August 2016 itu current awareness1

Clinical Librarian Service Musgrove Park Academy

Taunton and Somerset NHS Foundation Trust

Current Awareness

ICU Issue 6 July/August 2016 _________________________________________________________________________________

This Current Awareness Bulletin is produced by the Clinical Librarian, Musgrove Park Academy, to provide ITU staff with a range of ITU related resources to support practice. It includes recently published guidelines and research articles, news and policy items.

This guide provides a selection of resources relevant to the subject area and is not intended to be a comprehensive list. For further help or guidance, please contact a member of library staff.

Note: if any link does not open by clicking on it, just copy/paste that link in the browser’s address bar.

This guide has been compiled by: Terry Harrison Clinical Librarian Musgrove Park Hospital Library Service Terence.Harrison@tst.nhs.uk

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Contents Click on a section title to navigate to contents

Page Recent journal articles

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New books

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Cochrane reviews

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Other evidence updates

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Reports

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Training & events

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Other Services & Training and Athens

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Library contact details: Library Musgrove Park Academy Musgrove Park Hospital Taunton Somerset TA1 5DA Email: Library@tst.nhs.uk Tel: 01823 34 (2433) Fax: 01823 34 (2434) Clinical Librarian email: Terence.Harrison@tst.nhs.uk

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RECENT JOURNAL ARTICLES BACK TO TOP

This is a list of recent journal articles on the topic of ITU. Some articles are available in the library, or on-line via an Athens password, by following the link. If you would like an article which is not available as full text, please contact library staff: Library@tst.nhs.uk

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research Critical Care Medicine: August 2016 - Volume 44 - Issue 8 - p 1553–1602 Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence BMC Infect Dis. 2016; 16: 349.

Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.

How to improve ‘do not resuscitate’ decisions in England Dissemination Centre Discover Portal June 2016 This review has highlighted some variations in how ‘do not attempt cardiopulmonary resuscitation’ decisions are made across NHS hospitals. By describing the literature and 3

giving examples where things have gone well and less well in the past it begins to surface promising areas for improvement. These include the designing and implementing of structured forms to record decisions, talking sensitively about the decisions with patients and their families early and letting other health professionals know what has been decided.

A ‘do not attempt resuscitation’ decision allows resuscitation to be withheld following a cardiac arrest. This is usually done if there is little or no chance of success, if the risks outweigh the benefits, or if a person requests not to receive resuscitation. Lack of clarity can lead to confusion and conflicts within a fast-moving medical emergency. This can occasionally lead to complaints later. The main part of this study reviewed the worldwide literature to look for insights into the processes, barriers and facilitators to ideal care. Other data collected in this study showed variation and inconsistency in current practice.

Evaluation of hospital-wide computerised decision support in an intensive care unit: An observational study Anaesthesia and Intensive Care, 2016, vol./is. 44/4 Supplement(507-512), 0310-057X;14480271 (2016) We conducted an observational study with interviews in a 12-bed general/neurological intensive care unit (ICU) at a teaching hospital in Sydney, Australia, to determine whether hospital-wide computerised decision support (CDS) embedded in an electronic prescribing system is used and perceived as useful by doctors in an ICU setting. Twenty doctors were shadowed by the observer while on ward rounds (33.6 hours) and non-ward rounds (28 hours) in the ICU. These doctors were also interviewed to explore views of CDS. We found that computerised alerts were triggered frequently in the ICU (n=166, in 59% of orders), less than half of the alerts were read by doctors and only four alerts resulted in a medication order being changed. Pre-written orders were utilised frequently, however reference material was rarely accessed. Interviews with doctors revealed a willingness to use CDS features; however the primary barrier to use was lack of customisation for the ICU setting. Doctors working in the ICU triggered a high number of alerts when prescribing, 40% more alerts than doctors working on general wards of the same hospital. Certain procedures in place in the ICU (e.g. daily microbiology ward rounds) made many alerts redundant in this setting. Lack of customisation for the ICU led to dissatisfaction with CDS and infrequent use of some CDS features.

