Marja N. Storm-Versloot

Comparison of an Informally Structured Triage System, the Emergency Severity Index, and the Manchester Triage System to Distinguish Patient Priority in the Emergency Department

OBJECTIVES The objective was to compare the validity of an existing informally structured triage system with the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). METHODS A total of 900 patients were prospectively triaged by six trained triage nurses using the three systems. Triage ratings of 421 (48%) patients treated only by emergency department (ED) physicians were compared with a reference standard determined by an expert panel. The percentage of undertriage, the sensitivity, and the specificity for each urgency level were calculated. The relationship between urgency level, resource use, hospitalization, and length of stay (LOS) in the 900 triaged patients was determined. RESULTS The percentage of undertriage using the ESI (86 of 421; 20%) was significantly higher than in the MTS (48 of 421; 11%). When combining urgency levels 4 and 5, the percentage of undertriage was 8% for the informally structured system (ISS), 14% for the ESI, and 11% for the MTS. In all three systems, sensitivity for all urgency levels was low, but specificity for levels 1 and 2 was high (>92%). Sensitivity and specificity were significantly different between ESI and MTS only in urgency level 4. In all 900 patients triaged, urgency levels across all systems were associated with significantly increased resource use, hospitalization rate, and LOS. CONCLUSIONS All three triage systems appear to be equally valid. Although the ESI showed the highest percentage of undertriage and the ISS the lowest, it seems preferable to use a verifiable, formally structured triage system.

Diagnostic Accuracy of Routine Postoperative Body Temperature Measurements

BACKGROUND On surgical wards, body temperature is routinely measured, but there is no proof that this is useful for detecting postoperative infection. The aim of this study was to compare temperature measurements (the test) with the confirmed absence or presence of a postoperative infection (the reference standard). METHODS A prospective triple-blinded diagnostic study involving 308 consecutive patients was performed. A positive test result was defined as a postoperative temperature > or = 38.0 degrees C. The reference standard was considered to indicate a postoperative infection if results of a bacterial culture were positive or if an infection was suspected on clinical grounds. RESULTS Data for 284 of 308 patients were analyzed (2282 temperature measurements). The prevalence of infection was 7% (19 of 284 patients). The temperature curves of patients were used as units of analysis and revealed that a temperature > or = 38.0 degrees C had a sensitivity of 37% (95% confidence interval [CI], 0.16%-0.62%) and a specificity of 80% (95% CI, 0.75%-0.85%). The likelihood ratio for a positive test result was 1.8 (95% CI, 0.7-4.0) and for a negative test result was 0.8 (95% CI, 0.4-1.4). When all 2282 measurements were considered as independent test results, the positive predictive value was only 8% (95% CI, 5%-13%). Six of 8 patients with a severe infection had temperatures < 38 degrees C. CONCLUSION Routine measurement of body temperature is of limited value in the detection of infection after elective surgery for noninfectious conditions. Serious postoperative infections can even occur without an accompanying increase in temperature.

Clinical Relevance of Routinely Measured Vital Signs in Hospitalized Patients: A Systematic Review

BACKGROUND Conflicting evidence exists on the effectiveness of routinely measured vital signs on the early detection of increased probability of adverse events. PURPOSE To assess the clinical relevance of routinely measured vital signs in medically and surgically hospitalized patients through a systematic review. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, and Meta-analysen van diagnostisch onderzoek (in Dutch; MEDION) were searched to January 2013. STUDY SELECTION Prospective studies evaluating routine vital sign measurements of hospitalized patients, in relation to mortality, septic or circulatory shock, intensive care unit admission, bleeding, reoperation, or infection. DATA EXTRACTION Two reviewers independently assessed potential bias and extracted data to calculate likelihood ratios (LRs) and predictive values. DATA SYNTHESIS Fifteen studies were performed in medical (n = 7), surgical (n = 4), or combined patient populations (n = 4; totaling 42,565 participants). Only three studies were relatively free from potential bias. For temperature, the positive LR (LR+) ranged from 0 to 9.88 (median 1.78; n = 9 studies); heart rate 0.82 to 6.79 (median 1.51; n = 5 studies); blood pressure 0.72 to 4.7 (median 2.97; n = 4 studies); oxygen saturation 0.65 to 6.35 (median 1.74; n = 2 studies); and respiratory rate 1.27 to 1.89 (n = 3 studies). Overall, three studies reported area under the Receiver Operator Characteristic (ROC) curve (AUC) data, ranging from 0.59 to 0.76. Two studies reported on combined vital signs, in which one study found an LR+ of 47.0, but in the other the AUC was not influenced. CONCLUSIONS Some discriminative LR+ were found, suggesting the clinical relevance of routine vital sign measurements. However, the subject is poorly studied, and many studies have methodological flaws. Further rigorous research is needed specifically intended to investigate the clinical relevance of routinely measured vital signs. CLINICAL RELEVANCE The results of this research are important for clinical nurses to underpin daily routine practices and clinical decision making.

Do stakeholders in wound care prefer evidence-based wound care products? A survey in the Netherlands.

