Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments

Objectives The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). Methods A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. Results In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. Conclusions This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.

Adapting to concurrent expert evidence in medical litigation

In medical negligence litigation expert evidence has long played a dominant role. The trend towards the use of concurrent expert evidence is now well underway. However, for the lawyers and the doctors involved, the pathway is not yet familiar. Disputes have frequently arisen in the context of pre-hearing expert conclaves, given the adversarial nature of litigation and perhaps fuelled by fears of a less transparent process at this increasingly important stage. This article explains the concurrent expert evidence framework and examines areas of common dispute both in the conclaves and at trial, with a view to providing assistance to legal practitioners working in this area and the medical practitioners called upon to provide expert evidence in such litigation.

Cross-cultural adaptation and validation of the Foot Function Index to Spanish

Background The purpose of this study was to adapt and validate the Foot Function Index to the Spanish (FFI-Sp) following the guidelines of the American Academy of Orthopaedic Surgeons. Methods A cross-sectional study 80 participants with some foot pathology. A statistical analysis was made, including a correlation study with other questionnaires (the Foot Health Status Questionnaire, EuroQol 5-D, Visual Analogue Pain Scale, and the Short Form SF-12 Health Survey). Data analysis included reliability, construct and criterion-related validity and factor analyses. Results The principal components analysis with varimax rotation produced 3 principal factors that explained 80% of the variance. The confirmatory factor analysis showed an acceptable fit with a comparative fit index of 0.78. The FFI-Sp demonstrated excellent internal consistency on the three subscales: pain 0.95; disability 0.96; and activity limitation 0.69, the subscale that scored lowest. The correlation between the FFI-Sp and the other questionnaires was high to moderate. Conclusions The Spanish version of the Foot Function Index (FFI-Sp) is a tool that is a valid and reliable tool with a very good internal consistency for use in the assessment of pain, disability and limitation of the function of the foot, for use both in clinic and research.

Automated ventricular mapping with multi-atlas fluid image alignment reveals genetic effects in Alzheimer's disease

We developed and validated a new method to create automated 3D parametric surface models of the lateral ventricles in brain MRI scans, providing an efficient approach to monitor degenerative disease in clinical studies and drug trials. First, we used a set of parameterized surfaces to represent the ventricles in four subjects' manually labeled brain MRI scans (atlases). We fluidly registered each atlas and mesh model to MRIs from 17 Alzheimer's disease (AD) patients and 13 age- and gender-matched healthy elderly control subjects, and 18 asymptomatic ApoE4-carriers and 18 age- and gender-matched non-carriers. We examined genotyped healthy subjects with the goal of detecting subtle effects of a gene that confers heightened risk for Alzheimer's disease. We averaged the meshes extracted for each 3D MR data set, and combined the automated segmentations with a radial mapping approach to localize ventricular shape differences in patients. Validation experiments comparing automated and expert manual segmentations showed that (1) the Hausdorff labeling error rapidly decreased, and (2) the power to detect disease- and gene-related alterations improved, as the number of atlases, N, was increased from 1 to 9. In surface-based statistical maps, we detected more widespread and intense anatomical deficits as we increased the number of atlases. We formulated a statistical stopping criterion to determine the optimal number of atlases to use. Healthy ApoE4-carriers and those with AD showed local ventricular abnormalities. This high-throughput method for morphometric studies further motivates the combination of genetic and neuroimaging strategies in predicting AD progression and treatment response. © 2007 Elsevier Inc. All rights reserved.

Major project managers’ internal and external stakeholder relationships: The development and validation of measurement scales

In this paper, we detail the development of two stakeholder relationships scales. The scales measure major project managers' perceived competence in developing (establishing and maintaining) high quality, effective relationships with stakeholders who are internal and external to their organization. Our sample consists of 373 major project managers from a sub-set of the Australian defense industry. Both the internal stakeholder relationships scale and the external stakeholder relationships scale demonstrated validity and reliability. This research has implications for the interpersonal work relationships literature and the stakeholder management literature. We recommend that researchers test these scales with multiple samples, across different project types and project industries in the future. The stakeholder relationship scales should be versatile enough to be applied to project management generally but are perhaps best suited to major project environments.

