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Mastoiditis is an otological emergency, and cross-sectional imaging has a role in the diagnosis of complications and surgical planning. Advances in imaging technology are becoming increasingly sophisticated and, by the same token, the ability to accurately interpret findings is essential.
This paper reviews common and rare complications of mastoiditis using case-led examples. A radiologist-derived systematic checklist is proposed, to assist the ENT surgeon with interpreting cross-sectional imaging in emergency mastoiditis cases when the opinion of a head and neck radiologist may be difficult to obtain.
A 16-point checklist (the ‘mastoid 16’) was used on a case-led basis to review the radiological features of both common and rare complications of mastoiditis; this is complemented with imaging examples.
Acute mastoiditis has a range of serious complications that may be amenable to treatment, once diagnosed using appropriate imaging. The proposed checklist provides a systematic approach to identifying complications of mastoiditis.
Introduction: Transcutaneous cardiac pacing (TCP) is recommended for the treatment of symptomatic bradycardia, a life-threatening condition. Although TCP is taught in ACLS (advanced cardiac life support) courses, it is a difficult skill to master for junior residents. The main objective of this study is to measure the impact of having access to a checklist on successful TCP implementation. Our hypothesis was that the availability of a CL would improve performance of junior residents in the management of symptomatic bradycardia by facilitating TCP. Methods: We conducted a prospective, randomized, single-site study. First-year residents entering postgraduate programs and taking a mandatory ACLS course were enrolled. Students had didactic sessions on the management of symptomatic bradycardia followed by hands-on teaching on a low-fidelity manikin (ALS® simulator, Laerdal) using a CL conceived for this project as a teaching tool. Study participants were then assessed with a simulation scenario requiring TCP. Participants were randomly assigned to groups with and without CL accessibility. Performances were graded on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks. Participants then completed a post-test questionnaire. Sample size estimation was based on a previous project (Ranger et al., 2018). Accepting an alpha error of 0.05 and a power of 80%, 45 participants in each group would permit the detection of 26.5% in performance gain. Results: Of 250 residents completing the ACLS course in 2017, 85 voluntary participants were randomized to a control group (no CL available during testing, n = 42) or an experimental group (CL available during testing, n = 43). Six participants in the experimental group adequately used TCP compared to five participants in the control group (p = 0.81, chi-squared test). Out of the 43 participants who had access to the CL, only 2 (5%) used it. Reasons why the CL was infrequently used were stated as the following: 24 participants (56%) mentioned not realizing it was available, 8 (19%) considered it was of little to no utility and 5 (19%) forgot a CL existed. Conclusion: Availability of a checklist previously used during simulation teaching did not increase junior residents’ capacity to correctly apply TCP. Non-recognition of CL availability and decreased perceived need for it were the main reasons for marginal use. Our results suggest that there are many limiting factors to CL effectiveness.
In November 2017, a working feasibility analysis commenced of a local anaesthetic endonasal procedures out-patient clinic service at Freeman Hospital, Newcastle upon Tyne. Fundamental to introducing an innovative ambulatory out-patient practice is the development of a novel local safety standard for invasive procedures to support this service.
This paper presents the new safety standard developed for this purpose and implemented in our institution.
Increasingly, there is a shift toward ambulatory services, directed by patient choice, technological advances and the opportunity for cost savings. It is hoped that this local safety standard for invasive procedures will provide a useful template for those considering implementing ambulatory endonasal services, or other novel procedures, within the specialty of ENT.
Crop wild relatives (CWR) are valuable gene pools for crop improvement and offer unique potential and opportunity for enhancing food security and adaptation to climate change. However, current actions towards conservation of plant genetic resources in Zambia do not adequately cover CWR occurring in the country. The article describes the process leading to the development of a national strategic action plan (NSAP) for the conservation and sustainable use of priority CWR in Zambia. Based on 59 prioritized crops, a partial checklist of 459 CWR taxa was generated from the national flora checklist of 6305 taxa. The generated CWR taxa were prioritized based on the socio-economic value of the related crop, their utilization potential in crop improvement, relative distribution and threat status to produce 30 prioritized CWR taxa. Occurrence data were compiled for all CWR inventory taxa and used in spatial analyses to establish species distribution, species richness, gaps in in situ conservation and genebank collections, and to identify priority sites for in situ conservation and ex situ collecting. Consistent with the national developmental agenda, along with the contribution of national stakeholders, spatial analyses of occurrence data of priority CWR taxa are valuable input for the development of the NSAP for the conservation and sustainable use of the priority CWR.