Successful introduction of a daily checklist to enhance compliance with accepted standards of care in the medical intensive care unit Anaesthesia and Intensive Care, 2016, vol./is. 44/4 Supplement(498-500), 0310-057X;14480271 (2016) We introduced a simple checklist to act as an aid to memory for our junior medical staff to ensure that every patient in the intensive care unit (ICU) received every appropriate element 4

of a bundle of care every day. The checklist was developed in consultation with our junior doctors and was designed to be completed every morning for every patient by the junior doctor reviewing the patient. The completed checklist was then checked again by the attending intensivist on the main daily ward round to ensure all the appropriate elements of the checklist had been applied to the patient. It was also noted each day which of the elements of the checklist had been forgotten and was therefore prompted to be completed by use of the checklist. Of the 75 patients surveyed there were 99 occasions, in 48 patients, when the checklist detected a forgotten element of the bundle of care (i.e. in 64% of patients). There was a decrease in the incidence of missed elements of the bundle of care the longer the patient stayed in the ICU. Types of missed elements varied with the duration of the ICU stay. We found that the introduction of a simple checklist, developed in collaboration with the junior medical staff who would be using the checklist every day in the ICU, resulted in the detection and correction of missed elements of a bundle of care we had previously introduced in the ICU.

Organ support after death by neurologic criteria Neurology, Published online before print July 22, 2016 Our findings suggest that it is relatively common for neurologists who treat critically ill patients to encounter families who object to discontinuation of organ support after DNC at some point during their career. It would be beneficial for physicians, families, and society to rely on clear medicolegal guidelines on management of this situation.

Public education and misinformation on brain death in mainstream media Clinical Trans, First published: 25 July 2016 Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic.

Associations Between Ventilator Bundle Components and Outcomes JAMA Intern Med. Published online July 18, 2016.

Standard ventilator bundle components vary in their associations with patient-centered outcomes. Head-of-bed elevation, sedative infusion interruptions, spontaneous breathing trials, and thromboembolism prophylaxis appear beneficial, whereas daily oral care with chlorhexidine and stress ulcer prophylaxis may be harmful in some patients.

Unpacking the Bundle to Lower Rates of Ventilation-Associated Pneumonia 5

JAMA Intern Med. Published online July 18, 2016.

The concept of a bundle as a way to implement multiple best practices together to support quality improvement and better patient outcomes has great appeal.1,2 However, little is known about how bundles work and whether the individual components or the group are most important to care improvement. In this issue of JAMA Internal Medicine, Klompas and colleagues3 demonstrate that individual components of a bundle to lower rates of ventilatorassociated pneumonia may have different effects on the outcome.

Fluid overload in the ICU: evaluation and management BMC Nephrology BMC series – open, inclusive and trusted 2016 17:109 In critically ill patients, fluid overload is related to increased mortality and also lead to several complications like pulmonary edema, cardiac failure, delayed wound healing, tissue breakdown, and impaired bowel function. Therefore, the evaluation of volume status is crucial in the early management of critically ill patients. Diuretics are frequently used as an initial therapy; however, due to their limited effectiveness the use of continuous renal replacement techniques are often required for fluid overload treatment. Successful fluid overload treatment depends on precise assessment of individual volume status, understanding the principles of fluid management with ultrafiltration, and clear treatment goals.

Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock: The VANISH Randomized Clinical Trial JAMA. 2016;316(5):509-518 Among adults with septic shock, the early use of vasopressin compared with norepinephrine did not improve the number of kidney failure–free days. Although these findings do not support the use of vasopressin to replace norepinephrine as initial treatment in this situation, the confidence interval included a potential clinically important benefit for vasopressin, and larger trials may be warranted to assess this further.

Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial BMJ Open 2016;6:e012041 The PEQ revealed statistically significant between-group differences across 4 key intervention components: physiotherapy (p=0.039), nutritional care (p=0.038), case management (p=0.045) and information provision (p<0.001), suggesting greater patient satisfaction in the intervention group. Focus group data strongly supported and helped explain these findings. Specifically, case management by dedicated RAs facilitated greater access to physiotherapy, nutritional care and information that cut across disciplinary 6

boundaries and staffing constraints. Patients highly valued its individualisation according to their needs, abilities and preferences.

Anesthetizing Patients and Their Immune Systems: Volatile Anesthetics at Work Anesthesia & Analgesia: August 2016 - Volume 123 - Issue 2 - p 263 While volatile anesthetics are known primarily for their ability to provide general anesthesia, they also have important effects that extend beyond the nervous system and include modulation of the immune system. In this infographic, we review the impact that volatile anesthetics have on specific components of the immune system, and potential clinical implications that utilization of volatile anesthetics have on perioperative care.

