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Objective: Patient-Reported Experience Measures (PREMs) provide valuable patient feedback on quality of care and have been associated with clinical outcomes. We aimed to test the reliability of a modified adult trauma care PREM instrument delivered to adolescents admitted to hospital for traumatic injuries, and their parents. Modifications included addition of questions reflecting teen-focused constructs on education supports, social network maintenance and family accommodation., Results: Forty adolescent patients and 40 parents participated. Test-retest reliability was assessed using Cohen's kappa, weighted kappa, and percent agreement between responses. Directionality of changed responses was noted. Most of the study ran during the COVID-19 pandemic. We established good reliability of questions related to in-hospital and post-discharge communication, clinical and ancillary care and family accommodation. We identified poorer reliability among constructs reflecting experiences that varied from the norm during the pandemic, which included "maintenance of social networks", "education supports", "scheduling clinical follow-ups" and "post-discharge supports". Parents, but not patients, demonstrated more directionality of change of responses by responding with more negative in-hospital and more positive post-discharge experiences over time between the test and retest periods, suggesting risk of recall bias. Situational factors due to the COVID-19 pandemic and potential risks of recall bias may have limited the reliability of some parts of the survey., (© 2022. The Author(s).)

Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes)., Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions., Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications., Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

Background: The value of biomarkers for diagnosing bacterial infections in older outpatients is uncertain and limited official guidance exists for clinicians in this area. The aim of this review is to critically appraise and evaluate biomarkers for diagnosing bacterial infections in older adults (aged 65 years and above)., Methods: We searched Medline, Embase, Web of Science and the Cochrane Library, from inception to January 2018. We included studies assessing the diagnostic accuracy of blood, urinary, and salivary biomarkers in diagnosing bacterial infections in older adults. The QUADAS-2 tool was used to assess study quality., Results: We identified 11 eligible studies of moderate quality (11,034 participants) including 51 biomarkers at varying thresholds for diagnosing bacterial infections. An elevated Procalcitonin (≥ 0.2 ng/mL) may help diagnose bacteraemia in older adults [+ve LR range 1.50 to 2.60]. A CRP ≥ 50 mg/L only raises the probability of bacteraemia by 5%. A positive urine dipstick aids diagnosis of UTI (+ve LR range 1.23 to 54.90), and absence helps rule out UTI (-ve LR range 0.06 to 0.46). An elevated white blood cell count is unhelpful in diagnosing intra-abdominal infections (+ve LR range 0.75 to 2.62), but may aid differentiation of bacterial infection from other acute illness (+ve LR range 2.14 to 7.12)., Conclusions: The limited available evidence suggests that many diagnostic tests useful in younger patients, do not help to diagnose bacterial infections in older adults. Further evidence from high quality studies is urgently needed to guide clinical practice. Until then, symptoms and signs remain the mainstay of diagnosis in community based populations.

Background: Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement., Methods: This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines., Results: We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics)., Conclusions: We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

Objective: To enable the valid and reliable measurement of patient experiences we previously published a multicenter multi-center validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM). The purpose of this study was to derive a simplified, short form version of the QTAC-PREM to further enhance the feasibility of measuring patient experiences in injury care. To identify candidate items for the short form we reviewed the results of the original multi-center long form validation cohort study, which included 400 injury care patients and their family members recruited from three trauma centers. We only included the best performing items on the revised short form., Results: The acute care component of the measure was shortened by 30% and the post-acute care component was shortened by 42%. We identified two subscales on the acute measure (information and communication; clinical and ancillary care) and one subscale on the post-acute measure (post-discharge information and communication). The measurement properties of the short form measure were similar to that of the validated long form. This short form assessment of patient injury care experiences offers a useful, practical, and easy tool for trauma centers to implement for service evaluation, quality improvement, and injury care research.

