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Correspondence to Dr Jared M Wohlgemut; jwohlgemut@nhs.net Major trauma patients who develop hemostatic dysregulations, for example, trauma-induced coagulopathy, have significantly increased morbidity and mortality.1 Current guidelines recommend that point-of-care analyzers, such as viscoelastic testing (VET), should be used to monitor hemostasis and guide goal-directed resuscitation.2 In this multicenter prospective observational study,3 Moore et al report the diagnostic performance of a VET device that measures changes in clot strength using sonorheometry (Quantra QStat) in comparison to the thromboelastometry (ROTEM) delta and thromboelastography (TEG) 6s devices. Linear regression analysis demonstrated a moderate to strong positive correlation between Quantra QStat and ROTEM delta, or TEG 6s, respectively. [...]time to actionable results could have been derived and compared with Quantra QStat, with most likely similar results.7 While their findings support the clinical implementation of the Quantra QStat as a valid alternative to other VET devices, some dissimilarities remain between the results yielded by the different technologies of these tools.

Background The primary aim of this scoping review was to synthesise key domains and sub-domains described in existing clinical decision support systems (CDSS) implementation frameworks into a novel taxonomy and demonstrate most-studied and least-studied areas. Secondary objectives were to evaluate the frequency and manner of use of each framework, and catalogue frameworks by implementation stage. Methods A scoping review of Pubmed, Scopus, Web of Science, PsychInfo and Embase was conducted on 12/01/2022, limited to English language, including 2000–2021. Each framework was categorised as addressing one or multiple stages of implementation: design and development, evaluation, acceptance and integration, and adoption and maintenance. Key parts of each framework were grouped into domains and sub-domains. Results Of 3550 titles identified, 58 papers were included. The most-studied implementation stage was acceptance and integration, while the least-studied was design and development. The three main framework uses were: for evaluating adoption, for understanding attitudes toward implementation, and for framework validation. The most frequently used framework was the Consolidated Framework for Implementation Research. Conclusions Many frameworks have been published to overcome barriers to CDSS implementation and offer guidance towards successful adoption. However, for co-developers, choosing relevant frameworks may be a challenge. A taxonomy of domains addressed by CDSS implementation frameworks is provided, as well as a description of their use, and a catalogue of frameworks listed by the implementation stages they address. Future work should ensure best practices for CDSS design are adequately described, and existing frameworks are well-validated. An emphasis on collaboration between clinician and non-clinician affected parties may help advance the field.

Background Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. Methods Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. Results Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16–89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62–2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988–0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986–0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63–8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. Conclusions Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.

BackgroundTrauma recidivism refers to patients who are injured repeatedly. There has been no evaluation of trauma recidivism in England and Wales. We hypothesize that, because population demographics and predominant trauma mechanism differ from other studied populations, the typical demographics of patients suffering repeated trauma would differ. Our aim was to determine the demographic and injury characteristics, and outcomes of patients suffering repeated trauma.MethodsThis was a national, retrospective, population-based cohort study of patients included in the prospectively collected Trauma Audit & Research Network’s (TARN) National Trauma Registry for England and Wales between 2019 and 2020. We defined recidivism as a second admission, with different injuries, within 1 year of the initial admission. Analysis was descriptive.Results2517 patients (5136 admissions) were included. Median age at first admission was 81 years, and 1888 (75%) were ≥65 years. 1301 (52%) were female. The most common mechanism of injury at first and second admission was a fall ≤2 m (2159 86%, 2237 89%). 2035 (81%) suffered a fall ≤2 m on both admissions. Patients with severe injury increased from 838 (33%) to 982 (39%) from first to second admission. Patients discharged home decreased from 1776 (71%) to 1449 (58%) from first to second admission. Mortality on 2nd admission was 10.2%.ConclusionsIn England and Wales, trauma recidivism consists primarily of elderly patients who repeatedly suffer low-energy falls. It follows that prevention strategies should consist of greater and earlier involvement of multidisciplinary team input including geriatric physicians and allied health professionals, for anyone ≥65 who fulfills the criteria for TARN inclusion.Level of evidenceLevel III.

BackgroundHemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality.MethodsRetrospective evaluation of consecutive adult (≥16 years) patients injured in 2019–2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality.ResultsOf the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC.ConclusionClinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted.Level of evidenceLevel III—Retrospective study with up to two negative criteria.Study typeOriginal research; diagnostic accuracy study.

BackgroundThe impact of socioeconomic deprivation and comorbidities on the outcome of patients who require emergency general surgery (EGS) admission is poorly understood. The aim of this study was to examine the effect of deprivation and comorbidity on mortality, discharge destination and length of hospital stay (LOS) in patients undergoing EGS in Scotland.MethodsProspectively collected data from all Scottish adult patients (aged >15 years) requiring EGS admitted between 1997 and 2016 were obtained from the Scottish Government. Data included age, sex, Scottish Index of Multiple Deprivation (SIMD), 5-year Charlson Comorbidity Index (CCI), whether an operation took place and outcomes including mortality, discharge destination and LOS. Logistic regression was used for the analysis of mortality and discharge destination and Poisson regression was used for LOS.Results1 477 810 EGS admissions were analyzed. 16.2% were in the most deprived SIMD decile and 5.6% in the least deprived SIMD decile. 75.6% had no comorbidity, 20.3% had mild comorbidity, 2.5% had moderate comorbidity and 1.6% had severe comorbidity. 78.6% were discharged directly home. Inpatient, 30-day, 90-day and 1-year crude mortality was 1.7%, 3.7%, 7.2% and 12.4%, respectively. Logistic regression showed that severe comorbidity was associated with not being discharged directly to home (OR 0.38, 95% CI 0.37 to 0.39) and higher inpatient mortality (OR 13.74, 95% CI 13.09 to 14.42). Compared with the most affluent population, the most deprived population were less likely to be discharged directly to home (OR 0.97, 95% CI 0.95 to 0.99) and had higher inpatient mortality (OR 1.36, 95% CI 1.8 to 1.46). Poisson analysis showed that severe comorbidity (OR 1.69, 95% CI 1.68 to 1.69) and socioeconomic deprivation (OR 1.11, 95% CI 1.11 to 1.12) were associated with longer LOS.DiscussionIncreased levels of comorbidity and, to a lesser extent, socioeconomic deprivation are key drivers of mortality, discharge destination and LOS following admission to an EGS service.Level of evidenceIII (prospective/retrospective with up to two negative criteria).Study typeEpidemiological/prognostic.