The effect of vasoactive drugs on mortality in patients with severe sepsis and septic shock. A network meta-analysis of randomized trials Journal of Criti. Care. Article in Press.

Among several regimens for pharmacological cardiovascular support in septic patients, regimens based on inodilators have the highest probability of improve survival.

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For ICU automated tables of contents: click here.

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NEW BOOKS IN OUR COLLECTION BACK TO TOP

If you are unable to find a book, or require a book that is not on this list, please ask library staff, who will be able to locate the book for you using interlibrary loan.

Oxford textbook of critical care (2nd ed) (2016) Webb, Andrew R. Edited and written by an international group of recognized experts from many disciplines, the second edition of the Oxford Textbook of Critical Care provides an up-to-date reference that is relevant for intensive care units and emergency departments globally.

Physics for the anaesthetic viva (2016) Kalsi, Aman; Balani, Nikhail Physics for the Anaesthetic Viva is a succinct and practical text that comprehensively covers all aspects of the physics and clinical measurement curriculum for the FRCA examinations.

Each section begins by explaining the basic science concepts, which are then expanded and related to everyday practice. Illustrations are used to enhance understanding of the concepts, and are presented in such a way as to be easy to reproduce in the exam setting. In addition, sample viva questions are provided at the end of each chapter to test learning, or for use in a mock viva session.

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Enteral versus parenteral nutrition for adults in the intensive care unit Cochrane, July 2016 This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, length of hospital stay and adverse events.

Skin antisepsis for reducing central venous catheter-related infections Cochrane, July 2016 The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

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OTHER EVIDENCE UPDATES BACK TO TOP Up-to-date latest click here (and logon via Athens)

Sepsis: recognition, diagnosis and early management NICE guidelines [NG51] Published date: July 2016Last updated: July 2016 NICE has published new guidance Sepsis: recognition, diagnosis and early management (NG51).

This guideline covers the recognition, diagnosis and early management of sepsis for all populations.

The guideline committee identified that the key issues to be included were: recognition and early assessment, diagnostic and prognostic value of blood markers for sepsis, initial treatment, escalating care, identifying the source of infection, early monitoring, information and support for patients and carers, and training and education.

The guideline includes recommendations on:   

Identifying and assessing people with suspected sepsis Risk factors and risk stratification for sepsis Managing suspected sepsis in acute hospital settings and out of hospital

From Dynamed: Discontinuation of Antibiotic Therapy Based on Clinical Stability Criteria May Reduce Treatment Duration in Adults Hospitalized for Community-Acquired Pneumonia Reference - JAMA Intern Med 2016 early online (level 2 [mid-level] evidence) 

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Shortening the duration of antibiotic therapy for some conditions by discontinuing it once the patient is clinically stable may help reduce the emergence of drug-resistant pathogens.

Antibiotic therapy with duration based on clinical stability criteria significantly reduced the duration of antibiotic use with similar clinical success rates compared to 11

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antibiotic duration based on physicianâ&#x20AC;&#x2122;s discretion in a randomized trial of 312 adults hospitalized for community-acquired pneumonia (CAP).

Most patients were prescribed quinolones in this trial, potentially limiting the generalizability of the findings.

The emergence of drug-resistant pathogens is a growing problem, even among common community-acquired infections (WHO 2014 report, CDC 2013 report). Shortening the duration of antibiotic therapy by discontinuing it once the patient is clinically stable has been suggested as a strategy to address this problem (Clin Infect Dis 2008 Feb 15;46(4):491, J Infect Dis 2007 Jun 15;195(12):1818, J Antimicrob Chemother 2012 Nov;67(11):2570).

However, evidence assessing the safety and efficacy of this strategy is mainly limited to observational studies. To determine the safety and efficacy of shorter duration therapy in adults with CAP, a trial was conducted in which 312 adults in Spain hospitalized for CAP were randomized on day 5 to one of two strategies for antibiotic therapy discontinuation. The strategy for the intervention group used clinical stability criteria based on recommendations from Infectious Diseases Society of America and American Thoracic Society (IDSA/ATS) to discontinue antibiotic therapy after 5 days if the patient had a temperature below 37.8 degrees C (100 degrees F) for 48 hours and has â&#x2030;¤ 1 CAP-related sign of clinical instability. The control group had antibiotics discontinued at the treating physician's discretion. The primary outcomes were clinical success, defined as improved symptoms and signs without additional antibiotic therapy, and symptom severity assessed by questionnaire at day 10.

