BACKGROUND:Foundation doctors often feel underprepared to cope with uncertainty, particularly in an acute setting. Simulation is an established method for teaching about the management of acutely unwell patients, yet simulated cases are often simplified to ensure that a given learning outcome is reached. This approach may present learners with challenges in clinical practice when more complex nuanced cases are encountered. We explored final-year medical students' perceptions of clinical uncertainty when facing an 'authentically' complex simulated patient.METHODS:We adapted a simulation scenario in an attempt to replicate clinical uncertainty. The simulated patient had a confused history, only mildly deranged physiology, no current clear diagnosis and no diagnostic investigations yet available. Students engaged in debriefs facilitated by the researchers, which employed advocacy and enquiry to help students to reflect on their simulations (the 'Diamond Approach'). These were transcribed, coded and analysed thematically.RESULTS:Students found the 'uncertainty' simulation more challenging than a 'typical' simulation. Students found it disheartening when the patient had no clear diagnosis and expected 'an answer'. Students described task fixation and/or inaction in the face of uncertainty, struggled to identify appropriate times to seek senior support and were confused about their role in managing complex cases.DISCUSSION:We propose that this session prompted valuable discussion amongst students about how to react to clinical uncertainty. Students generally perceived the simulation as being useful. Affording space for reflection and allowing students to consider strategies for coping with uncertainty may help them when managing complex cases as Foundation doctors.

Emergencies occur infrequently in primary care, and when they do can be daunting for those involved, particularly those who have a non-clinical background. Previous work has described the importance of extending basic life support training to include management of emergencies using the available team and facilities.1 Simulating waiting room emergencies has been demonstrated to increase confidence in the clinical team in managing these challenging situations,2 but we are not aware of publications supporting the use of simulation in the wider primary care team including non-clinical colleagues. Northumbria Primary Care (NPC) is an innovative collaboration between six General Practices and Northumbria Healthcare NHS Foundation Trust (NHFT), serving a population of over 40 000 patients. With the aim of increasing confidence in management of potential encountered medical emergencies in primary care, a shared simulation programme for the clinical and non-clinical multidisciplinary team was developed at the Dinwoodie Assessment and Simulation Hub within NHFT. This state-of-the-art facility consists of multiple simulation areas, including consultation rooms and a waiting area, and several low-fidelity and high-fidelity manikins, which were used to recreate potential primary care emergencies. A programme was developed based on emergencies that may be encountered in a primary care environment, including meningococcal sepsis in a baby, myocardial infarction (MI) leading to cardiac arrest and anaphylaxis to a vaccine (table 1). View this table: Table 1 Scenarios used …

