Luke Regan

Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students

Background Distraction and interruption are endemic in the clinical environment and contribute to error. This study assesses whether simulation-based training with targeted feedback can improve undergraduate management of distractions and interruptions to reduce error-making. Design A prospective non-randomised controlled study. Methods 28 final year medical students undertook a simulated baseline ward round. 14 students formed an intervention group and received immediate feedback on distractor management and error. 14 students in a control group received no feedback. After 4 weeks, students participated in a post-intervention ward round of comparable rigour. Changes in medical error and distractor management between simulations were assessed with Mann-Whitney U tests using SPSS V.21. Results At baseline, error rates were high. The intervention group committed 72 total baseline errors (mean of 5.1 errors/student; median 5; range 3–7). The control group exhibited a comparable number of errors—with a total of 76 observed (mean of 5.4 errors/student; median 6; range 4–7). Many of these errors were life-threatening. At baseline distractions and interruptions were poorly managed by both groups. All forms of simulation training reduced error-making. In the intervention group the total number of errors post-intervention fell from 72 to 17 (mean 1.2 errors/student; median 1; range 0–3), representing a 76.4% fall (p<0.0001). In the control group the total number of errors also fell—from 76 to 44 (mean of 3.1 errors/student; median 3; range 1–5), representing a 42.1% reduction (p=0.0003). Conclusions Medical students are not inherently equipped to manage common ward-based distractions to mitigate error. These skills can be taught—with simulation and feedback conferring the greatest benefit. Curricular integration of simulated ward round experiences is recommended.

Telestroke Assessment on the Move Prehospital Streamlining of Patient Pathways

Thrombolysis as a treatment for ischemic stroke is only indicated within the first 3 to 4.5 hours after onset of symptoms, and is more efficacious the earlier it is given.1,2 Patients must thus seek help, receive a clinical diagnosis, and reach a center of care for imaging and treatment without delay. This is a problem in remote and rural areas, leading to a relative disadvantage for rural dwellers: symptom-to-needle time is nevertheless often too long even for people in major urban centers. In the Scottish Highlands, for example, the total amount of time taken from calling for help, transfer to the nearest diagnostic center, undergoing computed tomography scanning to exclude contraindications to thrombolysis treatment, and then receiving thrombolysis often exceeds the 4.5-hour limit.3 The ambulance service reports that the more rural the patient’s location, the longer their response time is likely to be, reflecting the geography and road network as well as the limited number of vehicles.4 Even among patients with stroke in the Highlands who make it to hospital within the 4.5-hour thrombolysis window, mean times from onset to thrombolysis range from 130 to 210 minutes at the various hospitals audited, and <8% of patients with stroke actually receive the treatment at all.5 Scotland has a telestroke program run by the Scottish Center for Telehealth and Telecare, featuring 5 networks around the country.6 They use videoconferencing from the acute hospital site where local physicians can discuss their patients with specialists many miles away. This service has been running successfully since 2008, and thus the idea of using communications technology in stroke assessment is already in place and being successfully used. However, this service is hospital-based, providing support to smaller institutions rather than in prehospital situations. Initial code stroke systems were set up …

Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service

Study objective We examine first‐look success in emergency pediatric intubation by a physician‐staffed helicopter emergency medical service (EMS). Methods A database analysis of all pediatric (<16 years) intubations during a 64‐month period was undertaken, using data from a prospectively enrolled electronic airway registry form. Recorded findings included patient demographics, operator background, airway intervention including intubation attempts, complications, and critical timings. Results Eighty‐two subjects were identified during the 64‐month study. All patients were successfully intubated. The overall first‐look success rate was 75 of 82 (91%), registrars achieving a first‐look success rate of 26 of 26 (100%), consultants 16 of 17 (94%), and paramedics 33 of 39 (85%). Overall complication rate was 14%; 84% of cases were rapid sequence induction, whereas 16% were “cold intubations.” Difficult airway indicators were present in 77% of patients. Conclusion A high first‐look success rate for pediatric intubation was achieved by adult helicopter EMS physicians and intensive care paramedics. To our knowledge, this compares favorably with the rate in published literature in pediatric emergency departments and critical care units.

Combining transcranial ultrasound with intelligent communication methods to enhance the remote assessment and management of stroke patients: Framework for a technology demonstrator:

