Beukenlaan 137
5616 VD Eindhoven
The Netherlands
+31 85064 55 82
info@interhospi.com
PanGlobal Media IS not responsible for any error or omission that might occur in the electronic display of product or company data.
Archive for month: August, 2020
Women and diabetes – questions on gender-specific impact
According to the World Health Organization’s ‘Global Report on Diabetes’ 2016, diabetes is directly responsible for 1.5 million deaths around the world. This makes it the eighth leading cause of mortality. However, its impact is higher in women, for who diabetes is the fifth leading cause of death. At present, more than 200 million women are estimated to live with diabetes.
One reason for the problem of diabetes in women is the rise in the number of patients with the disease. The prevalence of diabetes, according to the WHO, has doubled since 1980. Moreover, it is no longer a disease that largely affects rich nations. Indeed, prevalence is now growing quickest in middle-income countries. More than half of the total number of women with diabetes today live in southeast Asia and the Western Pacific.
Another issue here is the the lack of healthcare. This means that the management of diabetes is inadequate, particularly for poorer people.
Debate dates to end of 1990s
The debate about gender and diabetes began to intensify at the end of the 1990s, as epidemiology improved, especially outside Western countries.
In January 2001, a report by University of Bristol researchers in ‘Diabetologia’ found geography and gender to be a major factor in Type I diabetes. The report found an excess of male patients in regions with the highest incidence of diabetes, above all in populations of European origin. These showed a roughly 3:2 ratio of males to females in the 15-40 age group. On the other side of the equation, lowest risk populations for Type I diabetes (principally non-European) typically showed a female bias.
The Bristol researchers also observed that Type II diabetes had shown an excess of females in the first half of the 20th century but had become equally prevalent among men and women in most populations, with some evidence of male preponderance in early middle age. Men seemed to also be more susceptible than women “to the consequences of indolence and obesity, possibly due to differences in insulin sensitivity and regional fat deposition.” In addition, women were more likely to transmit Type II diabetes to their offspring.
Geography and gender
Recent figures from the WHO on mortality from high glucose confirm the dual impact of gender and geography. The data shows a fork in female mortality, from near equivalence to males in the Eastern Mediterranean, Africa and the Western Pacific, to being about three fourths of male mortality in Europe, the Americas and South-East Asia.
Women may also be more prone to dying from diabetes due to physiological factors. Data show that women with diabetes are more likely than male patients to have poor blood glucose control and be overweight, along with high blood pressure and cholesterol levels. The latter impact directly on cardiac risk factors, and do so in seemingly different ways for men and women.
Male death rates fall, women’s stays unchanged
In 2007, a study in the ‘Annals of Internal Medicine’ revealed a disturbing fact – that women with diabetes fared far worse than men. The study found that in 1971-2000, death rates for diabetic men fell, while the rate for women hardly changed. Worse, while men with diabetes lived on average for 7.5 fewer years than those who did not have the disease, the difference for women was 8.2 years. This disparity is probably due to a combination of multiple factors, according to the study.
Physiological factors and standards of treatment
Most factors are physiological. However, it seems outcomes for women with diabetes may also be worse due to differences in standards of care and treatment. Some of these were highlighted in 2005 in ‘Diabetes Care’, or two years before the ‘Annals of Internal Medicine’ study mentioned above.
The ‘Diabetes Care’ article covered risk factors in coronary heart disease (CHD) and treatment for Type II diabetes. It found that women with diabetes “received less treatment for many modifiable CHD risk factors than diabetic men.” This included staple therapies such as medication for high LDL cholesterol. The authors concluded that “more aggressive treatment of CHD risk factors” in women offered “a specific target for improvement in diabetes care.”
In 2010, a study in ‘Diabetic Medicine’ found the picture to be similar for Type I diabetes. The study by another Massachusetts General Hospital team, led by M.E Clarkin, found women reported lower use than men of medications to reduce CHD risk. These included glycated hemoglobin, as well as aspirin, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and statins.
The role of cardiac health
Key physiological differences do indeed concern cardiac health.
In the general population, women tend to live longer than men, mainly because of lower rates of heart disease. However, such an advantage becomes insignificant for diabetic women. Indeed, the risk of heart disease is reported to be six times higher for women with diabetes than those without, compared to an increase of just 2-3 times in men.
