (19)

0.31

Gastritis

15 (11)

1 (6)

Variceal bleeding

23 (17)

7 (44)

Esophagitis

12 (9)

0 (0)

Mallory-Weiss tear

7 (5)

0 (0)

Cancer

10 (7)

2 (13)

Lower GI bleeding

8 (6)

1 (6)

None

23 (17)

2 (13)

i

Final diagnosis, n (%) (hospitalized patients)

a

1 missing data b for 192 of 193 patients c for 162 of 193 patients d for 191 of 193 patients e for 187 of 193 patients f for 188 of 193 patients g for 169 of 193 patients h for 167 of 193 patients i for 155 of 193 patients

not significant, which could be due to a lack of statistical power of our

for these patients with a bleeding ulcer [21]. Use of anti-thrombotic agents,

study. When looking at published literature, mortality was higher in patient

a known risk factor of digestive hemorrhage [21], was frequent in our

with a history of cirrhosis [10, 23], with variceal bleeding [17, 20] but also

population but did not predict mortality.

RESUSCITATION TODAY - SUMMER 2018

Catecholamines Antibioticsg (excluding erythromycin)

13

CLINICAL PAPER Management of UGB in our cohort of patients shows an evolution of

Acknowledgments

practices, possibly influenced by recommendations [2, 7, 8]. Proton

The authors thank Laura Smales (BioMedEditing) for editing and all

pump inhibitors were used for three-quarters of our patients, and their

the members of the Initiatives de Recherche aux Urgences network

administration is now recommended as soon as possible without

(Additional file 1).

waiting for endoscopy [7]. Most patients with cirrhosis received vasopressor treatment in the first 24 h [2]. The number of transfusions

Funding

suggests that the policy of restricting transfusion is not yet followed [25].

This study did not receive any specific funding.

Only a few patients received nasogastric tubes (10%). Several studies indicated that nasogastric tube placement does not confirm the upper

Availability of data and materials

origin of a gastrointestinal bleeding [26, 27] and recommendations

Datasets are available upon request to the corresponding author.

remain unclear on this topic. Erythromycin perfusion before endoscopy is rarely used [28]. This practice, although validated by several

Authors’ contributions

studies, is not shared by some international recommendations [21].

PCT and DP designed the study. PCT acquired the data. PCT, DP, PAR,

The use of antibiotics in patients with cirrhosis remains low despite

YY drafted the paper. JEG performed the statistical analysis. All authors

recommendations on this topic [29]. Outpatient care concerned only

revised and reviewed the final paper. All authors read and approved the

14% of our patients, which is less than in studies using a severity score

final manuscript.

[30]. The use of these scores would probably increase the proportion of outpatients.

Ethics approval and consent to participate The study was approved by the institutional review board (IRB) (Comité de protection des personnes, Ile de France XI, Paris, France) and the

Limitations One main limitation of our study is the risk of selection. The departments participating in the study are a subset of the 600 French EDs, that are particularly interested in clinical research. Patients presenting at these EDs might not be representative of the general population. The IRU includes community and university hospitals, so this risk was deemed acceptable. Another limitation can be due to the short inclusion period of 4 days that might not perfectly reflect the distribution of the causes of upper GI bleeding. There’s also a possibility of under or overestimation

Advisory Committee on Information Processing in Material Research in the Field of Health (CCTIRS). Patients, or their next of kin, were informed that a study was being led and that their data might be used. They could refuse being included.

Consent for publication Not applicable.

Competing interests The authors declare no conflict of interest.

of UGB incidence, due possible natural variations in the number of patients presenting with UGB in EDs. The third limitation is the absence of precise quantitative data. Each local investigator, when including patients, had to choose between various categories (e.g., tachycardia >100 bpm, hemoglobin level > 10, 7–10 and <7 g/dL) to simplify data extraction sheets and ensure data quality and comprehensiveness, at the expense of severity score precision. The number of inclusions (194 patients) limits the statistical power of the study, especially for prognostic factors. Moreover, the number of deceased patients did not allow us to perform a robust multivariate analysis.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author details 1

Service des Urgences - Hôpital Saint Antoine, Assistance Publique–

Hôpitaux de Paris (APHP), Paris, France. 2Initiatives de Recherche aux Urgences, SFMU, French Society of of Emergency Medicine, Paris, France. 3Sorbonne Universités, UPMC Paris Univ-06, Paris,

RESUSCITATION TODAY - SUMMER 2018

14

Conclusions

France. 4INSERM, U1153, Paris, France. 5INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), ECSTRA Team, Saint-Louis Hospital, Paris, France. 6Emergency

Most of the UGB cases in EDs are revealed by hematemesis. The

department, CHU Ambroise Paré, Assistance Publique Hôpitaux de

emergency physician diagnosis of UGB is rarely challenged by the

Paris, Boulogne-Billancourt, France. 7Emergency department, Hôpital

endoscopic findings. Epidemiological data for patients with UGB

Edouard Herriot, Hospices Civils de Lyon, Lyon, France. 8Emergency

managed in the emergency departments are similar to the patients

department, Centre Hospitalier Annecy Genevois, Pringy Cedex,

treated in gastroenterology departments and/or in intensive care units.

Metz-Tessy, France.

More than one third of UGB patients are more than 75 years old.

References Additional file

1. Czernichow P, Hochain P, Nousbaum JB, Raymond JM, Rudelli A, Dupas JL, et al. Epidemiology and course of acute upper gastro-

Additional file 1: Appendix 1. Members of the Initiatives de Recherche

intestinal haemorrhage in four French geographical areas. Eur J

aux Urgences network. (DOCX 16 kb)

Gastroenterol Hepatol. 2000;12:175–181.