British Journal of Hospital MedicineVol. 79, No. 12 Core Training For DoctorsUpdate on the management of acute strokeRevin Thomas, Mark SudlowRevin ThomasSearch for more papers by this author, Mark SudlowSearch for more papers by this authorRevin Thomas; Mark SudlowPublished Online:8 Dec 2018https://doi.org/10.12968/hmed.2018.79.12.C178AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Alexander P, Heels-Ansdell D, Siemieniuk R et al.. Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis. BMJ Open. 2016 Nov;6(11):e014390. https://doi.org/10.1136/bmjopen-2016-014390 Crossref, Medline, Google ScholarAnderson CS, Heeley E, Huang Y et al.; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013 Jun 20;368(25):2355–2365. https://doi.org/10.1056/NEJMoa1214609 Crossref, Medline, Google ScholarBowen A, James M, Young G et al.. 2016. National clinical guideline for stroke-Fifth Edition 2016. (accessed 1 November 2018) https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx Google ScholarBrott T, Broderick J, Kothari R et al.. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997 Jan;28(1):1–5. https://doi.org/10.1161/01.STR.28.1.1 Crossref, Medline, Google ScholarBrunström M, Carlberg B. Thrombolysis in acute stroke. Lancet. 2015 Apr;385(9976):1394–1395. https://doi.org/10.1016/S0140-6736(15)60715-2 Crossref, Medline, Google ScholarCampbell BCV, Mitchell PJ, Churilov L et al.; EXTEND-IA TNK Investigators. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med. 2018 Apr 26;378(17):1573–1582. https://doi.org/10.1056/NEJMoa1716405 Crossref, Medline, Google ScholarDastur CK, Yu W. Current management of spontaneous intracerebral haemorrhage. BMJ. 2017 Mar;2(1):21–29. https://doi.org/10.1136/svn-2016-000047 Google ScholarEmberson J, Lees KR, Lyden P et al.; Stroke Thrombolysis Trialists' Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014 Nov;384(9958):1929–1935. https://doi.org/10.1016/S0140-6736(14)60584-5 Crossref, Medline, Google ScholarEvans MRB, White P, Cowley P, Werring DJ. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Pract Neurol. 2017 Aug;17(4):252–265. https://doi.org/10.1136/practneurol-2017-001685 Crossref, Medline, Google ScholarFugate JE, Rabinstein AA. Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. The Neurohospitalist. 2015;5(3):110–121. https://doi.org/10.1177/1941874415578532 Crossref, Medline, Google ScholarGoyal M, Menon BK, van Zwam WH et al.; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr;387(10029):1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-X Crossref, Medline, Google ScholarGreenberg SM, Vonsattel JPG. Diagnosis of cerebral amyloid angiopathy. Sensitivity and specificity of cortical biopsy. Stroke. 1997 Jul;28(7):1418–1422. https://doi.org/10.1161/01.STR.28.7.1418 Crossref, Medline, Google ScholarGrunwald IQ, Wakhloo AK, Walter S et al.. Endovascular stroke treatment today. AJNR Am J Neuroradiol. 2011 Feb;32(2):238–243. https://doi.org/10.3174/ajnr.A2346 Crossref, Medline, Google ScholarJauch EC, Saver JL, Adams HP Jr et al.. Guidelines for early management of patients with acute ischaemic stroke. Stroke. 2013 Mar;44(3):870–947. https://doi.org/10.1161/STR.0b013e318284056a Crossref, Medline, Google ScholarKumar G, Shahripour RB, Alexandrov AV. Recanalization of acute basilar artery occlusion improves outcomes: a meta-analysis. J Neurointerv Surg. 2015 Dec;7(12):868–874. https://doi.org/10.1136/neurintsurg-2014-011418 Crossref, Medline, Google ScholarMendelow A, Gregson B, Fernandes H et al.; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005 Jan 29;365(9457):387–397. https://doi.org/10.1016/S0140-6736(05)70233-6 Crossref, Medline, Google ScholarNogueira RG, Jadhav AP, Haussen DC et al.; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018 Jan 04;378(1):11–21. https://doi.org/10.1056/NEJMoa1706442 Crossref, Medline, Google ScholarPaciaroni M, Agnelli G, Falocci N et al.. Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation. Stroke. 2015 Aug;46(8):2175–2182. https://doi.org/10.1161/STROKEAHA.115.008891 Crossref, Medline, Google ScholarRimmele DL, Thomalla G. Wake-up stroke: clinical characteristics, imaging findings, and treatment option – an update. Front Neurol. 2014 5:35. https://doi.org/10.3389/fneur.2014.00035 Crossref, Medline, Google ScholarSprigg N, Flaherty K, Appleton JP, et al.; TICH-2 Investigators. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018 May;391(10135):2107–2115. https://doi.org/10.1016/S0140-6736(18)31033-X Crossref, Medline, Google Scholarteffel J, Verhamme P, Potpara TS et al.; ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018 Apr 21;39(16):1330–1393. https://doi.org/10.1093/eurheartj/ehy136 Crossref, Medline, Google ScholarStroke Association. 2018. State of the Nation: stroke statistics. (accessed 1 November 2018) https://www.stroke.org.uk/system/files/sotn_2018.pdf Google ScholarThomalla G, Simonsen CZ, Boutitie F et al.; WAKE-UP Investigators. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018 Aug 16;379(7):611–622. https://doi.org/10.1056/NEJMoa1804355 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 December 2018Volume 79Issue 12ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 8 December 2018 Published in print 2 December 2018 Information© MA Healthcare LimitedPDF download

Background Northumbria Primary Care (NPC) is an innovative collaboration between seven General Practices and Northumbria Healthcare NHS Foundation Trust (NHFT), serving a population of 45 000 patients. With the aim of increasing confidence in management of infrequently occurring medical emergencies in primary care, a shared simulation programme for the multidisciplinary team was developed at the Dinwoodie Assessment and Simulation Hub (DASH) within NHFT. Summary of education programme A programme was developed based on commonly occurring waiting room emergencies including anaphylaxis to a vaccine, meningococcal sepsis in a baby, and myocardial infarction leading to a cardiac arrest. Each attendee undertook a confidence-rating questionnaire prior to and following simulation. The stations were designed to be environmentally and situationally realistic to the typical primary care environment. Available equipment mirrored that which is available in primary care and required the multi-disciplinary team to work together to manage the patient’s condition in real time until paramedics arrived. Summary of results A total of 31 primary care staff attended this session including receptionists (n=5), practice nurses (n=9), managerial staff (n=5), general practitioners (n=7) and nurse practitioners (n=5). Pre- and post- simulation responses were compared using Student’s T test. Results were analysed in two categories: ‘All staff’ and ‘Clinical staff only’. Within ‘All staff’ there was a statistically significant change in 3 domains: confidence in managing emergencies in the GP practice (p Qualitative data gathered through free text feedback from participants emphasized the value of interactivity, team-working and realism in support of the learning process. Discussion, conclusions and recommendations The session was well received by staff with reassuring results showing improved confidence in all areas considered. Two outcomes of this programme were particularly beneficial. Firstly, non-clinical staff recognised the crucial role they play in the management of emergencies in the GP setting. Secondly, this learning experience demonstrated the need to standardise the availability of medical equipment within the NPC. We recommend that other primary care organisations consider the use of simulation in training their staff to manage emergencies.

