emergency and critical care

The operating room is a complex environment and knowledge and improvement of situation awareness can increase the performance in this domain , leading to better patient outcomes

Diana Zamudio Penko Situation awareness ( SA ) can be defined as ‘ the three levels : perception ( level I ), comprehension PhD perception of elements of the environment within a ( level II ) and projection ( level III ). 2 The first level volume of time and space , the comprehension of comprises the identification of the key elements Daniel Arnal Velasco their meaning and the projection of their status in that assess the ongoing situation ; in the OR , the MD the near future ’. 1 In simple terms , it is knowing what perception of the patient ’ s state is provided by

Department of is going on around you by extracting information the patient ( for example , through verbal Anaesthesia and Critical from the environment and then integrating that communication or appearance ), monitors , Care , The Alcorcon information to create a notion of the situation and patient charts , communication within the team , Foundation University anticipate future events . Therefore , SA is important anaesthesia machines , respirators , and the Hospital , Spain for effective decision-making , performance and surgical field . 3 The second level comprises the teamwork . 2 Understanding the meaning of SA and comprehension and integration of multiple pieces how to improve it in a complex work environment , of information and the determination of their such as the operating room ( OR ), is essential for relevance to the situation to form a coherent patient safety . mental picture . Finally , the highest level entails the ability to forecast the future development

Individual SA of the patient ’ s state and determine the best way According to the definition , SA is subdivided into to proceed .

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Generating SA and maintaining it at a high level can reduce the probability of patient injury , because the healthcare provider can respond more quickly to an emerging problem and it can allow proactive management of human and material resources during a crisis . 3 , 4

Team SA ( TSA ) TSA is ‘ the degree to which every team member possesses the SA required for his or her responsibilities ’. 5 Teamwork is characteristic to the OR , where an interdisciplinary team of individuals is engaged in the common project of ‘ patient treatment ’. 2 In a highly effective team approach , decisions should be based on information derived from all team members . This allows for an efficient plan of action ; otherwise , a breakdown of performance would occur when team members are not able to anticipate what help is needed by the others . 6 , 7 However , not all members of the team should be aware of the same thing at the same time and nor does all Patient the information need to be shared with every individual involved . Rather , it is necessary that simulation each person be aware of circumstances that are and debriefing relevant to their respective roles and responsibilities and to create a system where the right techniques

information reaches the right person at the right can enhance time , and this involves team coordination . 3 , 8 , 9 individual Team processes and behaviours that can improve TSA include closed-loop communication , group and team prioritisation , contingency planning and actively performance sharing SA about the patient , planned procedure and potential critical events . 6 , 10

Distributed SA ( DSA ) DSA is a concept that recognises the contribution of technical systems . The entire system including human and non-human subsystems , and the interactions between them , is considered to develop SA . Hence , cognitive processes occur at a system level rather than an individual level . 11 The DSA approach allows a better overall understanding of the operating theatre interactions where a group of people ( anaesthetist , surgeon , nurse , patient ) interact with external objects ( for example , equipment , monitors , charts ) in a dynamic explicit and implicit way , and it is only when the interactions between all the individual components are compiled that a coherent picture emerges . 12

SA errors There can be failures at each level of SA , leading to low performance . 13 In the first level ( perception ), relevant information may not be correctly detected or if too much data are perceived at a time , we become overloaded , focusing on just part of the information (‘ tunnel vision ’) and missing parts that matter . It is widely recognised that more data does not equal more information . Today ’ s systems ’ problems are not the lack of information but finding what is needed when it is needed ; therefore , a critical part of SA level I is learning the cues to watch for ( proper distribution of attention ). 2 An outside view sometimes helps to reveal what we cannot see or give additional information that might help highlight that something has been missed . In the second level ( comprehension ), the situation might not be understood correctly , despite all the relevant information being detected . This is due to an inappropriate or absent mental model ; with time pressure and high cognitive workload we may get drawn into bias by selecting a mental model that we prefer based on our experience . 3 In the third level ( projection ), the future is not correctly anticipated , although the situation is understood . As errors on SA levels II and III necessarily involve long-term memory content for the processing of basic data , this may be due to a lack of training and experience . 3 , 4

Schulz et al reviewed 200 reports from the German anaesthesia critical incident reporting system and found that SA errors were involved in 81.5 % of the cases ; in addition , more errors on the levels of perception ( 38 %) and comprehension ( 31.5 %) were identified . 4 With a similar methodology , we reviewed 100 incidents reported to the Spanish anaesthesia and intensive care incident reporting system ( SENSAR ; Safety Reporting System in Anaesthesia and Rescuscitation ) and found comparable results . SA errors were identified in 65 % of the cases and the majority were on the levels of perception ( 51 %) and comprehension ( 8 %).

