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IntroductionNational Early Warning Score 2 (NEWS2) is widely used to monitor and trigger assessment throughout a patient’s hospital journey. Since the development and role out of NEWS2, its ability to predict mortality has been assessed in several settings, although to date not within an undifferentiated ED population.MethodsWe conducted a retrospective observational study of all adult ED attendees at two EDs in Northern England, between March and November 2019. Multilevel multiple logistic regression analyses were conducted on patient episode data to assess the relationship between mortality at 2, 7 and 30 days from attendances; and maximum NEWS2, adjusting for age, sex, arrival mode and triage priority.ResultsData were collected from 91 871 valid patient episodes associated with 64 760 patients. NEWS2 was a significant predictor of mortality at 2 days (OR 1.75; 95% CI 1.58 to 1.93); at 7 days (OR 1.69; 95% CI 1.59 to 1.80); at 30 days (OR 1.58; 95% CI 1.52 to 1.64). For the analyses of categorised NEWS2, NEWS2 of 2–20 was significantly associated with mortality at 2, 7 and 30 days compared with none assigned: OR 3.54 (95% CI 2.15 to 5.85) at 2 days; OR 6.05 (95% CI 3.92 to 9.34) at 7 days; OR 12.4 (95% CI 7.91 to 19.3) at 30 days. Increasing age, male sex, arrival by ambulance and higher triage categories were also associated with significantly increased mortality. Area under the receiver operating characteristic curve values of 0.963, 0.946 and 0.915, respectively, were recorded for mortality outcomes, with optimum likelihood ratios associated with a trigger of 4 NEWS2 points.ConclusionsNEWS2 is an effective predictor of mortality for patients presenting to the ED. Findings suggest that maximum NEWS2 of 4 and over may be the best trigger point for escalation of treatment. Findings also suggest a NEWS2 of 0–1 can identify a very low-risk group within the ED.

IntroductionMany essential interventions are required to ensure in-patients receive safe and effective care with a good experience. In addition, healthcare organisations are assessed on numerous performance indicators, including the aforementioned interventions, where underperformance can lead to lower publicly reported ratings, loss of income and reputational damage. Most importantly, underperformance can lead to compromised patient experience and outcomes. We created a prompt card as a service improvement tool to be used on the daily ward rounds at the bedside of every patient, entitled ‘every patient, every day’ to improve documentation, antibiotic prescribing, venous thromboembolism (VTE) prophylaxis, coding and patient communication.MethodPreimplementation data around these interventions and patient experience factors were collected by shadowing ward rounds. The ‘every patient, every day’ tool was then implemented. The ward rounds were shadowed by the same individual to collect post-implementation data. Effect of implementation was assessed via Poisson regression models conducted on the documentation, antibiotics and VTE measures, and logistic regression models conducted on the communication and coding measures.ResultsThe corresponding rate ratios for the effect of the implementation of the service improvement tool were found to be 1.53 (95% CI 1.38 to 1.69) for improved documentation. Antibiotics prescribing improved by 1.44 (95% CI 1.06 to 1.94). VTE prescribing and documentation improved by a rate ratio 1.25 (95% 1.04 to 1.50). For communication, the effect of the implementation was significant at the 5% significance level (pConclusionThe ‘every patient, every day’ ward round prompt card is an extraordinarily simple tool shown to increase compliance with a number of safety and quality indicators to improve an organisation’s performance, and hopefully be a facet contributing to enhanced patient experience and outcomes.

Many statistical analyses in ophthalmic and other clinical fields are concerned with describing relationships between one or more ‘predictors’ (explanatory or independent variables) and usually one outcome measure (response or dependent variable). Our earlier statistical notes make reference to the fact that statistical techniques often make assumptions about data.1 ,2 Assumptions may relate to the outcome variable, to the predictor variable or indeed both; common assumptions are that data follow normal (Gaussian) distributions and that observations are independent. It is, of course, entirely possible to ignore such assumptions, but doing so is not good statistical practice and in medicine; poor statistical practice can impact negatively upon patients and the public.3 One approach when assumptions are not adhered to is to use alternative tests which place fewer restrictions on the data – non-parametric or so-called distribution free methods.2 A more powerful alternative, however, is to transform your data. While your ‘raw’ (untransformed) data may not satisfy the assumptions needed for a particular test, it is possible that a mathematical function or transformation of the data will. Analyses may then be conducted on the transformed data rather than the raw data. Scenario 1: A study to evaluate the accuracy of intraocular lens power estimation in eyes having phacovitrectomy for rhegmatogenous retinal detachment4 measured the axial length (in mm) of 71 eyes. The raw data (figure 1A) exhibited a fairly strong positive skew (rather than being symmetric there is an extended tail in the histogram to the right); the same data with a logarithmic transformation applied (figure 1B) appears much more normal (less of a …

Aim To present the anatomical and visual outcomes of patients with hypo-reflective cystic defects in outer fovea (outer foveal defect; OFD) in macular holes repaired with non-posturing vitrectomy and short term gas tamponade. To identify the incidence and risk factors for developing OFD foveal defect. Method A prospective consecutive case series of 58 patients undergoing macular hole surgery was undertaken. OFD detected on 2-week postoperative Optical coherence tomography (OCT) was measured. In these patients OCT was performed monthly until resolution of OCT. Results 27 eyes (46.6%) had an outer defect at 2 weeks, the presence of which was significantly associated with macular holes with larger base diameters preoperatively (p=0.006). All defects closed spontaneously without further intervention, and the final vision was not affected by the presence of an OFD. Visual recovery was only slightly (and not significantly) delayed by the presence of an outer defect. Conclusions This is the first study of outcomes of OFDs following macular hole surgery in patients who did not posture postoperatively. OFDs are common but do not adversely affect visual outcomes.

