Objective: To assess utility and accuracy of general observation modified early warning score charts; and compare sensitivity and specificity of single-and multipleparameter-based trigger scores on patient outcomes in the ED. Methods: Retrospective cohort clinical audit of all adult Modified Early Warning Score charts in the ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate Modified Early Warning Score and evidence of response. Results: Of 5901 ED presentations, medical records system identified 2482 Modified Early Warning Score; 347 were missing or blank. Of 2135 Modified Early Warning Score charts, 19.5% contained a calculation error, 51.9% had one or more missing parameters and 36.6% did not have usual/target systolic blood pressure recorded; with 25.1% (95% confidence interval [CI] 23.3-27.0) charts correctly completed. Four hundred and forty-three had a singleabnormal parameter of which chart review showed 96.6% (94.5-97.3) were identified as abnormal by nurses with 25.7% (21.9-30.0); only 5.6% (3.9-8.2) had evidence of recognition by medical staff. Modified Early Warning Score sensitivity and specificity for ward admission was 14.7% and 96.1%, respectively. Modelling using the dataset of a single-abnormal parameter suggested sensitivity and specificity of 31.6% and 85.8%, respectively. Conclusions: This study highlights serious deficiencies in documentation of abnormal parameters and emergency response. It has also shown poor accuracy of both single-and multipleparameter-based trigger scores in predicting patient outcomes within the ED. However, single-parameter-based trigger scores are twice as sensitive as total Modified Early Warning Score for admission and reduces documentation error by 23%.
Background: The modified Broström-Gould (MBG) procedure is the gold standard for patients with chronic ankle instability (CAI), but it is relatively contraindicated for patients with higher body weight or generalized ligamentous laxity (GLL). The use of the ligament augmentation reconstruction system (LARS) is an alternative. Hypothesis: It was hypothesized that clinical outcomes would be similar in patients with increased body weight (>90 kg) or GLL, relative to controls. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 66 patients satisfying the inclusion criteria were invited to participate and were divided into 3 groups: controls (no risk factors for inferior clinical outcome), patients with body weight >90 kg, and patients with GLL (Beighton score, ≥5 of 9). All patients underwent imbrication of the lateral collateral ligament complex augmented with the LARS. Primary outcomes of interest were Tegner activity scale (TAS) and Foot and Ankle Outcome Score (FAOS) subscale scores. Secondary outcomes were recurrence of ankle instability, the need for further surgery, and/or complications. Patients were reviewed at 2 and 5 years postoperatively, and outcomes between groups were compared using repeated-measures analysis of variance. Results: Complete data were available for 63 patients (21 patients in each group). TAS improved in all groups from preoperatively to 2 years and 5 years postoperatively ( P < .001 for all). Relative to the controls, the TAS scores were lower in the >90-kg group at 2 years and 5 years ( P < .001 for both periods), while the GLL group had similar scores to controls at both postoperative periods. Both the >90-kg and the GLL groups showed no significant difference in improvement on any FAOS subscale scores relative to the controls, at both 2 and 5 years postoperatively. There were no recurrences, repeat surgeries, or major complications. Conclusion: Relative to controls, patients with body weight >90 kg or GLL had similar FAOSs, and TAS scores were lower in the >90-kg group, at 2 and 5 years, after the use of the LARS to augment lateral collateral ligament imbrication for CAI. Use of the LARS in this manner is a viable option in patients for whom the MBG procedure is relatively contraindicated.
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