Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards

BACKGROUND: Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES: The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY: The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS: Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS: The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

A general framework for measuring inconsistency through minimal inconsistent sets

Hunter and Konieczny explored the relationships between measures of inconsistency for a belief base and the minimal inconsistent subsets of that belief base in several of their papers. In particular, an inconsistency value termed MIVC, defined from minimal inconsistent subsets, can be considered as a Shapley Inconsistency Value. Moreover, it can be axiomatized completely in terms of five simple axioms. MinInc, one of the five axioms, states that each minimal inconsistent set has the same amount of conflict. However, it conflicts with the intuition illustrated by the lottery paradox, which states that as the size of a minimal inconsistent belief base increases, the degree of inconsistency of that belief base becomes smaller. To address this, we present two kinds of revised inconsistency measures for a belief base from its minimal inconsistent subsets. Each of these measures considers the size of each minimal inconsistent subset as well as the number of minimal inconsistent subsets of a belief base. More specifically, we first present a vectorial measure to capture the inconsistency for a belief base, which is more discriminative than MIVC. Then we present a family of weighted inconsistency measures based on the vectorial inconsistency measure, which allow us to capture the inconsistency for a belief base in terms of a single numerical value as usual. We also show that each of the two kinds of revised inconsistency measures can be considered as a particular Shapley Inconsistency Value, and can be axiomatically characterized by the corresponding revised axioms presented in this paper.

No association between routinely recorded infections in early life and subsequent risk of childhood-onset Type 1 diabetes: a matched case-control study using the UK General Practice Research Database

Aims To determine whether children with infections in early life (recorded routinely in general practice) have a reduced risk of Type 1 diabetes, as would be expected from the hygiene hypothesis.

Optimum joint detail for a general cold-formed steel portal frame

In the design of cold-formed steel portal frames it is essential that joint flexibility is taken into account in frame analysis. This paper describes optimisation of the joint detail of a cold-formed steel portal frame, conducted concurrently with frame analysis. It is one of the outputs of an Industrial CASE award on the design of cold-formed steel portal frames, which is being used to support a KTP application.

Genetic testing and the relationship between specific and general self-efficacy

The study examined the extent to which variations in health-specific self-efficacy could affect general self-efficacy. In a repeated measures design, 300 participants were administered an efficacy questionnaire, before and after an alleged news report, aimed at increasing or decreasing self-efficacy over genetic-testing decision making. The results found that self-efficacy over testing was significantly reduced after reading the negative news report in those participants who felt personal efficacy over testing decisions was important. Levels of general self-efficacy were also significantly decreased. The findings suggest that being denied control over a specific area of self-efficacy can have a wider impact, with a lack of perceived efficacy over testing decision making adversely impacting on levels of general well-being. The wider implications of this generalization effect and the processes involved in efficacy generalization are discussed.

Extension of general practice training from three to four years: experiences of a vocational training programme in Southern Ireland

The aim of this study was to evaluate the experiences of trainees taking part in an extended (four-year) general practice training programme introduced in the South Eastern region of the Republic of Ireland to replace the previous traditional (three-year) programme. In a qualitative design, eight homogeneous focus groups were held to determine the value of the additional year of training. The first cohort of trainees was interviewed towards the start and at the end of their fourth year. Trainees finishing the following year were also interviewed, as were graduates from the final three-year programme. GP trainers and the four members of the programme directing team comprised two further independent focus groups. Trainees reported that the integration of hospital posts and general practice attachments over the four years was particularly beneficial. The exposure to a variety of different general practices and the opportunity to take part in specialty clinics were considered extremely useful. The fourth year of training was felt to be less pressurised than previous years. Professional and personal development was enhanced; improved readiness to practise and confidence were noted. Perceived disadvantages of extended training included a lack of acknowledgment for doctors in their fourth year and excessive emphasis placed on research during the final year of training. The addition of an extra year of vocational training improves professional and personal development and changes the learning experience for doctors. Doctors felt more confident and ready to enter independent practice at the end of the fourth year of training.

Do general practitioners change how they use the computer during consultations with a significant psychological component?

objectives: To describe the patterns of computer use during patient visits to family doctors and to determine whether doctors alter their pattern of computer use in consultations which have significant psychological content.