CLINICAL PAPER 2. de Franchis R, Faculty BVI. Expanding consensus in portal

16. Paspatis GA, Matrella E, Kapsoritakis A, Leontithis C, Papanikolaou

hypertension: report of the Baveno VI consensus workshop:

N, Chlouverakis GJ, et al. An epidemiological study of acute upper

stratifying risk and individualizing care for portal hypertension. J

gastrointestinal bleeding in Crete, Greece. Eur J Gastroenterol

Hepatol. 2015;63:743–752.

Hepatol. 2000;12:1215–1220.

3. Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper

17. Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding

gastrointestinal bleeding: incidence, etiology and outcomes in a

and outcomes in patients hospitalized with upper gastrointestinal

population-based setting. Scand J Gastroenterol. 2013;48:439–447.

bleeding. J Clin Gastroenterol. 2014;48:113–118.

4. Thomopoulos KC, Vagenas KA, Vagianos CE, Margaritis VG, Blikas

18. Lanas A, Aabakken L, Fonseca J, Mungan ZA, Papatheodoridis GV,

AP, Katsakoulis EC, et al. Changes in aetiology and clinical outcome

Piessevaux H, et al. Clinical predictors of poor outcomes among

of acute upper gastrointestinal bleeding during the last 15 years.

patients with nonvariceal upper gastrointestinal bleeding in Europe.

Eur J Gastroenterol Hepatol. 2004;16:177–182.

5. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22:209–224.

6. Theocharis GJ, Thomopoulos KC, Sakellaropoulos G, Katsakoulis E, Nikolopoulou V. Changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in Greece. J Clin Gastroenterol. 2008;42:128– 133.

7. Osman D, Djibré M, Da Silva D, Goulenok C, group of experts Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care. 2012;2:46.

8. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al.

International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–113.

9. Chassaignon C, Letoumelin P, Pateron D, Group HD 2000 Upper gastrointestinal haemorrhage in emergency Departments in France: causes and management. Eur J Emerg Med Off J Eur Soc Emerg Med. 2003;10:290–295.

10. van Leerdam ME, Vreeburg EM, Rauws E a J, Geraedts A a M, Tijssen JGP, Reitsma JB, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98:1494–1499.

11. Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol. 1997;92:236–243.

12. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J 13. Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ. 1997;315:510–514.

14. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,

19. Zeitoun J-D, Rosa-Hézode I, Chryssostalis A, Nalet B, Bour B, Arpurt J-P, et al. Epidemiology and adherence to guidelines on the management of bleeding peptic ulcer: a prospective multicenter observational study in 1140 patients. Clin Res Hepatol Gastroenterol. 2012;36:227–234.

20. Nahon S, Hagège H, Latrive JP, Rosa I, Nalet B, Bour B, et al. Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: results of a French prospective multicenter study. Endoscopy. 2012;44:998–1008.

21. Rotondano G. Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin N Am. 2014;43:643–663.

22. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823–832.

23. Di Fiore F, Lecleire S, Merle V, Hervé S, Duhamel C, Dupas J-L, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol. 2005;17:641–647.

24. Loperfido S, Baldo V, Piovesana E, Bellina L, Rossi K, Groppo M, et al. Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc. 2009;70:212–224.

25. Villanueva C, Colomo A, Bosch A, Concepción M, HernandezGea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.

26. Cuellar RE, Gavaler JS, Alexander JA, Brouillette DE, Chien MC, Yoo YK, et al. Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate. Arch Intern Med. 1990;150:1381–1384.

27. Kessel B, Olsha O, Younis A, Daskal Y, Granovsky E, Alfici R. Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena. Eur J Emerg Med Off J Eur Soc Emerg Med. 2016;23:71–73.

28. Pateron D, Vicaut E, Debuc E, Sahraoui K, Carbonell N, Bobbia X, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal

Vandenbroucke JP, et al. The strengthening the reporting of

bleeding: a multicenter randomized controlled trial. Ann Emerg

observational studies in epidemiology (STROBE) statement:

Med. 2011;57:582–589.

guidelines for reporting observational studies. Lancet Lond Engl.

2007;370:1453–1457.

15. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the

29. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, SoaresWeiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;(9):CD002907.

30. Longstreth GF, Feitelberg SP. Outpatient care of selected patients with

National Audit of acute upper gastrointestinal haemorrhage. BMJ.

acute non-variceal upper gastrointestinal haemorrhage. Lancet Lond

1995;311:222–226.

Engl. 1995;345:108–111.

RESUSCITATION TODAY - SUMMER 2018

Gastroenterol. 1995;90:206–210.

Aliment Pharmacol Ther. 2011;33:1225–1233.

15

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Life Connec

Aylesbury Event - Thu 6th September 2018 The G Paramedic Conference Programme

Around 200 delegates registered to attend each of our Harrogate and Bristol multi-conference/workshop events and we are hoping for a similar turnout in Aylesbury.

In addition to our Paramedic & Resuscitation conferences, separate conferences will also be taking place for First Responders and First Aid Trainers, both have excellent presentations in place that include:

Time

Presentation

Speaker

Position

Why Trauma Patients Die (Professor Sir Keith Porter), The Alternative Role of the CFR (James Crawley), The Changing Face of First Aid (Dr Mark Forrest), First Aid...The Need for Effective Teaching & Learning

9.00 - 9.30

Registration

(Rob Shaloe) and First Class First Aid...Enhancing Care at the Point of

9.30 - 10.00

Tea / Coffee

For full events details, please visit: www.lifeconnections.uk.com

Integrating Service Users & Carers 10.00 - 10.30 Into Undergraduate Paramedic Education 10.30 - 11.00

Impact Brain Apnoea & Head Injuries

11.00 - 11.30

Advanced Airway Management

11.30 - 12.00

Tea / Coffee Exhibition

Using Simulation as 12.00 - 12.30 a Learning, Teaching & Assessment Tool 12.30 - 13.00

Burns - Timing is Everything

Immediate Need (Paul Jones).