With over 150,000 strokes in the United Kingdom every year, and more than 1 million living survivors, stroke is the third most common cause of death and the leading cause of severe physical disability among adults. A major challenge in administering timely treatment is determining whether the stroke is due to vascular blockage (ischaemic) or haemorrhage. For patients with ischaemic stroke, thrombolysis (i.e. pharmacological ‘clot-busting’) can improve outcomes when delivered swiftly after onset, and current National Health Service Quality Improvement Scotland guidelines are for thrombolytic therapy to be provided to at least 80 per cent of eligible patients within 60 min of arrival at hospital. Thrombolysis in haemorrhagic stroke could severely compound the brain damage, so administration of thrombolytic therapy currently requires near-immediate care in a hospital, rapid consultation with a physician and access to imaging services (X-ray computed tomography or magnetic resonance imaging) and intensive care services. This is near impossible in remote and rural areas, and stroke mortality rates in Scotland are 50 per cent higher than in London. We here describe our current project developing a technology demonstrator with ultrasound imaging linked to an intelligent, multi-channel communication device − connecting to multiple 2G/3G/4G networks and/or satellites − in order to stream live ultrasound images, video and two-way audio streams to hospital-based specialists who can guide and advise ambulance clinicians regarding diagnosis. With portable ultrasound machines located in ambulances or general practices, use of such technology is not confined to stroke, although this is our current focus. Ultrasound assessment is useful in many other immediate care situations, suggesting potential wider applicability for this remote support system. Although our research programme is driven by rural need, the ideas are potentially applicable to urban areas where access to imaging and definitive treatment can be restricted by a range of operational factors.

Remotely supported prehospital ultrasound: A feasibility study of real-time image transmission and expert guidance to aid diagnosis in remote and rural communities:

Introduction Our aim is to expedite prehospital assessment of remote and rural patients using remotely-supported ultrasound and satellite/cellular communications. In this paradigm, paramedics are remotely-supported ultrasound operators, guided by hospital-based specialists, to record images before receiving diagnostic advice. Technology can support users in areas with little access to medical imaging and suboptimal communications coverage by connecting to multiple cellular networks and/or satellites to stream live ultrasound and audio-video. Methods An ambulance-based demonstrator system captured standard trauma and novel transcranial ultrasound scans from 10 healthy volunteers at 16 locations across the Scottish Highlands. Volunteers underwent brief scanning training before receiving expert guidance via the communications link. Ultrasound images were streamed with an audio/video feed to reviewers for interpretation. Two sessions were transmitted via satellite and 21 used cellular networks. Reviewers rated image and communication quality, and their utility for diagnosis. Transmission latency and bandwidth were recorded, and effects of scanner and reviewer experience were assessed. Results Appropriate views were provided in 94% of the simulated trauma scans. The mean upload rate was 835/150 kbps and mean latency was 114/2072 ms for cellular and satellite networks, respectively. Scanning experience had a significant impact on time to achieve a diagnostic image, and review of offline scans required significantly less time than live-streamed scans. Discussion This prehospital ultrasound system could facilitate early diagnosis and streamlining of treatment pathways for remote emergency patients, being particularly applicable in rural areas worldwide with poor communications infrastructure and extensive transport times.

Kissing carotid arteries: an unusual cause of prevertebral swelling.

An 80-year-old woman with a history of recurrent falls presented to the emergency department following a fall. On examination she was found to be tender at the C4/5 level. A cervical spine radiograph revealed no fractures, however, there was significant prevertebral soft tissue swelling which measured up to 3 cm (figure 1A). An occult fracture was suspected and a CT of the cervical spine was requested. No fracture was identified; however, there …

Supporting Novice Prehospital Transcranial Ultrasound Scanning for Brain Haemorrhage

Traumatic brain injury is a significant problem due to difficulties in early diagnosis in the field. Computed tomography is the gold standard for detecting brain haemorrhage, but scanners are bulky and expensive. A cheap, portable scanner such as transcranial ultrasound (TCUS) could allow early triage and intervention. Transmitting images to remote experts for diagnosis means TCUS could be used by any minimally trained person in the field. We propose a virtual 3-dimensional model of the head which shows which areas of the brain have been imaged already, where the probe currently is, and where still needs to be covered in order to generate a complete scan. Using sensors to measure the position and rotation of the TCUS transducer, we can link this to the 3D model of the head and visually display which areas have been imaged. The images can be analysed and composited to form a personalised 3D scan with maximal coverage of the brain, which can be transmitted for diagnostic review, reducing data loss compared with streaming ongoing images. Initial testing of the software has been performed in healthy volunteers and further testing is planned in patients with brain haemorrhage.

Review of therapeutic agents employed by an Australian aeromedical prehospital and retrieval service.

There is little current evidence regarding which therapeutic agents are actually used within existing aeromedical services. The Greater Sydney Area Helicopter Emergency Medical Service operates a large, physician‐staffed, multimodal, prehospital and interhospital retrieval service. The aim of the present study was to identify the range and frequency of drug, fluid and blood product use within our service.

Response to: ‘Driven to distraction and driving for excellence in ward round practice’ by Pucher and Aggarwal

We thank Pucher and Aggarwal1 for their interest in our paper and their kind words on how our research adds to the literature on this topic. We welcome the opportunity to share more detail about our study in response to their three specific questions. The first question related to how specific distractions used in the study were chosen. These were selected after discussion with a number of local clinical colleagues, ranging from relatively junior doctors through to experienced senior consultants. The results from these focus groups indicated six common workplace distractions. These were the doctors pager, dealing with ward telephone calls, background noise (such as the ward radio and a domestics hoover), managing ad hoc prescription tasks and interacting with relatives. …