BackgroundBlood transfusion for bleeding trauma patients is a promising pre-hospital intervention with potential to improve outcomes. However, it is not yet clear which patients may benefit from pre-hospital transfusions. The aim of this study was to enhance our understanding of how experienced pre-hospital clinicians make decisions regarding patient blood loss and the need for transfusion, and explore the factors that influence clinical decision-making.MethodsPre-hospital physicians, from two air ambulance sites in the south of England, were interviewed between December 2018 and January 2019. Participants were involved in teaching or publishing on the management of bleeding trauma patients and had at least 5 years of continuous and contemporary practice at consultant level. Interviews were semi-structured and explored how decisions were made and what made decisions difficult. A qualitative description approach was used with inductive thematic analysis to identify themes and subthemes related to blood transfusion decision-making in trauma.ResultsTen pre-hospital physicians were interviewed and three themes were identified: recognition-primed analysis, uncertainty and imperfect decision analysis. The first theme describes how participants make decisions using selected cues, incorporating their experience and are influenced by external rules and group expectations. What made decisions difficult for the participants was encapsulated in the uncertainty theme. Uncertainty emerged regarding the patient’s true underlying physiological state and the treatment effect of blood transfusion. The last theme focuses on the issues with decision-making itself. Participants demonstrated lapses in decision awareness, often incomplete decision evaluation and described challenges to effective learning due to incomplete patient outcome information.ConclusionPre-hospital clinicians make decisions about bleeding and transfusion which are recognition-primed and incorporate significant uncertainty. Decisions are influenced by experience and are subject to bias. Improved understanding of the decision-making processes provides a theoretical perspective of how decisions might be supported in the future.

Abstract Objective The aim of this study was to determine the methods and metrics used to evaluate the usability of mobile application Clinical Decision Support Systems (CDSSs) used in healthcare emergencies. Secondary aims were to describe the characteristics and usability of evaluated CDSSs. Materials and Methods A systematic literature review was conducted using Pubmed/Medline, Embase, Scopus, and IEEE Xplore databases. Quantitative data were descriptively analyzed, and qualitative data were described and synthesized using inductive thematic analysis. Results Twenty-three studies were included in the analysis. The usability metrics most frequently evaluated were efficiency and usefulness, followed by user errors, satisfaction, learnability, effectiveness, and memorability. Methods used to assess usability included questionnaires in 20 (87%) studies, user trials in 17 (74%), interviews in 6 (26%), and heuristic evaluations in 3 (13%). Most CDSS inputs consisted of manual input (18, 78%) rather than automatic input (2, 9%). Most CDSS outputs comprised a recommendation (18, 78%), with a minority advising a specific treatment (6, 26%), or a score, risk level or likelihood of diagnosis (6, 26%). Interviews and heuristic evaluations identified more usability-related barriers and facilitators to adoption than did questionnaires and user testing studies. Discussion A wide range of metrics and methods are used to evaluate the usability of mobile CDSS in medical emergencies. Input of information into CDSS was predominantly manual, impeding usability. Studies employing both qualitative and quantitative methods to evaluate usability yielded more thorough results. Conclusion When planning CDSS projects, developers should consider multiple methods to comprehensively evaluate usability. Lay Summary Healthcare professionals must make safe, accurate decisions, especially during medical emergencies. Researchers design and develop tools that can help medical experts make these decisions. These tools are called Clinical Decision Support Systems (CDSSs). CDSSs obtain and process information about a patient, and display information to the healthcare professional (user) to aid decision-making. Whether the user finds the system easy to use or useful is referred to the system’s usability. Usability affects how likely the CDSS is to be adopted and implemented into practice. We carefully searched the published literature and found 23 papers which measured the usability of CDSSs designed for medical emergencies. We found that CDSSs’ efficiency and usefulness were measured the most, and effectiveness and memorability the least. More studies used questionnaires and user testing than interviews or specific “heuristic” evaluations. However, we found that interviews and heuristic evaluations identified more usability issues than did the questionnaires and user tests. Studies which tested the usability of CDSS by using both numerical methods (quantitative) and narrative methods (qualitative) were better at identifying the most issues. We advised both numerical and narrative methods to test the usability of CDSS, because it will be most comprehensive.

Abstract A 65-year-old man developed acute arterial thrombosis with stent graft occlusion, during elective endovascular aneurysm repair, with bilateral acute lower limb ischaemia. We describe successful endovascular and pharmacological management using a combination of mechanical disruption of the thrombus (using the access sheaths) followed by intra-arterial thrombolysis (Actilyse) infusion. Within 4-h the endograft had completely re-canalized. The patient made an uncomplicated recovery and was discharged on the second post-operative day.