Background: The four-hour target is a key hospital emergency department performance indicator in England and one that drives the physical and organisational design of the ED. Some studies have identified time of presentation as a key factor affecting waiting times. Few studies have investigated other determinants of breaching the four-hour target. Therefore, our objective was to describe patterns of emergency department breaches of the four-hour wait time target and identify patients at highest risk of breaching., Methods: This was a retrospective cohort study of a large type 1 Emergency department at an NHS teaching hospital in Oxford, England. We analysed anonymised individual level patient data for 378,873 emergency department attendances, representing all attendances between April 2008 and April 2013. We examined patient characteristics and emergency department presentation circumstances associated with the highest likelihood of breaching the four-hour wait time target., Results: We used 374,459 complete cases for analysis. In total, 8.3% of all patients breached the four-hour wait time target. The main determinants of patients breaching the four-hour wait time target were hour of arrival to the ED, day of the week, patient age, ED referral source, and the types of investigations patients receive (p < 0.01 for all associations). Patients most likely to breach the four-hour target were older, presented at night, presented on Monday, received multiple types of investigation in the emergency department, and were not self-referred (p < 0.01 for all associations). Patients attending from October to February had a higher odds of breaching compared to those attending from March to September (OR 1.63, 95% CI 1.59 to 1.66)., Conclusions: There are a number of independent patient and circumstantial factors associated with the probability of breaching the four-hour ED wait time target including patient age, ED referral source, the types of investigations patients receive, as well as the hour, day, and month of arrival to the ED. Efforts to reduce the number of breaches could explore late-evening/overnight staffing, access to diagnostic tests, rapid discharge facilities, and early assessment and input on diagnostic and management strategies from a senior practitioner.

Background: Consensus methodologies are often used to create evidence-based measures of healthcare quality because they incorporate both available evidence and expert opinion to fill gaps in the knowledge base. However, there are limited studies of the key domains that are considered during panel discussion when developing quality indicators., Methods: We performed a qualitative content analysis of the discussions from a two-day international workshop of injury control and quality-of-care experts (19 panel members) convened to create a standardized set of quality indicators for injury care. The workshop utilized a modified RAND/UCLA Appropriateness method. Workshop proceedings were recorded and transcribed verbatim. We used constant comparative analysis to analyze the transcripts of the workshop to identify key themes., Results: We identified four themes in the selection, development, and implementation of standardized quality indicators: specifying a clear purpose and goal(s) for the indicators to ensure relevant data elements were included, and that indicators could be used for system-wide benchmarking and improving patient outcomes; incorporating evidence, expertise, and patient perspectives to identify important clinical problems and potential measurement challenges; considering context and variations between centers in the health system that could influence either the relevance or application of an indicator; and contemplating data collection and management issues, including availability of existing data sources, quality of data, timeliness of data abstraction, and the potential role for primary data collection., Conclusion: Our study provides a description of the key themes of discussion among a panel of clinical, managerial, and data experts developing quality indicators. Consideration of these themes could help shape deliberation of future panels convened to develop quality indicators.

Background: Patient-centeredness is a key component of health care quality. However, patient-centered measures of quality have not been developed in injury care. In response to this challenge, we developed the Quality of Trauma Adult Care Patient-Reported Experience Measure (QTAC-PREM) to measure injured patient experiences with trauma care and pilot-tested the instrument at a single Level 1 trauma centre. The objective of this study is to test the reliability, validity, and feasibility of the QTAC-PREM in multiple Canadian trauma centers and to refine the measure based on the results., Methods/design: This will be a prospective cohort study of consecutive adult (age ≥ 18 years) patients discharged from three trauma centres in Alberta, Canada with a primary diagnosis of injury. The target sample size is 400 participants to ensure precision for evaluating test-retest reliability. We will assess the psychometric properties of the measure (test-retest reliability, construct validity, internal consistency) and whether these properties vary by patient characteristics. We will also evaluate the predictive validity, convergent validity, and discriminant validity of the measure against other established tools (HCAHPS)., Discussion: A reliable and valid measure of patient reported experiences with injury care may be a valuable tool to evaluate quality of care and guide improvement efforts.