Validation and reliability of a Spanish version of Simple Shoulder Test (SST-Sp)

Background: The Simple Shoulder Test (SST-Sp) is a widely used outcome measure. Objective: The purpose of this study was to develop and validate a Spanish-version SST (SST-Sp). Methods: A two-stage observational study was conducted. The SST was initially cross-culturally adapted to Spanish through double forward and backward translation and then validated for its psychometric characteristics. Participants (n = 66) with several shoulder disorders completed the SST-Sp, DASH, VAS and SF-12. The full sample was employed to determine factor structure, internal consistency and concurrent criterion validity. Reliability was determined in the first 24–48 h in a subsample of 21 patients. Results: The SST-Sp showed three factors that explained the 56.1 % of variance, and the internal consistency for each factor was α = 0.738, 0.723 and 0.667, and reliability was ICC = 0.687–0.944. The factor structure was three-dimensional and supported construct validity. Criterion validity determined from the relationship between the SST-Sp and DASH was strong (r = −0.73; p < 0.001) and fair for VAS (r = −0.537; p < 0.001). Relationships between SST-Sp and SF-12 were weak for both physical (r = −0.47; p < 0.001) and mental (r = −0.43; p < 0.001) dimensions. Conclusions: The SST-Sp supports the findings of the original English version as being a valid shoulder outcome measure with similar psychometric properties to the original English version.

Prospective external validation of an accelerated (2-h) acute coronary syndrome rule-out process using a contemporary troponin assay

Background: Recently there have been efforts to derive safe, efficient processes to rule out acute coronary syndrome (ACS) in emergency department (ED) chest pain patients. We aimed to prospectively validate an ACS assessment pathway (the 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) pathway) under pragmatic ED working conditions. Methods: This prospective cohort study included patients with atraumatic chest pain in whom ACS was suspected but who did not have clear evidence of ischaemia on ECG. Thrombolysis in myocardial infarction (TIMI) score and troponin (TnI Ultra) were measured at ED presentation, 2 h later and according to current national recommendations. The primary outcome of interest was the occurrence of major adverse cardiac events (MACE) including prevalent myocardial infarction (MI) at 30 days in the group who had a TIMI score of 0 and had presentation and 2-h TnI assays <99th percentile. Results: Eight hundred and forty patients were studied of whom 177 (21%) had a TIMI score of 0. There were no MI, MACE or revascularization in the per protocol and intention-to-treat 2-h troponin groups (0%, 95% confidence interval (CI) 0% to 4.5% and 0%, 95% CI 0% to 3.8%, respectively). The negative predictive value (NPV) was 100% (95% CI 95.5% to 100%) and 100% (95% CI 96.2% to 100%), respectively. Conclusions: A 2-h accelerated rule-out process for ED chest pain patients using electrocardiography, a TIMI score of 0 and a contemporary sensitive troponin assay accurately identifies a group at very low risk of 30-day MI or MACE.

Spanish version of the screening Orebro Musculoskeletal Pain Questionnaire: A cross-cultural adaptation and validation

Background Spanish is one of the five most spoken languages in the world. There is currently no published Spanish version of the Örebro Musculoskeletal Pain Questionnaire (OMPQ). The aim of the present study is to describe the process of translating the OMPQ into Spanish and to perform an analysis of reliability, internal structure, internal consistency and concurrent criterion-related validity. Methods Design: Translation and psychometric testing. Procedure: Two independent translators translated the OMPQ into Spanish. From both translations a consensus version was achieved. A backward translation was made to verify and resolve any semantic or conceptual problems. A total of 104 patients (67 men/37 women) with a mean age of 53.48 (±11.63), suffering from chronic musculoskeletal disorders, twice completed a Spanish version of the OMPQ. Statistical analysis was performed to evaluate the reliability, the internal structure, internal consistency and concurrent criterion-related validity with reference to the gold standard questionnaire SF-12v2. Results All variables except “Coping” showed a rate above 0.85 on reliability. The internal structure calculation through exploratory factor analysis indicated that 75.2% of the variance can be explained with six components with an eigenvalue higher than 1 and 52.1% with only three components higher than 10% of variance explained. In the concurrent criterion-related validity, several significant correlations were seen close to 0.6, exceeding that value in the correlation between general health and total value of the OMPQ. Conclusions The Spanish version of the screening questionnaire OMPQ can be used to identify Spanish patients with musculoskeletal pain at risk of developing a chronic disability.

The new Vancouver Chest Pain Rule using troponin as the only biomarker: An external validation study

Objectives To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays. Methods Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results. Results Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay. Conclusions The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.