This impacts directly on mortality for several reasons. One of the most significant is that women can have heart attacks without its most notable symptom in males, namely chest pain. Indeed, women are more likely to experience only nausea, shortness of breath, and back or jaw pain during a heart attack. Many women and medical practitioners in poorer parts of the world do not recognize the latter as warning signs. This lowers the chance of recovery.
One study published in the ‘European Heart Journal’ in 2007 found a stronger association between diabetes and death by heart failure for women than men. A Finnish study also found that heart attacks are more often fatal for women with diabetes than they are for men.
Indeed, perception is linked to less effective health care for women with diabetes, and this is best typified by cardiac health. As women are less likely to have heart attacks than men, a woman may not raise the same alarm bells as a man, especially when she does not experience chest pain.
Renal disease
Women with diabetes face complications from renal disease, too. Men have a higher risk for kidney disease, but this disappears with the onset of diabetes. Women with diabetes are just as likely to get kidney disease as men. Moreover, such a likelihood is not dependent on age, although women tend to be unaffected by kidney disease until menopause, when a drop in oestrogen levels makes the female endocrine system more like a male’s.
Some studies have found that lower oestrogen levels are associated with kidney disease, but the mechanisms of this association are not yet clear. One theory is that high testosterone, which kicks in as estrogen levels drop, is responsible. Should this be proven clinically, it may be possible for women with diabetes to use hormone therapy to restore the balance between estrogen and testosterone, and thereby improve their kidney health.
Mental health
Depression is about twice as common in women as men and is believed to worsen the outlook for women with diabetes. A study of women in the ‘Archives of Internal Medicine’ in 2010 suggests a two-way relationship between depression and diabetes risk, with each influencing the other. Indeed, some women-only studies have shown women with both conditions are twice as likely to die early as those who had neither. In 2006, a study in ‘Public Health’ extended the scope to men and found that diabetes and depression were not associated in men, unlike in women.
Polycystic ovary syndrome
Women with diabetes are also likely to have several conditions which are female-specific.
One of these is polycystic ovary syndrome (PCOS), a metabolic disorder caused by hormonal imbalance in the female body. PCOS causes irregular periods and can result in fertility problems. It is also associated with acne, darkening of facial skin and hair growth on the face, loss of hair on the head etc. Females with PCOS are at heightened risk of getting diabetes, and the above signs are thus potential indicators of impending diabetes.
The precise mechanism of PCOS is not known, but there is clinical evidence that women with PCOS develop high levels of resistance to insulin and this then leads to development of Type II diabetes.
What has however been confirmed is that women diagnosed with PCOS at an early age show a higher risk of diabetes and fatal heart conditions later in life.
Gestational diabetes mellitus
Women also face the risk of gestational diabetes mellitus (GDM). This is defined as blood glucose values above normal but below those of diabetes. GDM is diagnosed through screening, since several of its symptoms such as increased thirst and urination needs, dry mouth and fatigue are commonplace in pregnancy and are not necessarily a sign of a problem.
Although the true prevalence of GDM is unknown, it is estimated to affect 1-14% of pregnancies in the US, depending on the population studied and the diagnostic tests used. Recent research has focused on high-risk groups. A pan-European study of women with body mass index greater than 29 kg/m2 found prevalence of 24% in early pregnancy, with another 14% developing GDM at mid gestation (24-28 weeks) and 13% at late gestation (35-37 weeks). The study was published in the October 2017 issue of ‘Diabetologia’ and covered women at 11 centres across Europe.
GDM increases the risk of certain complications during pregnancy and delivery, both for the women in question and for their infants. One of these is pre-eclampsia, which causes high blood pressure during pregnancy. Others include the baby growing larger than usual and polyhydramnios, which is the presence of excess amniotic fluid.
Though GDM is a temporary condition, affected women have an over-sevenfold increase in the risk of developing Type II diabetes 5-10 years after delivery. Moreover, children born to mothers with GDM are also more likely to develop impaired glucose tolerance.
Early diagnosis of GDM through testing for blood sugar and modifications to lifestyle can be effective in preventing or delaying the condition and treating its consequences.