The role of expertise and training Important cognitive mechanisms for the development of SA as well as knowledge bases and task skills are gained with experience . Many studies have shown that experienced subjects develop SA in a shorter time and with less effort than novices . These differences may be attributable to several factors that determine the achievement of good SA , such as correct distribution of attention , prioritising information , dynamic switching between goal-driven processing and data-driven processing , automaticity , which can provide good performance with very low level of attention demand , learned skills , pattern-matching with prototypical situations , and development of mental models that help in the integration of information and projection of future states . 2

Patient simulation and related debriefing techniques can enhance individual and team performance by focusing on skills and behaviours related to good SA , such as prioritisation , and coordination and communication that are essential for the effective treatment of critical incidents . 3 – 10

Assessment of SA Several direct and indirect methods have been developed to assess SA and can be summarised as query- , rating- and performance-based techniques . In query techniques , the subjects are asked directly about their perception of certain aspects of the situation . The Situation Awareness Global Assessment Technique ( SAGAT ) has been validated as an objective and direct method to evaluate different levels of SA during a simulated scenario , and consists of stopping at random points to ask the participants to complete a questionnaire regarding what is occurring at that specific time . This technique can be perceived as intrusive due to freezes in a simulation but many studies have shown it does not affect performance . 3 , 14 In rating techniques , the subjects or observers are asked to rate SA directly along a few dimensions ( SA Rating Technique ) or indirectly through

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Fiona Coath MBChB MRCP Faidra Laskou MBBS MRCP Bhaskar Dasgupta MBBS MD FRCP Rheumatology Department , Southend University Hospital , UK rheumatology and musculoskeletal

Giant cell arteritis remains a clinical emergency , which can lead to irreversible sight loss . New ‘ Fast Track Pathways ’, diagnostics and treatments are improving the standard of care and outcomes

Giant cell arteritis ( GCA ) remains a rheumatology Evidence from current services of this type has emergency . Critical ischaemia of the temporal shown significant reduction in morbidity . For arteries can lead to anterior ischaemic optic example , at Southend Hospital , the incidence of neuropathy and irreversible sight loss . This is sight loss has been reduced from 37 % to 9 %. 1 Similar a significant cause of morbidity among these results have been replicated in other centres . patients , not least due to subsequent loss of independence and depression . If the symptoms Presentation and classification of GCA are recognised promptly and treated In clinical practice , it is clear there are subgroups appropriately , then the incidence of this within GCA . Recognition of these subgroups is catastrophic event could be reduced . There is important to determine additional investigations increasing evidence regarding the efficacy and and management . It is no longer sufficient to label positive outcomes of ‘ Fast Track Pathways ’. This is this simply as a ‘ headache ’ disease . Some patients a process whereby patients are offered rapid access may have isolated cranial GCA , presenting with to specialist clinical assessment , with the goal of headaches and ischaemic symptoms such as jaw providing a secure diagnosis in as many patients or tongue claudication and uniocular visual as possible . Glucocorticoid therapy can then be disturbance . However many are found to have continued or importantly stopped if inappropriate . more extensive large vessel involvement , termed large vessel giant cell arteritis ( LV-GCA ). With the advent of improved imaging techniques , the estimated prevalence of this group is greater than previously recognised ; 12 – 37 % depending on the modality used . 2 A clinical suspicion of LV-GCA can be prompted by patients presenting with more predominant constitutional symptoms , including unintentional weight loss , and night sweats and fevers , or in patients who have already developed symptoms of vascular compromise such as limb claudication secondary to stenotic disease . In reality , there is a significant degree of symptom overlap between cranial GCA , LV-GCA and polymyalgia rheumatica ( PMR ), and it may be more accurate to think of them as a spectrum of disease rather than discrete conditions . 3

Another clinically significant method of classification is ‘ response to treatment ’. Figure 1 divides patients into four groups : remission ; relapse ; refractory disease ; and adverse effects or intolerance . 4 It is these latter three groups , outlined in the red box , for which there is currently an unmet need for effective disease modifying and glucocorticoid-sparing treatment . Observational cohort studies report flares in 34 – 62 % of GCA patients , with only 15 – 20 % achieving sustained remission with GC alone . 3

Investigations Advances in vascular ultrasound ( US ) have transformed the management of GCA in recent years . EULAR now recommends it as the first-line investigation in acute GCA if there is appropriate equipment and expertise available . 5 Vascular US forms a significant part of ‘ Fast Track Pathway ’ clinics , as it potentially offers a ‘ one-stop shop ’

