Feasibility of Informed Consent for CT in Acute Trauma Patients

Abstract

Background/Objective

Computed tomography (CT) is common for trauma victims, but is usually done without informing patients of potential risks or obtaining informed consent. The objective of this study was to determine the feasibility of two elements (time and normal level of alertness) necessary for informed consent for CT in adult trauma patients.

Methods

We conducted this prospective observational, two-phase cohort study at two urban, Level 1 trauma centers. In the first phase, we determined the median time needed to obtain informed consent for CT by performing sham consent on 11 injured patients at each site. In the second phase, we observed all adult trauma activation cases that presented during specified time blocks and recorded Glasgow Coma Scale (GCS) scores and the time available for consent (TAC) for CT—defined as the time between the end of the secondary trauma survey and when the patient left the resuscitation room to go to CT. We defined, a priori, feasible consent cases as those in which the patient had a GCS of 15 and a TAC > the median sham consent time at that site.

Results

The median times for sham CT consent at the two sites were 3:36 and 2:09 minutes:seconds (range 1:12 - 4:54). Of the 729 trauma patients enrolled during phase two, 646 (89%) had a CT scan, and of these 646 patients, 461 (71.4% [95% CI 67.8 – 74.7%]) met feasible consent criteria. Of the 185 patients who failed to meet feasible consent criteria, 171 (92.4%) had a GCS < 15, 1 (0.5%) had a TAC < the sham consent time, and 13 (7.0%) had both.

Conclusion

We found that informed consent for CT was likely feasible in over two-thirds of acute, adult trauma patients.

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Toward Precision Diagnostics

In January 2015 President Obama announced funding for the Precision Medicine Initiative, a multifaceted program that seeks to develop an individualized approach to disease prevention and treatment. Accounting for individual variability, precision medicine aims to deliver “the right treatment at the right dose to the right patient at the right time”, embracing human variation and its drivers: inheritance, exposures, lifestyle, and life experience.^1,2 Beyond treatment innovations, full realization of the benefits of precision medicine and individualized health care will require refinements to diagnostic practice – the medical history, physical examination, and diagnostic tests. Within the framework of this comprehensive initiative, we seek to advance the concept of precision diagnostics, and more specifically, precision emergency department (ED) diagnostic testing.

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A systematic review of instruments to identify mental health and substance use problems among children in the emergency department

Abstract

Objective

Specialized instruments to screen and diagnose mental health problems in children and adolescents are not yet standard components of clinical assessments in emergency departments (EDs). We conducted a systematic review to investigate the psychometric properties, accuracy, and performance metrics of instruments used in the ED to identify pediatric mental health and substance use problems.

Methods

We searched seven electronic databases and the grey literature for psychometric validation studies, diagnostic studies, and cohort studies that assessed any instrument to screen for or diagnose mental illness, emotional or behavioral problems, or substance use disorders. Studies had to include children and adolescents with mental health presentations or positive screens for substance use. Two reviewers independently screened studies for relevance and quality. Diagnostic study quality was assessed with the four QUADAS-2 domains. Psychometric study quality was assessed with published criteria for instrument reliability, validity, and usability. We present a descriptive analysis of the reported psychometric properties and diagnostic performance of instruments for each study.

Results

Of the 4832 references screened, 14 met inclusion criteria. Included studies evaluate 18 instruments for identifying suicide risk (6 studies), alcohol use disorders (6 studies), mood disorders (1 study), and ED decision-making (need for assessment, admission; 1 study). Nine studies include a psychometric focus but quality varies, with no studies fully meeting criteria for reliability, validity, and usability. Seven studies examined diagnostic performance of an instrument, but no study has a low risk of bias for all QUADAS-2 domains. The HEADS-ED instrument has good inter-rater reliability (r=0.785) for identifying general mental health problems and modest evidence for ruling in patients requiring hospital admission (positive likelihood ratio, LR⁺=6.30). Internal consistency (reliability) varies for instruments to screen for suicide risk (α=0.46-0.97), and no instruments have both high sensitivity and high specificity. The Ask Suicide-Screening Questionnaire (ASQ) is highly sensitive (98%) and has strong evidence for ruling out risk (negative likelihood ratio, LR⁻=0.04). Among screening instruments for alcohol use disorders, internal consistency is high for the consumption subscale of the Alcohol Use Disorders Identification Test (α=0.83-0.88) and the Adolescent Drinking Index (α=0.92). Both instruments also had sound internal validity. Diagnostically, however, a two-item instrument based on DSM-IV criteria is the most accurate in identifying patients with a disorder (area under the curve: 0.89) and has modest evidence for ruling in and out risk (LR⁺=8.80, LR⁻=0.13).

Conclusions

From available evidence, we recommend that ED clinicians use (a) the HEADS-ED to rule in ED admission among pediatric patients with visits for mental health care, (b) the ASQ to rule out suicide risk among pediatric patients with any visit type, and (c) the DSM-IV two-item instrument to rule in/rule out alcohol use disorders among pediatric patients currently using alcohol. These instruments require minimal to no training or time commitment. We also recommend that clinicians become familiar with each instrument's psychometric properties to understand the quality of the evidence base. In this review, however, we identify methodological limitations in the evidence base. To develop a robust evidence base, additional research is necessary.

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Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU.

Objectives: To study the prognostic value of fever in the emergency department in septic patients subsequently admitted to the ICU. Design: Observational cohort study from the Swedish national quality register for sepsis. Setting: Thirty ICU's in Sweden. Patients: Two thousand two hundred twenty-five adults who were admitted to an ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock were included. Interventions: None. Measurements and Main Results: Body temperature was measured and classified according to four categories (= 39.5[degrees]C). The main outcome was in-hospital mortality. Odds ratios for mortality according to body temperature were estimated using multivariable logistic regression. Subgroup analyses were conducted according to age, sex, underlying comorbidity, and time to given antibiotics. Overall mortality was 25%. More than half of patients had a body temperature below 38.3[degrees]C. Mortality was inversely correlated with temperature and decreased, on average, more than 5% points per [degrees]C increase, from 50% in those with the lowest temperatures to 9% in those with the highest. Increased body temperature in survivors was also associated with shorter hospital stays. Patients with fever received better quality of care, but the inverse association between body temperature and mortality was robust and remained consistent after adjustment for quality of care measures and other factors that could have confounded the association. Among vital signs, body temperature was best at predicting mortality. Conclusions: Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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LiquidSpring at EMS Today 2017

SALT LAKE CITY — LiquidSpring™ LLC is exhibiting at EMS Today, the JEMS Conference & Exposition in Booth #1519 from February 23 - 25. Held at the Calvin L. Rampton Salt Palace Convention Center in Salt Lake City, UT, EMS Today is the fastest growing EMS event in the United States, providing information and experience for EMS personnel through sessions and workshops. LiquidSpring will ...

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Video medicine platform swyMed announces formation of Scientific Advisory Board

LEXINGTON, Mass. — swyMed, a provider of exceptional-quality video telemedicine solutions, today announced the creation of its Scientific Advisory Board (SAB) with four key appointments: Lester Wold, M.D.; James McCarthy, M.D.; Ronald Merrell, M.D.; and Noah Rosen, M.D. The Scientific Advisory Board will advise swyMed on the highest value applications for swyMed’s truly mobile telemedicine ...

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Program Director, Emergency Medical Services (EMS) - Yavapai College

Directly responsible for the oversight and administration of all aspects of the Emergency Medical Services Program. Identifies needs and develops plans and projections for future programs and courses. Participates in building and maintaining community and agency partnerships by development of good working relationships and involvement with district committees on various issues related to program. - ...

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