The use of clinical stability criteria significantly decreased the antibiotic therapy duration compared to using the physician's discretion (median 5 days vs. 10 days, p = 0.001). Despite the shorter duration of treatment, there was no statistical difference in most outcomes between the 2 groups. Clinical success was achieved within 10 days of hospital admission in 56.3% with length of therapy based on clinical stability criteria vs. 48.6% with therapy discontinued at physician's discretion (not significant). At 30 days, the clinical success rate was 91.9% vs. 88.6% and the recurrence rate was 2.4% and 4%, respectively. The 2 groups were similar in other outcomes such as symptom severity at day 10, rates of in-hospital and 30-day mortality, and in-hospital complications. However, the clinical stability group fared better for in 30-day readmission rates (1.8% vs. 6.7% [p = 0.03, NNT 21]).

These results support the IDSA/ATS recommendation to discontinue antibiotic therapy after 5 days in adults hospitalized for CAP if they meet defined clinical stability criteria, but some limitations of this trial temper the support. In particular, steps were not taken to blind patients or physicians to treatment allocation. This introduces a high potential for bias, especially considering that discontinuation was based on physician's discretion in one group. However, despite the lack of blinding, using clinical stability criteria did shorten median duration of antibiotic therapy, and so some conclusions regarding safety and efficacy can be made. Also, generalizability is limited in two ways: 1) quinolones were used in 79% of patients, so the effect of a shorter duration with other types of antibiotics remains unclear; and 2) patients were excluded if they were admitted to the intensive care unit before randomization, or had other complications such as being immunocompromised or had pneumonia caused by an uncommon pathogen. Finally, although this trial was described as a noninferiority trial, only conventional superiority analyses were reported. Statistical analyses explicitly testing whether or not clinical stability criteria were inferior to physician's discretion by more than a prespecified margin were not reported. This concern is partly mitigated by the high 30-day clinical success rates in both groups. Overall, in adults hospitalized with CAP, discontinuing 12

antibiotic therapy after 5 days in clinically stable patients appears to have similar outcomes as longer course antibiotic therapy, and potentially reduces the risk of developing drug-resistant pathogens as well as treatment-related adverse events.

For more information, see the Antibiotics for adult inpatients with community-acquired pneumonia topic in DynaMed Plus.

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All Our Health framework Public Health England has updated its All Our Health framework. This includes respiratory disease, liver disease and healthy beginnings information. The framework was originally published in April 2015 and topic areas have added to over subsequent months. This framework of evidence aims to guide healthcare professionals in preventing illness, protecting health and promoting wellbeing.

NICE Sepsis guide (chart): How to assess risk and identify appropriate level of monitoring and management for suspected sepsis: http://www.bmj.com/content/bmj/suppl/2016/08/11/bmj.i4030.DC1/sepsis_nice_v66_web_v6.pdf

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TRAINING & EVENTS

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EVENT: Sepsis Unplugged 2016 The UK Sepsis Trust ‘Sepsis Unplugged’ Conference 2016 13th – 14th October 2016 Hilton Brighton Metropole https://fitwise.eventsair.com/sepsis-unplugged-2016/info Hosted by The UK Sepsis Trust, this conference will bring together all healthcare professions and patient groups as equals and will ask the questions which will help shape better care for patients with...