In addition, Pre-Hospital Care Consultancy are running a morning Miriam Perry

Senior Lecturer

Trauma Workshop that includes Trauma Patient Assessment, Catastrophic Bleeding and Splintage Skills followed by an afternoon Airway Management Workshop that includes Direct and Video Laryngoscopy and Emergency Surgical Airways.

Amy Kyle

Amy Chan-Dominy

Paediatric Consultant

Dr Natasha Taylor

Principal Lecturer

Kristina Stiles

Clinical Nurse Specialist

13.00 - 14.00 Lunch, Exhibition

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

To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434

Only 50 Places are available on each of our Paramedic and Resuscitation Conferences at a cost of ÂŁ30pp to include VAT, lunch/tea/cof combined rate of just ÂŁ42 to include VAT, lunch, etc. To view all programmes and to secure your delegate place please visit: www.lifec

A further Conference is planned later in th

www.lifeconnections.uk.com

ctions 2018

Gateway Conference Centre, Aylesbury HP19 8FF Delegate feedback received from our Harrogate and Bristol events has been very positive, a typical example being as follows: ‘We had 6 x personnel attend your workshops / conference last week in Harrogate. The feedback from this has been very positive. Everyone felt they benefited from attending for the day’ Thanks to the generosity of WEL Medical, delegate rates at our Aylesbury event start from just £18 per person to include lunch,

Resuscitation Conference Programme Time

Presentation

Speaker

Position

Amy Chan-Dominy

Paediatric Consultant

Jonathan Leung

HEMS Pre-Hospital Registrar

Mike Davis

Keele University

Joanne Mildenhall

Paramedic Team Leader

Ken Spearpoint

Principal Lecturer

tea/coffee, free parking, etc. Combined rates are also available for those wishing to attend both a morning and afternoon conference or, alternatively, a conference plus a workshop or,

12.00 - 12.30 Registration

two workshops. As delegate places are limited, particularly on the workshops, early registration is recommended to avoid disappointment.

Our Life Connections road show will then move on to Stoke-onTrent (October 25th).

We look forward to welcoming you to Life Connections 2018.

12.30 - 14.00 Lunch/Exhibition

What Does Adult 14.00 - 14.30 Congenital Heart Disease Mean?

Ultrasound Application 14.30 - 15.00 for Traumatic Cardiac Arrest 15.00 - 15.30

Simulation Challenging Reality

15.30 - 16.00 Tea/Coffee/Exhibition

16.00 - 16.30

Dealing with Distressing Incidents

16.30 - 17.00

Application of Educational Theory

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

To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434

ffee and free parking. Delegates can attend both our morning Paramedic Conference and afternoon Resuscitation Conference for a connections.uk.com or call the organisers on: 01322 660434

he year for Stoke-on-Trent (October 25th)

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RESUSCITATION TODAY - SUMMER 2018

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Quality, innovation and choice

20

CLINICAL PAPER

DEVELOPMENT OF THE MAJOR TRAUMA CASE REVIEW TOOL Kate Curtis1,2, Rebecca Mitchell3, Amy McCarthy1, Kellie Wilson4, Connie Van1*, Belinda Kennedy1, Gary Tall5, Andrew Holland6, Kim Foster1,7, Stuart Dickinson8 and Henry T. Stelfox9 Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Abstract Background

Results

As many as half of all patients with major traumatic injuries do

The final trauma case review tool contained ten sections, including patient

not receive the recommended care, with variance in preventable

factors (such as pre-existing conditions), presenting problem, a timeline

mortality reported across the globe. This variance highlights the

of events, factors contributing to the care delivery problem (including

need for a comprehensive process for monitoring and reviewing

equipment, work environment, staff action, organizational factors), positive

patient care, central to which is a consistent peer-review process

aspects of care and the outcome of panel discussion. After refinement,

that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review.

The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure.

Methods

the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters.

Discussion This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care.

Conclusions This tool can be used to identify opportunities for improvement in

Development of the trauma case review tool was multi-faceted,

trauma care and guide quality assurance activities. Validation is required

beginning with a review of the trauma audit tool literature.

in the adult population.

Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement

Keywords: Injury, Quality, Safety, Peer review, Adverse event, Mortality,

was assessed for both the pilot and finalised versions of the tool.

Morbidity, Human factors, Organizational factors, Emergency

Background ought not to be hospital-centric and silo driven and should include

ideal care, with between 2.5% and 14% of medical errors in trauma deaths

elements of trauma system safety and human factors [9]. A process

determined as potentially clinically preventable [1]. The 2014 Australian

with standardized criteria (definitions) and measures of trauma care

Trauma Registry report demonstrated a variance in mortality rates

quality, along with consistent approaches to measurement, monitoring

between states and hospitals [2], such variance is reported across clinical

and reporting between hospitals is required to ascertain areas for

specialties and the globe [3, 4]. The literature also suggests that there is

improvements in care and identify corrective strategies. Further,

great variability in the quality of care for injured youth [5, 6], that deficiencies

the impacts of the trauma system should include all phases of care

exist in the quality of care for 8% to 45% of severely injured children, and

including prehospital, trauma triage criteria, hospital type and interfacility

that 6% to 32% of in-hospital deaths are preventable [7]. This variance in

transfer, focusing on timeliness and appropriateness of care [10].

