Increasing workloads in our radiology department prompted a study of casualty officers' use of x ray examinations, of which there were 5463 in the period. While casualty officers were in post referrals for x ray examination did not become more selective, but skills in interpreting films improved. Overall, 4 9% of trauma radiographs were misinterpreted, but this fell from 7 1% to 2-9% during tenure ofpost. One in four errors was clinically important. Clinical guidelines for selective radiography produced a significant and sustained reduction in the number ofx ray examinations requested by the department. Analysis of one common injury indicated that the quality of patient care was not adversely affected.The number of x ray examinations carried out in the accident and emergency department can be reduced by using guidelines, and this does not compromise the quality of patient care. Appreciable savings may be made in patients' waiting times and radiodiagnostic expenditure.
Objectives & BackgroundRecent consensus guidelines have suggested using the qSOFA score as a tool for the identification of patients with sepsis outwith the ICU setting. In the UK, we currently use the SIRS criteria as a means of identifying these patients in the ED. We wanted to look at whether the qSOFA would reliably identify septic patients in our ED population.MethodsWe retrospectively reviewed 200 cases of adult patients presenting to our ED over a six month period who had a sepsis 6 form completed. SIRS and qSOFA scores were calculated for all patients and the results compared. Patients identified as requiring critical care input and those who died were noted.Results200 patients were identified over a 6 month period–109 male, 91 female; age range 18–95 yrs; average 66.7 yrs; IQR 1–58 yr; IQR 3–79 yrs.Of these 200 patients, 4 were admitted to ITU and 17 were admitted to HDU from the Emergency Department. There were 22 deaths in total of whom 1 died on ITU with full escalation of care, and 8 died in HDU with a decision they were not for further escalation. Of those that died outwith critical care, 8 had a decision of ward as ceiling of care made in the ED.195 cases were positive for SIRS of which 4 were admitted to ICU; 16 to HDU and 22 died. SIRS identified all patients who died and all but 1 patient who received critical care input.SIRS test was 97% sensitive and 2.4% specific. The positive predictive value is 15.9%, the negative predictive value is 80%.29 cases were positive for qSOFA of whom 1 was admitted to ICU and 9 to HDU. There were 9 deaths in this group of which 5 were patients on HDU. 4 patients identified as qSOFA positive were determined as not for escalation of care and subsequently died.qSOFA was 90% specific for identifying patients who died or required critical care input but only 48% sensitive. The positive predictive value is 42%, the negative predictive value is 92%.ConclusionqSOFA is a more specific test to identify patients requiring critical care input or at risk of death. Although SIRS is more sensitive, its lack of specificity makes it a much less effective screening tool for severe sepsis.Practically, SIRS is useful as a triage tool to identify potentially septic patients but once identified qSOFA should be used to assess severity and need for critical care involvement.
Objectives & BackgroundA previous audit has shown that in general with each rise in NEWS group there is an increase in serum lactate measured. However, it was noted that in the lowest NEWS Group 0–4 the average lactate was 2.5. A lactate level of >2 has been used as an initial marker of severity of illness yet these patients would be missed at triage.We decided to look at whether adding the lactate to the NEWS group would improve the early identification of septic patients at triage.A recent paper has used this in the context of patients with pneumonia.MethodsWe retrospectively reviewed 200 cases of adult patients who presented to the ED who had been identified as septic and had a sepsis 6 form completed. Initial NEWS scores and serum lactate levels were noted.Results200 cases were identified over a 6 month period–109 male; 91 female; age range 18–95 yrs, average 66.7 yrs. 3 notes were excluded as a serum lactate was not taken.4 patients were admitted to ICU; 17 admitted to HDU and 22 patients died.NEWS scores ranged from 1–19, average 7.4; IQR 1–NEWS 5; IQR 3–NEWS 9.Initial serum lactate levels ranged from 0.6–15.4, average 2.7; IQR1–1.4; IQR 3– 3.NEWSL scores ranged from 2.5–27.4, average 10.2; IQR1 –7.4; IQR 3– 12.3.The paper by S Jo et al combined lactate with NEWS scores and used ranges –<3; 3.1–5.2; 5.3–8; and 8.1+. We have adopted the same ranges.Numbers of patients are shown in table 1.Table 2 shows the number of patients in each NEWS group who required critical care input or died. With each rise in NEWS group, critical care patients are identified. However, 1 patient died in the NEWS 0–4 group which would not be deemed high risk at triage.Table 3 shows the number of patients in each NEWSL group who required critical care input or died. When adding the lactate to the NEWS score all patients were identified that required critical care or died in the highest NEWSL 8.1+ group. This group takes into account the patient in the NEWS 0–4 group who died.The ROC curve for NEWS vs NEWSL is shown in figure1. The AUC is 0.7187 with an accuracy of 0.6617 which is deemed fair discriminatory ability for the NEWSL score.ConclusionThe addition of lactate to the NEWS score identified all patients requiring critical care input or who died in the highest group –8.1+. This is a simpla calculation that can be performed at triage using point of care testing.Larger studies are required to confirm its validity. Figure 1 Table 1Number of patients in each groupNEWS GroupsNEWSL Groups0–429<325–6483.1–5.2107–8535.3–8539+708.1+132N/A3 Table 2Number of patients in each group requiring critical care or diedNEWS GroupITU AdmissionHDU AdmissionDied0–40015–61217–81639+2917 Table 3Number of patients in each NEWSL group requiring critical care input or died.NEWSL GroupITU AdmissionHDU AdmissionDied<30003.1–5.20005.3–80208.1+41522
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