Introduction: The purpose of this study is to determine if the introduction of a pre-arrival and pre-departure Trauma Checklist as a cognitive aid, coupled with an educational session, will improve clinical performance in a simulated environment. The Trauma Checklist was developed in response to a quality assurance review of high-acuity trauma activations. It focuses on pre-arrival preparation and a pre-departure review prior to patient transfer to diagnostic imaging or the operating room. We conducted a pilot, randomized control trial assessing the impact of the Trauma Checklist on time to critical interventions on a simulated pediatric patient by multidisciplinary teams. Methods: Emergency department teams composed of 2 physicians, 2 nurses and 2 confederate actors were enrolled in our study. In the intervention arm, participants watched a 10-minute educational video modelling the use of the trauma checklist prior to their simulation scenario and were provided a copy of the checklist. Teams participated in a standardized simulation scenario caring for a severely injured adolescent patient with hemorrhagic shock, respiratory failure and increased intracranial pressure. Our primary outcome of interest was time measurement to initiation of key clinical interventions, including intubation, first blood product administration, massive transfusion protocol activation, initiation of hyperosmolar therapy and others. Secondary outcome measures included a Trauma Task Performance score and checklist completion scores. Results: We enrolled 14 multidisciplinary teams (n=56 participants) into our study. There was a statistically significant decrease in median time to initiation of hyperosmolar therapy by teams in the intervention arm compared to the control arm (581 seconds, [509-680] vs. 884 seconds, [588-1144], p=0.03). Time to initiation of other clinical interventions was not statistically significant. There was a trend to higher Trauma Task Performance scores in the intervention group however this did not reach statistical significant (p=0.09). Pre-arrival and pre-departure checklist scores were higher in the intervention group (9.0 [9.0-10.0] vs. 7.0 [6.0-8.0], p=0.17 and 12.0 [11.5-12.0] vs. 7.5 [6.0-8.5], p=0.01). Conclusion: Teams using the Trauma Checklist did not have decreased time to initiation of key clinical interventions except in initiating hyperosmolar therapy. Teams in the intervention arm had statistically significantly higher pre-arrival and pre-departure scores, with a trend to higher Trauma Task Performance scores. Our study was a pilot and recruitment did not achieve the anticipated sample size, thus underpowered. The impact of this checklist should be studied outside tertiary trauma centres, particularly in trainees and community emergency providers, to assess for benefit and further generalizability.
Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.
Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.
Introduction: A cricothyroidotomy is a life-saving procedure and essential skill for EM physicians. The bougie-assisted cricothyroidotomy (BAC) is a newly describe technique that is both simple and reliable. There remains no consensus for the essential steps and ideal training strategy for the procedure. Using a modified Delphi process, we created an expert-derived checklist as a transferable educational tool for BAC instruction. Methods: A literature search was conducted to identify relevant articles describing the steps for BAC performance. These steps formed the first-iteration checklist for the modified Delphi process. Fourteen experts from general surgery, emergency medicine, otolaryngology, and anesthesia were recruited as participants for the Delphi process which consisted of three iterations. In the first two rounds, experts ranked each checklist step on a scale of 1-7, suggested additions, and provided comments. After each round the comments and rankings were integrated and steps with an average ranking of ≤3.0 were removed from the checklist for the next round. In the final round, consensus was sought by asking experts to indicate if this checklist was acceptable for teaching BAC to a novice learner. Results: A 22-item checklist was developed from a literature review. Following a modified Delphi methodology, the final BAC checklist contained 17 items. Internal consistency of the checklist was very good (α=0.855). In the third and final round, 86% of the participants agreed that the final iteration of the checklist. There was disagreement regarding “bougie hold up” as an appropriate method to confirm bougie position within the tracheal lumen. The checklist was modified, replacing “hold up” with digital palpation in the trachea as confirmation of successful bougie placement. With these modifications, consensus was achieved. Conclusion: Using a modified Delphi process, derived from existing literature and expert opinion, a 17-item BAC checklist was developed for novice instruction. This BAC checklist represents the first consensus-based set of steps for the procedure which may serve as a useful tool for trainee instruction and evaluation. Future research is required to test the validity of this checklist in training for a BAC and its applicability within competency-based medical education.