in-hospital mortality between hospitals highlights the need for a systematic, comprehensive system for monitoring and reviewing patient care to inform

Within hospitals, there have been a range of classification frameworks

processes for change to ultimately improve patient outcomes.

and taxonomic tools developed to attempt to identify the causal factors of adverse events from a human factors perspective [11]. Many of the

Trauma centres have a wide and varying range of trauma quality

frameworks developed have been based on Reasonâ&#x20AC;&#x2122;s Organisational

improvement projects, and initiatives, including morbidity and mortality

Accident Causation Model [12], such as the London Protocol [13].

meetings. Such meetings are longstanding throughout healthcare

Several of these do not consider the underlying causes of adverse

for review of patient deaths and complications, however, there

incidents, however, nor do they consider all human factors, including

remains a need to standardise the approach taken to review cases

human behavior (ie. human error), that may contribute towards an

across hospitals and other trauma care providers [8]. This approach

adverse event or a potential adverse event occurring.

* 1

Correspondence: connie.van@sydney.edu.au Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia Full list of author information is available at the end of the article

RESUSCITATION TODAY - SUMMER 2018

As many as half of all patients with major traumatic injuries do not receive

21

CLINICAL PAPER Currently, there is no published, evidence-informed standardised tool

issues. Error was classified using Rasmussen’s [19] skill, rule or

that considers both system safety and human factors for use in adult or

knowledge-based error classifications, or a violation classification

paediatric trauma case peer review. To address this evidence-practice

[20]. Skill-based errors referred to unintentional failures in the

gap, the aim of this research was to develop and validate a trauma

execution of a well-rehearsed action or routine task that required

case review tool to facilitate clinical review of trauma patient care that

little conscious attention. Rule-based errors referred to unintentional

addresses the recommendations of the World Health Organization

failures during activities conducted in familiar situations that

(WHO) [8] and Australasian Trauma Quality Improvement Program

were controlled by stored rules. Knowledge-based errors referred

Guidelines [2].

to unintentional failures during a novel situation that required conscious analytic processing and stored knowledge. A violation

Aim

was considered to be an intentional failure to follow accepted work

To describe the development and validation of a trauma case review tool

practices, guidelines or procedures during the execution of a task.

to facilitate peer-review of adverse events in paediatric major trauma

It is noted that within this classification system a violation does not

designed to extract information to facilitate monitoring, inform change

indicate the intent to cause harm.

and facilitate loop closure.

Data collection

Methods

Each of the clinical reviewers was provided verbal instruction on how to use the tool and a data dictionary and each signed a confidentiality agreement. Clarification on definitions and aspects

This trauma case review tool is intended for use to facilitate peer-

of the tool was provided as required, and modifications made

review of major paediatric trauma cases flagged for analysis as a

accordingly following the testing.

result of an adverse event and was developed during a state-wide, prospective paediatric trauma system evaluation in Australia’s most

For the pilot, the reviewers were emailed links to the de-identified

populous State, New South Wales [14]. Development was multi-

files using the secure Cloudstor platform (Australia Academic and

faceted, beginning with a review of the literature on trauma audit

Research Network). A second round of testing following refinement

tools. Data were extracted from the literature to inform iterative

of the tool was conducted by eight trauma clinicians who used the

tool development using a consensus approach, which was then

tool to classify eight de-identified paediatric trauma cases. This

followed by pilot and inter-rater reliability testing. Each step is

group included the same clinicians who reviewed the pilot tool, as

described below.

well as interstate and international clinicians from nursing, surgical, emergency and retrieval backgrounds. For the second round of

Review of literature

testing, a day long face-to-face meeting was held, orientation to

A review of key principles from the WHO Trauma Quality Improvement

the tool conducted, and hard copies of de-identified trauma cases

Program Guidelines [8], National Safety and Quality Framework [15], the

provided for peer-review. Each reviewer completed the case review

Institute of Medicine [16] and the London Trauma Protocol [17] along

independently using the tool. Cases used for testing had been

with the international literature on Trauma audit tools was conducted.

identified as having adverse events by the site trauma service and the

Electronic database search was conducted using the terms “injury”,

age range of the injured children was 8 weeks to 15 years.

“audit”, “tool”, “peer review”.

Data management and analysis Development of the trauma case review tool

Data from both rounds of testing were entered in ExcelTM. Double data

Extraction of data from the literature identifying categories of factors

entry was conducted to ensure accuracy. Inter-rater reliability of the

found to be causally related to adverse events was conducted and a

adverse event causal factors and outcomes components sections of

draft tool containing seven components that considered the trauma

the tool was assessed using percent agreement [18, 21]. Entries had to

system, and human factors was developed. A pre-existing, validated,

agree exactly to be considered the same, and only those answered as

hierarchical human factors framework was included in the tool [18],

‘yes/no/not applicable’ were assessed.

RESUSCITATION TODAY - SUMMER 2018

consisting of three levels to categorise the human factors contributing to any care delivery problems (Section 6).

The draft tool was reviewed by the NSW Institute of Trauma and Injury Management’s Clinical review committee and then trialed by five experienced trauma clinicians (including a trauma nurse, emergency physicians, and surgeons) using medical records from three deidentified paediatric trauma cases from different hospitals. Following feedback from the reviewers, refinements and retesting of the tool with additional de-identified cases was conducted.