British Journal of Hospital MedicineVol. 79, No. 10 Core TrainingLearning opportunities in simulation for traineesNony G Mordi, Mark Sudlow, Richard K ThomsonNony G MordiSearch for more papers by this author, Mark SudlowSearch for more papers by this author, Richard K ThomsonSearch for more papers by this authorNony G Mordi; Mark Sudlow; Richard K ThomsonPublished Online:5 Oct 2018https://doi.org/10.12968/hmed.2018.79.10.C154AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Brown JS, Collins A, Duguid P. Situated Cognition and the Culture of Learning. Am Educ Res J. 1989;18(1):32–42. https://doi.org/https://doi.org/10.3102/0013189X018001032 Google ScholarCook DA, Brydges R, Hamstra SJ et al.. Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simul Healthc. 2012 Oct;7(5):308–320. https://doi.org/https://doi.org/10.1097/SIH.0b013e3182614f95 Crossref, Medline, Google ScholarEraut M. 1994. Developing Professional Knowledge and Competence. London: Routledge Falmer Press. Google ScholarJoint Royal College of Physicians Training Board. 2017. Curriculum for Internal Medicine Stage 1 Training. (accessed 4 July 2018) https://www.jrcptb.org.uk/sites/default/files/Internal%20Medicine%20stage%201%20curriculum%20FINAL%20221217.pdf. Google ScholarKnowles MS. 2014. The adult learner. 8th edn. Milton Park, Abingdon, Oxon; New York, NY: Routledge. Crossref, Google ScholarKolb DA. 1984. Experiential Learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall. Google ScholarLave J, Wenger E. 1991. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press. Crossref, Google ScholarSchön DA. 1995. The reflective practitioner: how professionals think in action. Aldershot: Arena. Google Scholar FiguresReferencesRelatedDetails 2 October 2018Volume 79Issue 10ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 5 October 2018 Published in print 2 October 2018 Information© MA Healthcare LimitedPDF download

OBJECTIVE:To describe the process, efficacy and safety of intravenous thrombolysis for acute ischaemic stroke in an emergency department (ED) setting with remote specialist support through structured telephone consultation.DESIGN:Retrospective case series.SETTING:Three EDs within a single stroke service in northern England.PARTICIPANTS:Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010.OUTCOME MEASURES:Combined death and dependency at 90 days (0-2 on the modified Rankin Scale for a good outcome vs 3-6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage.RESULTS:192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone).CONCLUSION:In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

The guidelines from the National Institute for Health and Clinical Excellence (NICE) are a thorough and helpful summary of evidence in acute management of stroke and transient ischaemic attack.1 They are a welcome contribution to increasing understanding of stroke as a major cause of death and disability and to improving the structure and funding of services to tackle the problem. Controversy is likely to centre on: NICE guidance carries considerable influence over funding for services. It …

BACKGROUND AND PURPOSE:The assessment of any health care intervention should consider both risks and benefits and take patients' preferences about these into account. The study reported in this paper aimed to elicit patient valuations of health states relevant to assessment of the prevention of stroke by warfarin anticoagulation therapy for patients with atrial fibrillation.METHODS:A sample of patients over the age of 60 years with atrial fibrillation from three family practices in North-East England was interviewed. Their health state values were elicited using the standard gamble method for general practitioner (GP)-managed warfarin treatment, hospital-managed warfarin treatment, major bleed, mild stroke and severe stroke.RESULTS:Of 180 patients, 69 (38%) agreed to participate, of whom 57 (83%) completed interviews. Median (mean) utility values were for GP-managed warfarin treatment 0.986 (0.948), hospital-managed warfarin treatment 0.984 (0.941), major bleed 0.880 (0.841), mild stroke 0.675 (0.641) and severe stroke 0 (0.189). There was wide variation in values between patients and the distributions were highly skewed.CONCLUSIONS:The results are of value in applying decision analysis to groups of patients. They should be used with caution in reaching decisions about appropriate treatment for individual patients, but may provide a starting point for necessary further exploration of those patients' individual preferences.