In brief…

5 September 2016

Sunderland FFICM Preparation Course

23rd September

Portsmouth Intensive Care Exam Revision (PINCER) Course

27th September

West Midlands Final FFICM SOE/OSCE Preparation Course

28-29 September 2016 Fundamental Critical Care Support Course 13-14 October 2016

The UK Sepsis Trust: Sepsis Unplugged 2016

20 October 2016

Designing a Reliable Response to Sepsis - Interactive Masterclass

31st Annual BACCN Conference 2016 19th - 20th September 2016; Technology & Innovation Centre, Glasgow Back to the Future for Intensive Care: Communicating and Caring in an e-ICU World Themes include: 

Research, education & innovation

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Patient & family experiences

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Patient safety and outcomes 15

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Workforce development

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Organisation and service delivery

Earlybird closes: 30th June 2016. Abstract submission closes: 31st March 2016 Registration now open! - CLICK HERE for further details

European Federation of Critical Care Nursing Associations (EfCCNa) Congress 2017 Belfast Waterfront, Belfast, Northern Ireland, United Kingdom 15th – 18th February 2017 Don't miss Europe’s largest critical care nursing conference! The next EfCCNa conference will be held in Belfast at the Belfast Waterfront Hall between 15 to 18 February 2017. Belfast Waterfront is an award-winning multi-purpose facility hosting many events including concerts, exhibitions and conferences. We welcome you to join this international nursing conference with focus of enhancing knowledge through research, education and clinical practise. Belfast is a city with history, culture, exciting events and great food. Waterfront hall is very well located with easy access to centre Belfast and walking distance to city hall and the main shopping streets. There are also several good hotels nearby with reasonable prices.

For more information click here: http://www.efccna.org/congress

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OTHER SERVICES, TRAINING & ATHENS

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Most electronic resources are available via an Athens password. You can register for this via the Library intranet page, or from home at http://www.swice.nhs.uk/ and following the link for Athens self-registration. Please note that registering from home will take longer as it will need to be verified that you are NHS staff/student on placement.

Library staff are available to train individual staff or small groups. Training can take place in the library or at your work place if you have access to appropriate IT facilities.

COURSES INCLUDE: Library Induction You will be given a detailed overview of all library information systems and resources and how to use them. Library registration and obtaining an OpenAthens password are included.

Accessing NHS eResources You will be introduced to all the electronic information resources available to NHS staff including eJournals, eBooks, healthcare databases and useful websites.

Searching for Evidence (beginners) You will be introduced to the 8 leading healthcare databases and shown how to plan your literature search, how to execute it effectively and how to save and print your results.

Searching for Evidence (advanced) You will be shown how to search across multiple databases, how to use the thesaurus, the subject headings and the full range of limit options.

Introduction to Critical Appraisal This course introduces the basics of critical appraisal and its role in evidence-based practice.

Pre-Course Skills Parts 1 & 2 These 2 sessions are designed for staff about to start a course who need a thorough update on information gathering skills. Attendance at both sessions is required.

Library Mini-Breaks 30 minute sessions tailored to meet your needs e.g. Cochrane Library, how to find clinical guidelines, using eBooks, library electronic A-Z website, RSS feeds, journal contents pages using Outlook.

Rapid Evidence Searching Using tried and tested techniques, rapid searching of the evidence base for when quick solutions are needed.

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Reflective Practice How to read and comment upon a paper Writing for publication Everything you need to know about writing a paper for publication Collaborative "Living Evidence" Searching/Appraisal Group searching/appraisal of evidence in computer labs (suitable for MDTs and similar).

TO BOOK A COURSE, click here

Literature & Evidence searches 

Are you looking for the latest evidence-based research, but haven’t got time to trawl the databases?

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Do you need a literature search carried out?

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Do you need to find evidence to support an improvement?

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Do you want to know how something has been done elsewhere and whether it worked?

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Library staff provide a literature and evidence search service for busy clinicians who are pressed for time.

To request a search, please complete and return this form, providing as much information as possible.

Alternatively if you would like an assisted search training session, where we will sit down with you and go through the steps of a literature search, then please contact the library.

Library training drop-in sessions The Library at Musgrove Park Academy is running a series of drop-in sessions that will be held in the Academy e-learning room. No booking necessary, but if you decide to attend you will need to arrive on time.    

Introduction to Critical Appraisal Evidence Searching Literature Searching Rapid Evidence review

For a list of the course dates click here

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Horizon Scanning service

Horizon Scanning – also known as Early Warning Systems - is a systematic examination of information to identify potential threats, risks, emerging issues and opportunities and filter and prioritise new and emerging health technologies. Horizon Scanning service maps ‘forward alerts’ and ‘evidence predictions’, based on emerging trends. Sources searched include the usual clinical evidence sources, as well as ‘grey literature’, specialist medicines databases, health technology databases and specialist Horizon Scanning databases.

To access, click here.

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