Classification of terms

-Addition of a timeline displaying key events in chronological order to provide a snapshot of what happened -Addition of Section 8 which allows for the recording of positive aspects of care -Addition of Section 9 to identify whether reviewers have had prior knowledge of the case which may impact on their review -Addition of answer options in cases where not all options are covered -Minor modification to the wording of some questions to avoid ambiguity

Information on the role of error in any adverse events was identified

-Minor modification to the layout and structure to improve usability

for the staff action-related classifications involving medical task

-Prompts to interview relevant staff to gather further information

failures, monitoring tasks, delays, misdiagnoses, or medication

22

Table 1 Modifications made to the case peer review tool

CLINICAL PAPER

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RESUSCITATION TODAY - SUMMER 2018

23

CLINICAL PAPER Table 2 Components of the major trauma case peer review tool Basic information Record ID

This is the unique record used by the study team to identify each record

Reviewer ID

Each reviewer has a unique identification number

Date of review

For recording when the review was conducted

Date and time of injury

Key time variables allow for the development of a chronology

Age and gender

Age and gender to allow comparative analysis across groupings and determination of specific areas for education/change within the trauma system that considers age related physiology, age specific injury patterns [36, 37]

Date and time of incident(s)

Key time variables allow for the development of a chronology

Section 1: Patient factors Background

Such as whether the child is Aboriginal or Torres Strait Islander, culturally and linguistically diverse or a refugee to assist with the identification of potentially vulnerable groups and engagement with appropriate stakeholders when required

Previous location and source of referral

Primary presentation, secondary presentation (e.g. inter-hospital transfer) and source of referral (e.g. self, road ambulance) to assist with mapping of patient flow and identification of potential areas of deficits

Other patient factors

This component attempts to capture the unique characteristics of the patient in the context of their presentation including: complexity and acuity of presentation; behavioural and social factors

Table 2 Components of the major trauma case peer review tool (Continued) Was a toxicology screen/post mortem conducted? If yes, what type was completed and is the report available?

Category of the problem (either To assist with the determination of clinical, systems or communication) how the clinical deficit occurred and to allow comparative analysis across groupings and determination of specific areas for education/ change within the trauma system [27] Section 5: Specific services involved in the care delivery problem Specific department and staff involved in the care delivery problem

These sections capture the cause and nature of the injury

Equipment

Including: lack of medical equipment, medical equipment breakage or failure, equipment failure (design), medical equipment not elsewhere classified, non-medical equipment and medical supplies

Work environment

Including: light, temperature, noise, physical layout, security and work environment not elsewhere classified

Staff action

Including: verbal communication and written documentation issues, medical task failure, monitoring, delay, misdiagnosis, medication issue and human factors not elsewhere classified

Patient

Including: physical health, health state, communication issues, medication, toxicology, clothing, and patient characteristics not elsewhere classified

Organisational factors

Including: work practices, policies or guidelines, supervision, organisational resources, work pressure and organisational factors not elsewhere classified

Individual factors

Including: training, experience, fatigue, stress and individual factors not elsewhere classified

Other factors

This is a free text response for factors the reviewer feels are not addressed in the previous categories

Section 3: Timeline of events Timeline of events

RESUSCITATION TODAY - SUMMER 2018

24

Timeline of events in chronological order

Section 4: General incident information Did the patient die?

Phase of care the patient died in (pre-hospital/during transport/ in-hospital/which ward?)

To determine whether the child died as a result of their injuries and to assist with further questioning To provide a construct on where the incident occurred, allowing monitoring of one point of care or service

This multiple choice and free text response section allows for determination of services involved in the care delivery problem

Section 6: Factors contributing to the care delivery problem

Section 2: Presenting problem/diagnosis Injury mechanism, injuries, and signs and symptoms on presentation

Autopsy reports are a valuable source of information and provide an important adjunct to any investigation of factors potentially contributing to patient mortality [8]

Section 7: Outcome Best description of the incident

How the incident can be best described ranging from clinically preventable to clinically nonpreventable death, near miss of death, near miss of incident that did not result in death, preventable error causing lasting disability or no problems identified

The percentage agreement was calculated as the ratio of the total

concordance in the human factors framework section that consists

number of â&#x20AC;&#x2DC;sameâ&#x20AC;&#x2122; responses for each data element divided by

of three levels to categorise the human factors contributing to any

the total number of data elements assessed. For measurement of

care delivery problems, agreement pertained to raters recording the

CLINICAL PAPER Table 2 Components of the major trauma case peer review tool (Continued) Section 8: Positives of care

Section 9: Prior knowledge Section 10:prior Panelknowledge discussion of Reviewer the case Summary of review and recommendations Section 10: Panel discussion Interview involved?

Summaryofofstaff review and recommendations

Interview of staff involved?

Review of literature Several papers reported that they conducted a peer-review process and

Positive of care theofpatient Thistrauma free textcase response allow fortool Table aspects 2 Components the major peer review received the recording of positives of care (Continued) the patient received Section9:8:Prior Positives of care Section knowledge Positive aspects of care the Reviewer prior knowledge of patient received the case

Results

This freetotext response allowthe for Included identify whether the recording of positives of care reviewer had prior knowledge received ofthe thepatient case which may affect their review of the case Included to identify whether the reviewer had priortoknowledge Free text response allow for a of the case which mayand summary of the review affect their review of the case recommendation for corrective strategies after panel discussion ToFree allow details to recorded textstaff response to be allow for a ifsummary staff are recommended of the review for and interview to obtain further recommendation for corrective information for completing strategies after panel discussion the assessment To allow staff details to be recorded if staff are recommended for interview to obtain further information for completing the assessment

‘same’ response for up to three levels for each factor, for example, a Level 1 factor was ‘Work Environment - Did the work environment contribute to difficulties in delivering the required care?”. Level 2 of ‘Work Environment’ is the subsection within Level 1, with a possible response being ‘Light’ and a Level 3 response could have been ‘No or too little light’.