A generic key to 81 genera representing 255 naturally occurring species known from Belize is presented using easily distinguished characters and including illustrations of many of the genera. An up-to-date list of the grasses of Belize is also given.
Disasters often overwhelm a community’s capacity to respond and recover, creating a gap between the needs of the community and the resources available to provide services. In the wake of multiple disasters affecting nursing homes in the last decade, increased focus has shifted to this vital component of the health care system. However, the long-term care sector has often fallen through the cracks in both planning and response.
Two recent reports (2006 and 2012) published by the US Department of Health and Human Services (DHHS), Office of Inspector General (OIG), elucidate the need for improvements in nursing homes’ comprehensive emergency preparedness and response. The Center for Medicare and Medicaid Services (CMS) has developed an emergency preparedness checklist as a guidance tool and proposed emergency preparedness regulations. The purpose of this study was to evaluate the progress made in nursing home preparedness by determining the level of completion of the 70 tasks noted on the checklist. The study objectives were to: (1) determine the preparedness levels of nursing homes in North and South Carolina (USA), and (2) compare these findings with the 2012 OIG’s report on nursing home preparedness to identify current gaps.
A survey developed from the checklist of items was emailed to 418 North Carolina and 193 South Carolina nursing home administrators during 2014. One hundred seventeen were returned/“bounced back” as not received. Follow-up emails and phone calls were made to encourage participation. Sixty-three completed surveys and 32 partial surveys were received. Responses were compared to data obtained in a 2010 study to determine progress.
Progress had been made in many of the overall planning and sheltering-in-place tasks, such as having contact information of local emergency managers as well as specifications for availability of potable water. Yet, gaps still persisted, especially in evacuation standards, interfacing with emergency management officials, establishing back-up evacuation sites and evacuation routes, identification of resident care items, and obtaining copies of state and local emergency planning regulations.
Nursing homes have made progress in preparedness tasks, however, gaps persist. Compliance may prove challenging for some nursing homes, but closer integration with emergency management officials certainly is a step in the right direction. Further research that guides evacuation or shelter-in-place decision making is needed in light of persistent challenges in completing these tasks.
LaneSJ, McGradyE. Nursing Home Self-assessment of Implementation of Emergency Preparedness Standards. Prehosp Disaster Med. 2016;31(4):422–431.
Objectives: Colloquial evidence (CE) has been described as the informal evidence that helps provide context to other forms of evidence in guidance development. Despite challenges around quality, and the potential biases, the use of CE is becoming increasingly important in assessments where scientific literature is sparse and to also capture the experience of all stakeholders in discussions, including that of experts and patients. We aimed to ascertain how CE was being used at the National Institute for Health and Care Excellence (NICE).
Methods: Relevant data corresponding to the use of CE was extracted from all NICE technical and process manuals by two reviewers and quality assured and analyzed by a third reviewer. This was considered in light of the results of a focused literature review and a combined checklist for quality assessment was developed.
Results: At NICE, CE is utilised across all guidance producing programmes and at all stages of development. CE could range from information from experts and patient/carers, grey literature (including evidence from websites and policy reports) and testimony from stakeholders through consultation. Six tools for critical appraisal of CE were available from the literature and a combined best practice checklist has been proposed.
Conclusions: As decisions often need to be made in areas where there is a lack of published scientific evidence, CE is employed. Therefore to ensure its appropriateness the development of a validated CE data quality check-list to assist decision makers is essential and further research in this area is a priority.
The decapod Crustacea from Ascension Island are reported upon on the basis of major expeditions undertaken during 2008 and 2012, including several minor additional collections made in other years. Two species, Gnathophyllum americanum and Corallianassa longiventris are new records for the island bringing the total known marine decapod fauna to 75 species, of which 11 are currently endemic to Ascension Island.