Objective: To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment.Design: Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample.Subjects: 15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied.Main outcome measures: Evaluation of guidelines and the methods of dissemination, implementation, review and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines.Results: There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, kappa = 0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used, 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus, Methods to support effective dissemination, implementation, and evaluation were limited.Conclusion: The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making, There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated.

EDITOR—Roderick and Cox's work shows that it is feasible to identify patients with atrial fibrillation in clinical practice, which confirms the suggestions from our data. They say, however, that only a small proportion of those detected would be eligible for and would accept warfarin treatment. Their eligibility estimates are considerably lower than our own,1 and we suspect that this difference partly reflects the effect of using different eligibility criteria, which we have noted previously.2 Patients' understanding of the risks and benefits …

BACKGROUND:Anticoagulants are effective in preventing stroke in those with atrial fibrillation, but most patients remain untreated.AIM:To investigate the prevalence of disability, cognitive impairment, and problems with compliance in a representative sample of the elderly with atrial fibrillation, and to determine whether they would want treatment and how they would like services to be arranged.METHOD:In a survey of a random sample of 4843 elderly subjects, those with atrial fibrillation were identified using electrocardiograms. Views on treatment were obtained using a structured interview. Disability was assessed using the Office of Population Censuses and Surveys Disability Scale and cognitive status using the Mini Mental State Examination. General practitioners were asked, via questionnaire, for their views on each subject's compliance.RESULTS:Two hundred and seven elderly people with atrial fibrillation were identified. Almost all subjects expressed a willingness to undertake treatment to prevent stroke and preferred blood testing performed outside of hospital. Disability (82.7%), cognitive impairment (25.7%), and problems with compliance (25.0%) were common, but the prevalence of these difficulties was not substantially different from the general elderly population, and in many cases they could be overcome (e.g. only 10% of subjects had problems with compliance and no-one who could help them to comply).CONCLUSIONS:Most elderly people with atrial fibrillation would accept treatment to prevent stroke. Disability, cognitive impairment, and problems with compliance may make it difficult to treat this patient group. An increase in the use of anticoagulants should be accompanied by the development of services appropriate to this frail population.

BackgroundAnticoagulants are effective in the prevention of stroke in atrial fibrillation and flutter (AF). We aimed to find out the prevalence of AF in the UK and to estimate the proportion of patients with AF who might benefit from anticoagulation.MethodsWe screened with electrocardiography a random sample of 4843 people from the community aged 65 years and older for AF. Participants with AF had further investigations to identify risk factors for stroke and contraindications to anticoagulants. We used three sets of criteria to assess risk and elibility for anticoagulation.Findings228 (4·7%) participants had AF. According to analyses derived from risk stratifications based on the Stroke Prevention in Atrial Fibrillation (SPAF) study 61% of these patients would have benefited from anticoagulation, 49% according to pooled analysis of trial results, and 41% according to the inclusion criteria for the SPAF 3 study. Anticoagulants were used by 1114 (23%) of all patients and were least used among elderly women, who may be the most likely to benefit. Echocardiography would be useful to assess the need for anticoagulation only in patients younger than 75 years with no contraindications to treatment and no clinical risk factors for stroke.Interpretation:Anticoagulants seem to be underused and misdirected in treatment of AF, according to various criteria. Efforts to promote and support wider and more appropriate use of anticoagulants would seem to be justified, and should decrease the incidence of stroke amongst elderly patients.

Introduction: we report the results of a questionnaire survey into the effect of patients' age and of medico-social factors on hospital consultants' and general practitioners' reported use of warfarin anticoagulation to treat patients with non-valvular atrial fibrillation (NVAF).Methods: half of the general practitioners (n = 824) and all consultants in specialities likely to be involved in treating such patients (n = 207) in the former Northern Region were sent questionnaires asking for their views on the treatment of patients with atrial fibrillation using anticoagulants.Results: the response rate was 56% (459/824) for general practitioners and 76% (163/207) for consultants. A patient's age was of significance to many clinicians. Forty-six percent of consultants and 43% of general practitioners felt that no patient above the age of 84 years should be treated. Medico-social factors also had an important effect on whether clinicians felt patients ought to be treated with anticoagulants. ii patient's quality of life was the most important medico-social factor, with handicap and place of residence having much smaller effects.Conclusions: age and medico-social factors have an important effect on clinicians use of anticoagulants in NVAF and reluctance to treat elderly subjects is likely to explain much of the apparent under-use of this treatment.