For several wound products compelling evidence is available on their effectiveness, for example, from systematic reviews. The process of buying, prescribing and applying wound materials involve many stakeholders, who may not be aware of this evidence, although this is essential for uniform and optimum treatment choice. In this survey, we determined the general awareness and use of evidence, based on (Cochrane) systematic reviews, for wound products in open wounds and burns among wound care stakeholders, including doctors, nurses, buyers, pharmacologists and manufacturers. We included 262 stakeholders. Doctors preferred conventional antiseptics (e.g. iodine), while specialised nurses and manufacturers favoured popular products (e.g. silver). Most stakeholders considered silver‐containing products as evidence‐based effective antiseptics. These were mostly used by specialised nurses (47/57; 82%), although only few of them (9/55; 16%) thought using silver is evidence‐based. For burns, silver sulfadiazine and hydrofibre were most popular. The majority of professionals considered using silver sulfadiazine to be evidence‐based, which contradicts scientific results. Awareness and use of the Cochrane Library was lower among nurses than among doctors (P < 0·001). Two thirds of the manufacturers were unaware of, or never used, the Cochrane Library. Available compelling evidence in wound care is not equally internalised by stakeholders, which is required to ensure evidence‐based decision making.

Long-term adherence to a local guideline on postoperative body temperature measurement: mixed methods analysis.

AIM To find out whether a successful multifaceted implementation approach of a local evidence-based guideline on postoperative body temperature measurements (BTM) was persistent over time, and which factors influenced long-term adherence. METHODS Mixed methods analysis. Patient records were retrospectively examined to measure guideline adherence. Data on influencing factors were collected in focus group meetings for nurses and a plenary meeting with an interactive questionnaire for doctors. RESULTS Records from 102 surgical patients were studied, totalling 1226 BTM. According to the guideline, an indication for BTM was present in 55% (679/1226). Actually, BTM were taken in 60% (736/1226), of which 55% (403/736) was in accordance with the guideline. The overall adherence rate to the guideline was 50% (617/1226). Belief in the advantages of the guideline and strong staff support appeared to facilitate long-term adherence. Barriers were, the controversial nature of the guideline, the lack of self-efficacy among nurses and doctors as to clinical judgement to identify an infection when refraining from BTM, and a lack of management and staff doctor support. Furthermore, newly appointed nurses and doctors were trained to measure BTM during their initial medical or nursing education, which was in contradiction with the guideline. CONCLUSIONS A multifaceted implementation strategy is not sufficient to maintain long-term adherence. To ensure long-term adherence, especially of controversial guidelines, adherence should be monitored and reported regularly over time. Strong staff support and leadership on all wards is crucial to maintain awareness. Medical and nursing curricula should include the pros and cons of taking BTM, combined with enhancing self-efficacy.

The number of smokers needed to screen and treat in a smoking cessation programme

Objective Smoking cessation is an important factor in reducing cardiovascular mortality, but considerable effort is needed to successfully persuade patients to quit smoking. We studied the efficiency of the Minimal Intervention Strategy (C-MIS) in addition to nicotine replacement therapy (NRT) for smoking cessation in cardiovascular outpatients in relation to the outcome of mortality. Design Prospective cohort data studying the C-MIS in three outpatient clinics: cardiology, vascular surgery and vascular medicine. Methods Two thousand, two hundred and seventy-five consecutive patients attending the clinics for first or routine follow-up visits were screened for atheroscleroses and smoking. The efficiency of the C-MIS was expressed as the number of smokers needed to screen and needed to treat in relation to the number of deaths prevented over a 5-year period. Mortality estimates were derived from the literature. Results One thousand, four hundred and thirty-one patients were screened at first-time follow-up visits and 1294 at routine follow-up visits. With a rate of effectiveness of 4.3% for the C-MIS, the number needed to treat was 240 (min-max: 64-∞) to prevent one death. The corresponding number needed to screen was 687 (min-max: 141-∞) in the cardiology clinic, 574 (min-max: 134-∞) in the vascular surgery clinic and 444 (min-max: 90-∞) in the vascular medicine clinic. Within 5 years, 10 (min-max: 0–58) deaths could be prevented in all three clinics together. With the effectiveness of the C-MIS for first-time and routine follow-up attendees, only six (min-max: 0–36) and zero (min-max: 0–25) deaths could be prevented, respectively. Conclusion In terms of the efficiency of the C-MIS in addition to nicotine replacement therapy, there is some benefit for first-time attendees and no benefit for routine follow-up attendees in preventing death.

Vaardigheden en educatie

Educatie ontvangen en vaardigheden opdoen is van belang om onzekerheid bij de implementatie van het Evidence Based Practice (EBP) gedachtegoed of evidence-based handelingen te voorkomen. Dit overzichtsartikel geeft een aansprekend gebleken mogelijkheid om EBP op praktische wijze aan te leren. Cruciaal is de leersituaties zo dicht mogelijk bij de praktijk te zoeken en vragen uit de dagelijkse praktijk op te halen.