No original research studies of a validated peer-review tool for use in trauma care were identified.

Iterative refinement The usability testing and pilot of the trauma case review tool by the clinical reviewers identified that several modifications of the tool needed to be made. Modifications made are presented in Table 1.

Inter-rater reliability For the pilot, the interrater reliability of the human factors and outcome components of the tool had an average 81% agreement between raters at level 1, 69% at level 2 and 69% at level 3. After refinement of the tool, the interrater reliability of the human factors and outcome components of the tool improved and had an average 86% agreement between raters at Level 1. There was a moderate decrease in reliability with 67% at level 2 and 63% at level 3.

Final trauma case review tool The final tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, specific services involved in the care delivery, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), patient outcome, positive aspects of care and the outcome of panel discussion (Additional files 1 and 2).

RESUSCITATION TODAY - SUMMER 2018

Fig. 1 Factors contributing to the care delivery problem

classified outcomes as either preventable or non-preventable [22–24].

Fig. 1 Factors contributing to the care delivery problem

25

CLINICAL PAPER Each component of the tool was informed by the aforementioned

organisational and environmental factors that may have contributed to

literature search and is outlined in Table 2.

the occurrence of the event which is in line with WHO recommendations that the review process should identify clinical errors, consider work

Trauma system components

system factors that contributed to the occurrence of the errors, and

The first sections (Sections 1–3) of the case review tool include

facilitate corrective action plans [8].

demographic and injury information to allow for the development of a chronology and consideration of age- and any patient- specific

Adverse events are directly linked to actual harm resulting from (or

physiology [25]. The following sections (Sections 4–5) collect clinical

omission of) health care and are generally independent of the patient’s

management and service delivery information in the standardised

disease. An adverse event may occur despite the correct care being

Airway, Breathing, Circulation format known to improve trauma

given under correct circumstances but ultimately associated with a

patient outcomes when followed [26]. This clinical categorisation of

poor outcome [30]. Errors are one aspect of failure in the processes

treatment in common trauma language facilitates case-specific areas

of care. While historically there has been a focus on the individuals

of improvement and longer term monitoring of areas of care that may

that perpetrated the error we know that human performance and the

require widespread education or intervention for change [1, 23, 27,

occurrence of errors is influenced by a range of factors in the environment

28]. It also enables identification of compliance with specific local

and organisational systems. It is through understanding these influences

or statewide trauma management guidelines or protocols. Detailed

that we can identify potential improvements in the system and thereby

information on the locations and services involved in a particular

reduce the re-occurrence of similar incidents in the future. The approach

incident or near miss will also allow specific intervention if required, and

of applying a structured framework of these influencing/causal factors

ongoing monitoring to provide evidence for change.

is particularly suited to the case review methodology where the detailed data around individual action may not be available but environmental and

Consideration of causal factors

organisational factors can be identified by experienced reviewers. This

Section six records information on human factors that may have

tool records adverse events, but also informs understanding of the areas

influenced clinical practice including: equipment, work environment,

of the system that require further investigation, and monitoring for trends

staff action, patient, organizational, individual and other factors. The

to highlight where change is needed.

human factors component was adapted from the Human Factors Classification Framework for patient safety [18]. This framework

Adverse patient events require monitoring, and, for system-wide

was adopted as previous inter-rater reliability for human factors

change, active monitoring and investigation of local, state-based

classifications has been demonstrated to be high [29] and the approach

and a national registry(s) is optimal as they are designed to provide

was based on James Reason’s model of organisational incidents [20].

information that can be used to improve the efficiency and quality of trauma care. However, trauma registries require more rigour to

The human factors component was used to identify influencing or

be reliable in the quality of the reproducible data [31, 32], and they

causal factors that were thought to play a role in leading to the adverse

lack the detail afforded by a human factors enhanced peer-review

event. Each causal factor was classified into one of seven categories

process. There are growing efforts to improve patient safety in trauma

(Fig. 1) then a number of subcategories.

and quantification of the burden of iatrogenic harm could catalyse awareness and stimulate changes in trauma practice and healthcare

Discussion

RESUSCITATION TODAY - SUMMER 2018

26

policy [33]. Future work should include integration of the two.

There are some limitations to the development of the tool. Evaluation of

This manuscript describes the development, refinement and reliability of

the trauma case review tool in this study was restricted to the paediatric

a trauma case review tool to facilitate peer-review of adverse events in

trauma population whose anatomical, physiological and psychological

pre- and in-hospital care provision for major trauma patients. The major

management varies significantly compared to adults [34, 35]. There was

trauma case review tool, informed by evidence, is designed to extract

a wide range of ages of children examined using the development of

trauma system safety and human factor causal information to facilitate

the tool, and recognition of these differences in a review tool, including

monitoring, inform change and facilitate loop closure in the provision of

age-specific injury patterns and appropriate care of children’s families

care of major trauma patients.

should be included [36, 37]. Future clinical care review tools should also include the patient experience where possible, although challenges

This tool incorporates human factors with the intent of enhancing current

remain in how best to obtain this information. Doyle et al. [38] found a

Morbidity and Mortality review practices. Following an adverse event it

positive association between patient experience and measures of the

is common across industries for the focus to be understanding what

technical quality of care and adverse events and support the inclusion

happened. The focus in a human factors approach is to understand

of patient experience as one of the central pillars of quality in healthcare.

why an adverse event occurred. Identifying the underlying systemic factors that contributed to the occurrence of an adverse event and the

This tool was tested using a retrospective review of medical records.

event outcomes will assist in understanding why particular decisions

This method provided informative timelines and information about

and actions occurred. It can also provide insight as to what can be

procedures and immediate patient outcomes. However it was more

done to prevent these events from occurring in the future, by addressing

difficult to extract human factors information. The tool is recommended

the underlying causal factors. Incorporating a human factors review

to be used in conjunction with staff who were part of the treating team,

component within this case review tool seeks to place greater focus on

so they can be involved in the review process to ensure accurate and

why the event occurred. This involves investigating human, equipment,

informed classification of human factors.