Background/Aims To compare several methods of macular hole measurement using optical coherence tomography (OCT), and to assess their predictive capability against anatomical and visual outcomes in a single cohort of patients. Methods A retrospective study of 50 eyes undergoing standardised macular hole surgery. All patients underwent preoperative OCT scanning with measurement of macular hole inner opening diameter, minimum linear diameter, base diameter and macular hole height. Values were calculated for the macular hole index and the tractional hole index. Results Logistic regression analyses indicated that the preoperative base diameter, macular hole inner opening and minimum linear diameter were associated with both anatomical and visual success. Derived parameters as alternatives to these basic ophthalmic parameters add little to the modelling of either anatomical or visual success. Conclusion Base diameter, macular hole inner opening and minimum linear diameter can each be used to predict anatomical and/or functional success in macular hole surgery. Preoperative base diameter is the most useful variable in this regard, as it holds the strongest association with anatomical and visual outcome and is easily measured on a OCT scan.

Krishna Murari Goel was born in Agra, India, on 4 September 1936. He was the youngest of five children of devout Hindu parents who used their limited resources to fund their children’s education. His early medical training in Lucknow made him acutely aware of the poverty and the high morbidity and mortality in mothers and children he found there. Therefore, he decided to devote his career to paediatric medicine. His mother tongue was Hindi and his command of English good. Inspired by reading the first edition of Practical Paediatric Problems , written by James Holmes Hutchison und published in 1964, he applied and was accepted for a registrar post with Hutchison, starting in October 1964. He was met at Glasgow airport by a taxi driver organised by Hugh Park, superintendent of the Yorkhill Royal Hospital for Sick Children and Queen Mother’s Maternity Hospital. That welcome had a lasting effect on him, particularly when coupled with his initial disbelief that he could treat or admit any child according to their illness without first asking how much money their families could afford to pay. Krishna worked with Hutchison and Robert Shanks, forming a critical link between Glasgow’s neonatal services at the Southern General Hospital and Rotten Row Maternity Hospital, together with the Yorkhill co-located Queen Mother’s Maternity Hospital and Royal Hospital for Sick Children. Hutchison retired from his Glasgow chair in 1976 to take the chair of paediatrics in Hong Kong. His successor in Glasgow was Forrester Cockburn, and they shared the editorship of the sixth edition of Practical Paediatric Problems . Krishna was delighted when in 1986 the publishers, Lloyd Luke, issued a low priced Asian postgraduate economy edition of the sixth edition, printed in …

Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK)as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a ‘‘model’’ arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p,0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p,0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p,0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation.

Previous notes in this series have been concerned with the common situation in ophthalmic and other clinical fields of describing relationships between one or more ‘predictors’ (explanatory variables) and, usually, one outcome measure (response variable). A classic method used in deriving relationships between outcomes and predictors is linear regression analysis. Linear regression is a member of a family of techniques known as general linear models, which also include analysis of variance and analysis of covariance; the latter of which was covered in a previous Ophthalmic Statistics Note.1 A key feature of all these models is that the outcome measure—for example, postoperative refractive prediction error or intraocular pressure—is continuous. While other notes in the series2 warn of the dangers of unnecessary dichotomisation of variables, sometimes outcomes naturally fall into two categories. In both examples, our objective is to examine …

Prehospital intravenous (IV) cannulation by paramedics is a key intervention which enables administration of fluids and drugs in the prehospital setting. Inappropriate use and poor technique of IV cannulation carry potential risks for patients such as pain and infection. Cannulation rates vary widely between paramedics and ambulance stations and rates have increased over the past decade. A baseline audit carried out in …

One-hundred-sixty-five children without known neurological disorder who presented with their first febrile convulsion between the ages of six months and three years were assigned to daily phenobarbitone treatment or to a control group and followed up at a special clinic for six months. One-hundred-and-sixty-one-one children completed the trial, and of the 88 children assigned to phenobarbitone treatment 10 had further convulsions during this period compared with 14 of the 73 control children. Only 49 of those assigned to phenobarbitone took the drug regularly throughout the trial, and four of these had further febrile convulsions, a proportion not significantly different from that in the controls. All four had mean plasma phenobarbitone concentrations over 69 mumol/l (16 mug/ml) during the trial and in three the plasma concentration was at or over this figure within eight hours over 69 mumol/l (16 mug/ml) during the trial and in three the plasma concentration was at or over this figure within eight hours of the repeat convulsion. Regular phenobarbitone does not seem to prevent febrile convulsions. Attention should instead be directed to organising emergency services to allow early termination of fevrile convulsions, whether first or subsequent, to prevent irreversible brain damage.