This paper provides a comprehensive checklist of the marine benthic macroalgal flora of Ascension Island (tropical South Atlantic Ocean), based on both new collections and previous literature. 82 marine macroalgae were identified from our work, including 18 green algae (Ulvophyceae), 15 brown algae (Phaeophyceae) and 49 red algae (Rhodophyta). Among our collections, 38 species and infraspecific taxa are reported for the first time from Ascension Island, including seven green, three brown and 28 red macroalgae, raising the total number of seaweeds recorded in Ascension so far to 112 taxa in species and infraspecific level. No seagrasses have been recorded at Ascension Island.
An updated checklist of manta and devil rays (family Mobulidae) occurring in waters of the Azores archipelago is given based on new data from underwater images and on the re-evaluation of previous citations for the region. There are, at least, three species of mobulids occurring in the region, possibly four: giant manta Manta birostris; Chilean devil ray Mobula tarapacana; and one or both of the giant devil ray Mobula mobular/spinetail devil ray Mobula japanica species complex. These findings have direct implications for the known ranges of all these species and for the conservation of their North Atlantic populations.
This paper presents an inventory of the species of molluscs collected on the continental shelf and upper slopes (70–500 m depth) on the Pacific side of Colombia. In 2002, 39 trawl samples were taken on soft bottoms by the RV ARC ‘Malpelo’. Thirty-eight species of bivalves were collected, comprising living animals and dead collected shells. Information on abundance, Colombian distribution and depth range is provided. Thirty-four species represent the first records for the Colombian Pacific, significantly increasing the number of shelf and slope species known in the region.
Sabellidae is the second most diverse polychaete family in the Adriatic Sea, after Syllidae. Herein we report the updated list of the Sabellidae and Fabriciidae families in the Adriatic Sea deriving both from literature data and presently conducted researches in the northern Adriatic. During these researches polychaetes were sampled from three offshore soft-bottom and three coastal rocky shore stations. Among the analysed material three Sabellidae species are new records for the Adriatic fauna, while four Sabellidae and one Fabriciidae species were recorded for the first time in the northern part. Two new species were found and described: Amphicorina rovignensis spec. nov. and Megalomma pseudogesae spec. nov. These findings increase the number of Sabellidae taxa recorded in the northern Adriatic from 29 to 38. Our results point out the lack of the recent taxonomic studies in the area, but might also indicate the widening of the species areal. Taking into consideration that studies on only six stations raised the number of known sabellid taxa from the area by 31%, our results support the need for the regular taxonomic updating of the polychaete fauna in the northern Adriatic.
The World Health Organization ‘Surgical Safety Checklist’ has been adopted by UK surgical units following National Patient Safety Agency guidance. Our aim was to assess compliance with our local version of this Checklist.
Otolaryngology trainee doctors prospectively assessed compliance with the local Checklist over a six-week period. A staff educational intervention was implemented and the audit was repeated 12 months later.
A total of 72 cases were assessed. The initial audit found that: 44 per cent of procedures were undocumented at ‘Sign in’; ‘Time out’ was inappropriately interrupted in 39 per cent of cases; the procedure started before Checklist completion in 33 per cent of cases; and the ‘Sign out’ was not read out in 94 per cent of cases and was not fully documented in 42 per cent of cases. Following education, re-audit indicated that overall compliance had improved from 63.7 per cent (±8.9 per cent standard error of the mean) to 90.4 per cent (±2.7 per cent standard error of the mean).
Our completed audit cycle demonstrated a significant improvement in Checklist compliance following educational intervention. We discuss barriers to compliance, as well as strategies for quality improvement, and we call for other surgeons to similarly publish their Checklist experience and assess its impact on surgical outcomes.
A checklist of published records of coronuloid barnacles (Cirripedia: Thoracica: Coronuloidea) attached to marine vertebrates is presented, with 44 species (including 15 fossil species) belonging to 14 genera (including 3 fossil genera) and 3 families recorded. Also included is information on their geographical distribution and the hosts with which they occur.
The Brazilian Northeastern coast includes diverse ecosystems, particularly mangroves, coral and sandstone reefs. Although apparently high, the biodiversity of marine invertebrates from the State of Alagoas is still poorly documented. This study presents 28 new records of opisthobranch molluscs from Alagoas, 11 of which are also new records from the Brazilian Northeastern coast. In addition to comprising an important addition to knowledge about Alagoas reef biodiversity, the new records are useful data for future investigations such as biogeographical studies. Therefore, a list of all opisthobranch species known to date from Alagoas, as well as colour photographs of 32 species is provided.