CLINICAL PAPER It is anticipated that more intimate knowledge of situation and

Authors’ contributions

organizational factors will allow even more useful information to be

KC and RM designed the study, AM and BK collected the data, all

captured in the human factors section of the tool. To attempt to link the

authors analysed the data and contributed to the development of the

adverse event to longer term patient outcomes would require linkage

Major Trauma Case Review Tool. All authors drafted/critically revised the

with a trauma registry that collects such information or a follow-up study

article for important intellectual content. All authors read and approved

with adversely affected patients.

the submitted version.

The next stages of evaluation of the trauma case review tool could include

Competing interests

a trial of the tool with an adult population and heuristic evaluation (that is,

The authors declare that they have no competing interests.

usability evaluation by a human factors expert against a set of usability rules/principles) and could entail observing clinicians using the tool.

Consent for publication

This would include consideration of the clinicians’ ability to understand

Not applicable.

and apply the human factors component of the tool, which requires a degree of understanding of human factors principles. Also, although

Ethics approval and consent to participate

the case review tool is evidence-informed, and has been piloted by

Ethics approval was obtained from NSW Population and Health Services

trauma clinicians it requires validation for sensitivity and specificity in

Research Ethics Committee (HREC/15/CIPHS/6).

identifying causes of adverse events. A retrospective cohort study to measure operating characteristics and prospective implementation of

Author details Sydney Nursing School, The University of Sydney, 88 Mallet Street,

the tool into quality assurance activities to gauge how it is received, how

1

well it identifies adverse events, and what type of quality improvement

Camperdown, NSW, Australia. 2St George Clinical School, Faculty of

activities it spurs, would be valuable. Such evaluation could also lead to

Medicine, University of New South Wales, Gray St, Kogarah, NSW,

the development of trauma specific trigger tools, to be used in real time

Australia. 3Australian Institute of Health Innovation, Faculty of Medicine

as a predictor for adverse events and provide the basis of a measurable

and Health Sciences, Macquarie University, Sydney, Australia. 4NSW

trauma quality improvement program [33, 39].

Institute of Trauma and Injury Management, Level 4, Sage Building, 67 Albert Avenue, Chatswood, NSW, Australia. 5NSW Ambulance, Level 2, Sydney Ambulance Centre, Garden St Eveleigh, NSW 2015, Australia.

Conclusions As many as half of all patients with major traumatic injuries do not receive the recommended care and up to 14% of medical errors in trauma deaths are potentially preventable. This research has developed an evidence-informed tool for use in trauma case review that considers system safety and human factors to facilitate clinical review of trauma patient care. This tool can be used to identify opportunities for

Sydney Medical School, The University of Sydney and The Children’s

6

Hospital at Westmead, Sydney, NSW, Australia. 7NorthWestern Mental Health & School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Level 1 North, City Campus, The Royal Melbourne Hospital Grattan Street, Parkville, VIC 3050, Australia. 8Human Risk Solutions, Victoria, Australia. 9Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada.

improvement in trauma care and guide quality assurance activities.

Additional files Additional file 1: Major trauma case peer review tool. (PDF 422 kb) Additional file 2: Data dictionary. (PDF 236 kb)

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3. Moore L, Evans D, Hameed SM, et al. Mortality in Canadian Trauma

Acknowledgements Not applicable.

Funding The development of this tool was funded by an NHMRC Partnership Grant GNT1092499. Partners include NSW Ambulance, NSW Institute of Trauma and Injury Management, NSW Agency for Clinical Innovation, Thyne Reid Foundation, The Day of Difference Foundation and The NSW Office of Kids and Families.

Availability of data and materials

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Abbreviations

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Pediatrics. 2016;137(6):e20154076

Life Connections 2018 CLINICAL PAPER

Aylesbury/Stoke-on-Trent Resuscitation Conference Harrogate - March 15 Resuscitation Conference Programme

Bristol - June 21 Resuscitation Conference Programme

Thursday 6th September 2018

Thursday 25th October 2018

The Gateway Conference Centre, Gatehouse

The North Staffordshire Medical Institute,

Road, Aylesbury, Bucks, HP19 8FF

Hartshill Road, Stoke-on-Trent, ST4 7NY

Time

Presentation

Speaker

Position

Time

Presentation

12.00 - 12.30

Registration

12.00 - 12.30

Registration

12.30 - 14.00

Lunch/Exhibition

12.30 - 14.00

Lunch/Exhibition

14.00 - 14.30

What Does Adult Congenital Heart Disease Mean?

14.30 - 15.00

Ultrasound Application for Traumatic Cardiac Arrest

15.00 - 15.30

Simulation Challenging Reality

15.30 - 16.00

Tea/Coffee/Exhibition

16.00 - 16.30

Dealing with Distressing Incidents

16.30 - 17.00

Application of Educational Theory

Speaker

Position

Amy Chan-Dominy

Paediatric Consultant

14.00 - 14.30

Communication within Resus Team

Himanshu Kataria

Specialty Lead for Injuries

Jonathan Leung

HEMS Pre-Hospital Registrar

14.30 - 15.00

What Does Adult Congenital Heart Disease Mean?

