Having an understanding of critical appraisal and evidence-based medicine is a prerequisite to being an effective clinician. However, critical appraisal is often taught by people not involved in ...day-to-day clinical care, meaning the clinical relevance is not always brought to the fore.
This book takes a different approach. It is written by clinicians, for clinicians. It takes the reader step by step through the process so that any journal article can be easily read, evidence evaluated and the results - and their reliability - truly understood. By integrating this with knowledge of local skills and resources and patient preference, the reader will be able to apply the best possible care that his or her patients deserve.
This accessible book is suitable for undergraduates and postgraduates of all medical specialties, nursing, paramedics, pharmacists and all allied health professions. It is the ideal reference for anyone needing help writing a clinical topic review, reviewing a paper in a journal club or preparing for a critical appraisal exam. But most importantly, it is essential for those who wish to practice medicine in the best possible way for their patients, using the best evidence, tailored to the individual.
About the authors
Foreword
Introduction
Section 1: Introduction to critical appraisal
Chapter 1: Types of papers and grades of evidence
Chapter 2: An approach to appraising papers
Section 2: Basic Statistics
Chapter 3: Types of Data and moving from samples to populations
Chapter 4: P values, confidence intervals and types of Error
Chapter 5: Basic Probability
Section 3: Appraising different types of papers
Chapter 6: Observational papers (Case series, case control, cohort, cross sectional, ecological)
Chapter 7: papers
Chapter 8: Therapeutic papers
Chapter 9a: Diagnostic papers / Chapter 9b: Screening papers
Chapter 10: Prognostic papers
Chapter 11: Economic Assessment Papers
Chapter 12: Meta-analysis
Section 4: Applying the knowledge
Chapter 13: Writing a clinical topic review
Chapter 14; Running a journal club
Chapter 15: Creating a ‘best available’ evidence based clinical environment
Section 5: Critical appraisal exams
Chapter 16: An approach to critical appraisal exams
Chapter 17: Practice papers
Glossary of terms
Early transfusion of packed red blood cells (PRBC) has been associated with improved survival in patients with haemorrhagic shock. This study aims to describe the characteristics of patients ...receiving pre-hospital blood transfusion and evaluate their subsequent need for in-hospital transfusion and surgery.
The decision to administer a pre-hospital PRBC transfusion was based on clinical judgment. All patients transfused pre-hospital PRBC between February 2013 and December 2014 were included. Pre-hospital and in-hospital records were retrospectively reviewed.
One hundred forty-seven patients were included. 142 patients had traumatic injuries and 5 patients had haemorrhagic shock from a medical origin. Median Injury Severity Score was 30. 90% of patients receiving PRBC had an ISS of >15. Patients received a mean of 2.4(±1.1) units of PRBC in the pre-hospital phase. Median time from initial emergency call to hospital arrival was 114 min (IQR 103-140). There was significant improvement in systolic (p < 0.001), diastolic (p < 0.001) and mean arterial pressures (p < 0.001) with PRBC transfusion but there was no difference in HR (p = 0.961). Patients received PRBC significantly faster in the field than waiting until hospital arrival. At the receiving hospital 57% required an urgent surgical or interventional radiology procedure. At hospital arrival, patients had a mean lactate of 5.4(±4.4) mmol/L, pH of 6.9(±1.3) and base deficit of -8.1(±6.7). Mean initial serum adjusted calcium was 2.26(±0.29) mmol/L. 89% received further blood products in hospital. No transfusion complications or significant incidents occurred and 100% traceability was achieved.
Pre-hospital transfusion of packed red cells has the potential to improvde outcome for trauma patients with major haemorrhage. The pre-hospital time for trauma patients can be several hours, suggesting transfusion needs to start in the pre-hospital phase. Hospital transfusion research suggests a 1:1 ratio of packed red blood cells to plasma improves outcome and further research into pre-hospital adoption of this strategy is needed.
Pre-hospital PRBC transfusion significantly reduces the time to transfusion for major trauma patients with suspected major haemorrhage. The majority of patients receiving pre-hospital PRBC were severely injured and required further transfusion in hospital. Further research is warranted to determine which patients are most likely to have outcome benefit from pre-hospital blood products and what triggers should be used for pre-hospital transfusion.
•Feedback from coroners’ reports to prehospital teams is important.•Coroners’ reports are unavailable for many patients who die after traumatic cardiac arrest (TCA).•A full postmortem evaluation is ...only performed in a minority of the patients who die after TCA.•The causes of death provided by the coroner are often nonspecific.
The aim of this study was to establish if in patients who die at scene as a result of traumatic cardiac arrest (TCA), their cause of death could be determined through coroners reports, and to ascertain the quality of the feedback provided.
This is a retrospective study of all patients presenting in TCA who were attended by the Air Ambulance Kent, Surrey and Sussex between January 1, 2015, and June 30, 2016.
In total, 159 patients were attended to during the study period. Postmortem reports could not be obtained for 37 patients, mainly because of unestablished identities at the scene. Forty of the 122 reports obtained were full postmortem reports, 3 were inquest reports, and for 79 patients only their (presumed) cause of death was provided. A specific cause of death was provided for 68 patients, whereas in the remaining 54 patients the cause of death was given as “multiple injuries.” In 32% of the patients with a full postmortem report, injuries were identified during the postmortem examination that had not been noted on scene.
Feedback from coroners to prehospital teams after patients die as a result of TCA is important but currently suboptimal.
Editorial on the role of the ward manager in the critical care setting. Challenges and difficulties experienced are identified and strategies employed to balance management duties and clinical ...patient contact and to minimise burnout and stress are discussed. The leadership role of the ward manager is highlighted. (BNI unique abstract) 19 references
This study explores the role of the contemporary ward manager in the NHS. Using a grounded theory methodology, 9 ward managers and 32 other clinical staff participated in semi-structured interviews. ...In addition, ward managers were observed in practice on eight occasions. A pragmatist philosophical tradition informing symbolic interaction guided the interpretive analytical framework to generate a substantive theory of the role of a modern day ward manager through the analysis of their narratives and by observing them at work. The simultaneous collection, coding, memoing and analysis of the data, together with the body of existing literature, enabled a process of theoretical sampling to build an emerging theory of identity and agency.
Abstract Background Major trauma commonly occurs at night. Helicopter emergency medical services (HEMS) can provide advanced prehospital care to victims of major trauma but do not routinely operate ...at night in the United Kingdom. We sought to prospectively examine the need for a night HEMS service in Kent, Surrey, and Sussex in the United Kingdom. Methods A 4-month, prospective study was conducted (July 1, 2012-October 31, 2012). HEMS dispatch paramedics were present in the ambulance dispatch center and undertook simulated HEMS activations when a suitable case was identified. All trauma cases from the 4-month study period were collated. Five independent HEMS clinicians reviewed the simulated tasking and trauma cases and gave an opinion on whether the patient met HEMS activation criteria. Results A mission rate of 1 case per night was predefined as cost-effective. During the prospective study, 145 calls were identified by the HEMS dispatch paramedic as appropriate for an HEMS response. If HEMS had deployed to all 145 incidents, this would have resulted in an average mission rate of 1.2 activations per night. Two hundred eight incidents were identified as potentially appropriate for HEMS activation. Responding to all 208 incidents would have resulted in a mean activation rate of 1.7 per night. Conclusion This study justifies the need for Kent, Surrey and Sussex Air Ambulance Trust to operate a service at night for a trial period, with an estimated average mission load of 1 per night spread over the entire night period. Further research is warranted to determine the potential impact of a night HEMS service on outcome from major trauma.
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