Development and validation of a multilevel model for predicting workload under routine and nonroutine conditions in an air traffic management center

Objective: The aim of this study was to develop a model capable of predicting variability in the mental workload experienced by frontline operators under routine and nonroutine conditions. Background: Excess workload is a risk that needs to be managed in safety-critical industries. Predictive models are needed to manage this risk effectively yet are difficult to develop. Much of the difficulty stems from the fact that workload prediction is a multilevel problem. Method: A multilevel workload model was developed in Study 1 with data collected from an en route air traffic management center. Dynamic density metrics were used to predict variability in workload within and between work units while controlling for variability among raters. The model was cross-validated in Studies 2 and 3 with the use of a high-fidelity simulator. Results: Reported workload generally remained within the bounds of the 90% prediction interval in Studies 2 and 3. Workload crossed the upper bound of the prediction interval only under nonroutine conditions. Qualitative analyses suggest that nonroutine events caused workload to cross the upper bound of the prediction interval because the controllers could not manage their workload strategically. Conclusion: The model performed well under both routine and nonroutine conditions and over different patterns of workload variation. Application: Workload prediction models can be used to support both strategic and tactical workload management. Strategic uses include the analysis of historical and projected workflows and the assessment of staffing needs. Tactical uses include the dynamic reallocation of resources to meet changes in demand.

Validation of a Spanish version of the Spine Functional Index

Background The Spine Functional Index (SFI) is a recently published, robust and clinimetrically valid patient reported outcome measure. Objectives The purpose of this study was the adaptation and validation of a Spanish-version (SFI-Sp) with cultural and linguistic equivalence. Methods A two stage observational study was conducted. The SFI was cross-culturally adapted to Spanish through double forward and backward translation then validated for its psychometric characteristics. Participants (n = 226) with various spine conditions of >12 weeks duration completed the SFI-Sp and a region specific measure: for the back, the Roland Morris Questionnaire (RMQ) and Backache Index (BADIX); for the neck, the Neck Disability Index (NDI); for general health the EQ-5D and SF-12. The full sample was employed to determine internal consistency, concurrent criterion validity by region and health, construct validity and factor structure. A subgroup (n = 51) was used to determine reliability at seven days. Results The SFI-Sp demonstrated high internal consistency (α = 0.85) and reliability (r = 0.96). The factor structure was one-dimensional and supported construct validity. Criterion specific validity for function was high with the RMQ (r = 0.79), moderate with the BADIX (r = 0.59) and low with the NDI (r = 0.46). For general health it was low with the EQ-5D and inversely correlated (r = −0.42) and fair with the Physical and Mental Components of the SF-12 and inversely correlated (r = −0.56 and r = −0.48), respectively. The study limitations included the lack of longitudinal data regarding other psychometric properties, specifically responsiveness. Conclusions The SFI-Sp was demonstrated as a valid and reliable spine-regional outcome measure. The psychometric properties were comparable to and supported those of the English-version, however further longitudinal investigations are required.

A benchmark for numerical scheme validation of airborne particle exposure in street canyons

Measurements of particle concentrations and distributions in terms of number, surface area, and mass were performed simultaneously at eight sampling points within a symmetric street canyon of an Italian city. The aim was to obtain a useful benchmark for validation of wind tunnel experiments and numerical schemes: to this purpose, the influence of wind directions and speeds was considered. Particle number concentrations (PNCs) were higher on the leeward side than the windward side of the street canyon due to the wind vortex effect. Different vertical PNC profiles were observed between the two canyon sides depending on the wind direction and speed at roof level. A decrease in particle concentrations was observed with increasing rooftop wind speed, except for the coarse fraction indicating a possible particle resuspension due to the traffic and wind motion. This study confirms that particle concentration fields in urban street canyons are strongly influenced by traffic emissions and meteorological parameters, especially wind direction and speed.

Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol

Objective Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Methods Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final score (Emergency Department Assessment of Chest pain Score [EDACS]). EDACS was combined with electrocardiogram results and troponin results at 0 and 2 h to develop an ADP (EDACS-ADP). The score and EDACS-ADP were validated and tested for reproducibility in separate cohorts of patients. Results In the derivation (n = 1974) and validation (n = 608) cohorts, the EDACS-ADP classified 42.2% (sensitivity 99.0%, specificity 49.9%) and 51.3% (sensitivity 100.0%, specificity 59.0%) as low risk of major adverse cardiac events, respectively. The intra-class correlation coefficient for categorisation of patients as low risk was 0.87. Conclusion The EDACS-ADP identified approximately half of the patients presenting to the ED with possible cardiac chest pain as having low risk of short-term major adverse cardiac events, with high sensitivity. This is a significant improvement on similar, previously reported protocols. The EDACS-ADP is reproducible and has the potential to make considerable cost reductions to health systems.