Amy Chan-Dominy

Paediatric Consultant

Mike Davis

Keele University

15.00 - 15.30

Using Simulation as a Learning, Teaching & Assessment Tool

Dr Natasha Taylor

Principal Lecturer

15.30 - 16.00

Tea/Coffee/Exhibition

Joanne Mildenhall

Paramedic Team Leader

16.00 - 16.30

Leadership and Management During Crisis

Adam Layland

Senior Lecturer

Ken Spearpoint

Principal Lecturer

16.30 - 17.00

Simulation Challenging Reality

Mike Davis

Keele University

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

To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434

To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434

Only 50 Places are available on each Conference at a cost of ÂŁ30pp to include VAT, lunch/tea/coffee and free parking. Delegates can also attend our morning Paramedic Conference for a combined rate of just ÂŁ42 to include VAT, lunch, etc. To view all programmes and to secure your delegate place please visit: www.lifeconnections.uk.com or call the organisers on: 01322 660434

Further Conferences are planned later in the year for Aylesbury and Stoke-on-Trent

www.lifeconnections.uk.com

RESUSCITATION TODAY - SUMMER 2018

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

29

NEWS Study finds only half of infants with deadly meningitis display classic signs of the disease • Only around half of babies under three months of age who have bacterial meningitis present with fever which has for decades been the trigger for further medical investigation • Other features associated with meningitis in infants like a bulging fontanelle - the gap on the top of skull where the bones have not yet come together, coma, seizures and neck stiffness were found to be uncommon • Clinical presentation in young babies is often non-specific and hard to distinguish from mild illnesses common features were found to be poor feeding, lethargy and irritability

Experts are warning that doctors may miss

“Guidelines focusing on serious infections in

correctly diagnosing babies with deadly

children - including meningitis - have been

bacterial meningitis as they may assume

introduced in the UK and the USA but all

infants without a fever (a classic sign of the

specify fever as a key feature of infection.

disease) do not have the illness.

“Unfortunately, neither the rates of bacterial Researchers at St George’s, University of London, say their new study shows the classic symptoms associated with bacterial meningitis are uncommon in young infants less than three months of age – the group at highest risk of the disease.

Only around half of babies under three months of age who have bacterial meningitis display fever, which has for decades been the trigger for further medical investigations.

Professor Paul Heath, one of the study investigators at St George’s, University

meningitis in babies, nor the numbers of deaths, has changed since the 1980s.

“Clinicians must, therefore, still consider bacterial meningitis in the diagnosis of an unwell infant that doesn’t present with fever.”

The study, Clinical Characteristics and Risk Factors for Poor Outcome in Infants Less Than 90 Days of Age with Bacterial Meningitis in the United Kingdom and Ireland, is published in the Paediatric Infectious Diseases journal.

The study led by experts at St George’s University of London, funded by charity

of London, said: “The classic features of

Meningitis Research Foundation (MRF),

meningitis were uncommon in many cases.

involved 263 infants across the UK and Ireland

The symptoms displayed by young infants

and found that fever (temperature above 38°C)

when they are seen by doctors at first in

was reported in only 54% of cases, seizures

hospital are often non-specific and only half of

in 28%, bulging fontanelle in 22%, coma in 6%

cases showed signs of a fever.

and neck stiffness in only 3%.

WHY NOT WRITE FOR US? Resuscitation Today welcomes the submission of clinical papers, case reports and articles that you feel will be of interest to your colleagues.

RESUSCITATION TODAY - SUMMER 2018

30

The publication is mailed to all resuscitation, A&E and anaesthetic departments plus all intensive care, critical care, coronary care and cardiology units.

All submissions should be forwarded to info@mediapublishingcompany.com

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NEWS In the UK, babies under three months of age are 70 times more likely to get bacterial meningitis than adults. Newborn babies are at the highest risk of all.

The study found that infants who did present with fever tended to be older than infants without fever.

The median age for this symptom was around 21 days old.

Common features were found to be poor feeding, lethargy and irritability, all of which can be difficult to distinguish from mild illness.

The study suggests that there should be a low threshold for performing investigations on young infants when they arrive at hospital.

Vinny Smith, Chief Executive at MRF, said: “Young babies are particularly vulnerable to bacterial meningitis. Meningitis and septicaemia are deadly diseases

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that strike without warning. Rapid diagnosis and treatment provides the best chance of survival.

“Based on this research, we have collaborated with the study investigators to create a teaching package aimed at doctors and health professionals to aid rapid diagnosis and treatment.

“The package includes an eTool to help clinicians recognise bacterial meningitis in young infants; a lumbar puncture information sheet to help explain

Of note, 52% of the infants without fever did have other features suggestive of bacterial meningitis, such as apnea (33%), seizures (32%), bulging fontanelle (16%), coma (7%) and neck stiffness (3%).

Earlier research from the same experts, in collaboration with the British Paediatric Surveillance Unit, found there to be in the region of 350 cases of bacterial meningitis in infants under three months of age per year in the UK and Ireland. Group B streptococci (GBS) and Escherichia coli remain the main causes of bacterial meningitis in this age group.

this procedure to parents; and an algorithm to aid management of bacterial meningitis. We hope that this can ultimately improve outcomes for this vulnerable age group. We have also updated our symptoms information for parents so that they know not to rely on fever alone as the main symptom to look out for in babies.”

MRF’s teaching package including the eTool and Babywatch card for parents can be accessed at www.meningitis.org/ HCPresources.

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