186 HHE 2018 | hospitalhealthcare . com for investigation and treatment . Vascular US can detect characteristic sonographic findings , which allows for a diagnosis of GCA without the need to progress to temporal artery biopsy ( TAB ). Specifically the ‘ Halo ’ sign is indicative of an acutely inflamed vessel wall . This is seen as a homogenous , hypo-echoic wall thickening , which should be appreciable in both the longitudinal and transverse planes , and does not disappear on compression with the ultrasound probe . 6 Vascular US has multiple advantages . Visualising the entire length of the temporal arteries bilaterally can give increased sensitivity compared with TAB , as it minimises the problem of skip lesions . Furthermore , it is widely available and well tolerated by patients . There is also reasonable evidence to suggest that additional ultrasound of the axillary and subclavian arteries assessing intima-medial complex thickness would be a useful screening tool for LV-GCA . 7 At the axillary artery , an intima-medial complex > 1.0mm is considered abnormal . 8 US changes in acute GCA typically start to diminish after initiation of glucocorticoid treatment ; however observed changes at the axillary arteries can persist for months . 9 The role of vascular US in monitoring and follow-up is yet to be determined . Further studies on the persistence of sonographic findings and effect of glucocorticoids are required .

Cross-sectional imaging may be useful for assessing disease extent in LV-GCA , as well as monitoring vascular complications . However there is currently no consensus on the best modality . This is a decision that is influenced by practical constraints as well as clinical considerations .

figure 1

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18 F-FDG PET-CT , MRI and CT have all been utilised .

High-resolution MRI has comparable sensitivity and specificity to TAB in detecting GCA , as well as identifying cranial vessel involvement other than the temporal artery . 10 However these facilities are not widely available . 18 F-FDG PET-CT attributes the FDG signal to a precise anatomic location , and is therefore useful in establishing disease extent and severity . It is particularly useful in situations where there is ongoing concern of LV-GCA despite prior negative tests , or to exclude differential diagnoses such as infection or malignancy . Athough it should be interpreted with caution because FDG signal is attenuated by glucocorticoid use and increased with vascular re-modelling and atherosclerosis . 11 This could lead to under- and over-diagnosis of active inflammation , respectively .

Treatment options in GCA Initial treatment of new onset GCA remains high-dose glucocorticoids , at a dose of either 1mg / kg , or a dose equivalent to 40mg prednisolone for uncomplicated disease and 60mg prednisolone for those with ischaemic and sight-threatening presentations . 3 Methylprednisolone pulses may be required initially for those with severe visual complications . 3 Yet the traditional view that this will provide a complete response in all patients is not borne out in clinical practice . From the GiACTA trial baseline data , 17 % of the overall cohort was classified as having disease refractory to glucocorticoids . 12 In PMR , a related condition , some groups of patients also respond less well to glucocorticoids , with only 45 – 55 % having a complete response , 25 – 27 % with a partial

Treatment algorithm for LVV ( target refractory group highlighted in the red box )

Remission

GC tapering with monitoring

GCA , TAK

High dose GC

Relapse

Outcome

Conventional immunosuppressants

Refractory disease

Adjunctive therapy

Biologics

Isolated PMR

Low dose GC

Adverse effects intolerance

Adapted from reference 4

Marvin Lim Chang Jui MBBCh BAO BA MRCPUK

Anne-Marie Baird BSc ( Hons ) PG Dip ( Statistics ) PhD

Stephen Finn MB BAO BCh FDS PhD FRCPath FFPATH Trinity College Dublin , School of Medicine , Dublin , Ireland pathology and diagnostics

Next generation sequencing is practical and reliable to use on tissue specimens and potentially on liquid biopsies , which potentially will further revolutionise the diagnostic landscape of lung cancer

Lung cancer continues to be the major cause compared with standard platinum doublet of cancer-related death globally . 1 More than chemotherapy laid the foundation for targeted two-thirds of lung cancer patients present with therapy as the first-line treatment for ALK-positive advanced disease , 2 , 3 which excludes the option NSCLC . 21 Second-generation ALK inhibitors such of potentially curative treatments . Another as ceritinib and alectinib have not only been important reason accounting for the high shown to be effective in the first-line treatment mortality rate is excessive mutational load in setting but are also effective in patients who patients with smoking history , a phenomenon develop crizotinib resistance . 22 – 24 In 2013 , central to the pathogenesis of lung cancer

FDA granted the approval of crizotinib for progression , compared with patients with treatment of metastatic ALK-positive NSCLC age-related cancers . 4 Five-year survival of all with FISH as companion diagnostic based patients with lung cancer is only 18 %. 5 Recently , on efficacy and safety data of Phase II and III

21 , 25 great advances have been made in terms of studies . screening , minimally invasive techniques for diagnosis and new treatments . 6 – 9

Benchmark technique

The recognition of genetic driver mutations FISH is currently the benchmark technique for in NSCLC has paved the way for the development diagnosis of ALK rearrangements ; however , of targeted therapies , which often provides meticulous preparation and skillful interpretation outstanding responses in patients harbouring according to guidelines is necessary for achieving specific genetic mutations . 10 , 11 Approximately accurate results . Thus , it is expensive , labourintensive and requires a high level of pathology two thirds of lung adenocarcinomas contain actionable driver mutations , which can be expertise . 26 – 29 On rare occasions , FISH may detected using comprehensive molecular produce equivocal results because in 5 – 10 % of profiling . 11 – 13 ALK gene rearrangement in NSCLC NSCLC , the rate of rearrangement of positive cells was first discovered by Japanese researchers falls within the range of 10 – 20 %; however , the a decade ago . 14 This gene rearrangement , which current accepted cut-off for positive cells is 15 % or precipitates expression of oncogenic fusion more . 30 , 31 Immunohistochemistry ( IHC ) is another proteins , is found in approximately 3 – 7 % of method that can be used for ALK diagnosis in lung patients with metastatic lung carcinoma based cancer . An IHC companion diagnostic assay was on early studies using reverse transcriptionpolymerase chain reaction ( RT-PCR ) and identify patients with ALK-rearranged NSCLC .

approved in 2015 based on its ability to accurately 32 , 33

14 , 15

fluorescence in situ hybridisation ( FISH ). Although IHC has been extensively used in ALK gene fusion with echinoderm microtubule- laboratories due to the cost effectiveness , its associated protein like 4 ( EML 4 ) represents the interpretation requires experience and rarely most frequent rearrangement among the ALK protein expression may be absent in cases with alterations . 12 , 16 Other atypical ALK 34 , 35 fusion partners have also rearrangement . been reported such as Despite these

TPR , HIP 1 , FAM 179 A limitations , ALK IHC

17 – 20 and COL25A1 . is gaining momentum The recognition of genetic in Europe as the Drug discovery driver mutations in NSCLC has primary test usually The discovery of ALK paved the way for the development in a two-step approach rearrangement led to with FISH being advent of crizotinib , of targeted therapies performed only to a tyrosine kinase confirm positive or inhibitor ( TKI ) with powerful activity against ALK . equivocal IHC results . 36 – 38 However , Crizotinib showed a response rate of 74 % with a few studies have reported false negative results progression-free survival ( PFS ) of 10.9 months using IHC , which potentially risk excluding compared with a response rate of 45 % with PFS patients from receiving standard of care of 7 months in standard platinum doublet treatment . 39 , 40 , 41 Molecular diagnosis could surpass chemotherapy ( either carboplatin or cisplatin the limitations of both FISH and IHC either as a plus pemetrexed ). 21 This superior outcome stand alone assay or in concert with either FISH

146 HHE 2018 | hospitalhealthcare . com or IHC . Next-generation sequencing ( NGS ) has of targeted sequencing to detect and validate emerged as a promising molecular diagnostic genome alterations related to cancer genes by technique for clinical practice due to its accuracy in performing deep sequencing on genomic regions detecting most genomic alterations by allowing of interest . 45 parallel sequencing in

It has been acknowledged that molecular a single assay . 42 , 43 NGS is the blanket term used approaches improve the accuracy of ALK fusion to describe a number of different second- and detection , by resolving discordant or borderline third- generation sequencing technologies , which cases . 46 – 48 However , one of the most valuable are more efficient and show higher throughput advantages of NGS should be attributed to its than Sanger sequencing , a first-generation high negative predictive value compared with sequencing technology . Platforms for NGS from FISH testing . Ali et al reported that 35 % of ALKpositive cases detected by NGS were negative in ALK

Illumina and Thermo Fisher are used widely . 44 NGS can be applied in the form of large-scale FISH , where only 20 of the 31 ALK-positive cases sequencing to detect genetic alterations such were concordant for ALK rearrangement and the as gene mutation and amplification by sequencing remaining 11 cases were only NGS-positive . 49 the whole genome , exome or transcriptome . Importantly , the majority of ALK NGS-positive , By contrast , NGS can also be applied in the form FISH-negative patients responded to crizotinib ,

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