Neonatal imaging – beyond MRI-compatible incubators
Diagnostic and prognostic MRI is recommended for infants for a range of conditions. These include gestational age below 30 weeks, in premature infants suspected of metabolic disease, and in term infants who might have sustained perinatal brain injuries or who show Stage 2 or 3 hypoxic-ischemic encephalopathy.
MRI preferred imaging solution for numerous conditions
Although ultrasound (US) is used as first-line imaging in certain cases like intracranial hemorrhage, MRI is indicated for most other infant brain and head neuroimaging. This has been the case for some time. One example is a report published in 1990 in the French-language journal ‘Pediatrie’ by a team from the CHU Hautepierre hospital in Strasbourg, which discusses the advantages of MRI over ultrasound in areas such as brain injury. The report, nevertheless, also points out the problems with neonatal MRI, such as the need for immobilization and lack of accessibility. Such difficulties have persisted over the years.
Indeed, in the early 1990s, Britain’s Hammersmith Hospital installed a 1T MRI scanner in the NICU. However, it had a limited field of view and was replaced with a conventional adult-sized 3T system. In fairly short order, the 3T system was found not only challenging to use in the NICU due to its long bore and problems of access to infants, but also expensive to operate.
Guidelines for infant MRI imaging
At present, a multitude of guidelines recommend that MRI is used to follow up ultrasound diagnosis of parenchymal brain injury, post-hemorrhage ventricular dilatation as well as US (or clinical) suspicion of abnormalities in the posterior fossa and at the brain’s convexity. Other conditions in infants that indicate MRI imaging include brain inflammation (meningitis, encephalitis, brain abscess etc.) and seizures, abnormal consciousness and/or asymmetry which cannot be satisfactorily explained by US findings.
The case for MRI after ultrasound has also been studied extensively. One report from the Medical University of Vienna in 2010 stated that among infants undergoing cranial ultrasounds after clinical seizure, MRI was able to identify a causative pathology in 42% of cases where US findings were unspecific.
Conventional MRI “not designed” for infants
As mentioned in an ‘Advances in Neonatal Care’ analysis in 2005, it takes a single look at a typical MRI scanner to know that “it was not designed for an infant.”
Technically, a baby’s head size poses one of the first challenges. Standard MR head coils lead to sub-optimal picture quality and adult knee coils are often used instead.
Cooperation between neonatal team and radiologists
Given the very small size of a neonate brain, it is especially important to have high signal-to-noise ratios (SNR) for delineation of anatomical details. This was one of the major limitations of smaller, customized low-field MRIs designed for NICUs. At Royal Hallamshire Hospital in Sheffield, for example, a 0.17T system with 15mT/m gradients was installed in the early 2000s, but its low SNR made it impossible to use emerging MRI techniques such as diffusion tensor imaging and MR spectroscopy in neonates.
The best way forward has instead been seen in tailoring MR protocols to the neonatal brain. This is however a complex task. MR protocols involve a wide range of technical factors: echo time, repetition time, flip angle, slice numbers, slice thickness, scan duration, field of view etc. Achieving this “requires close cooperation between the neonatal team, radiographers and radiologists,” according to a study at Ireland’s University of Cork, published in 2012 in the ‘British Journal of Radiology’.
The challenge of transfers
The transfer of infants from a continuously-monitored NICU to MRI suites has been one of the most vexatious problems. As discussed in the 2005 edition of ‘Advances in Neonatal Care’ cited above, MRI scanners “are often situated far away from the NICU.”
The move of infants to an MRI room involves multiple transfers – from NICU bed to incubator to scanning table, and then backwards. These have to be made in a relatively short period of time, which can add dramatically to physiological stress.
Specific problems during transfer include the chance of extubation and arterial or venous decannulation. Excessive movement in a premature infant is also known to adversely affect cerebral blood flow. This, in turn, can defeat the very purpose of an MRI, by altering results.
Sedation and hypothermia
The question of whether or not to sedate infants before transfer is also a major challenge. Sedation has risks. Moreover, a sedated neonate requires continuous monitoring during an MRI.
There are problems after the transfer, too. Once in the MRI room, infants must be removed from the warmth of the incubator to a cooler scanning table. Towards this, they are usually swaddled in blankets, accompanied sometimes by neonatal thermal packs to prevent heat loss. The American College of Radiology (ACR) also recommends use of temperature probes for infants to take an auxiliary temperature before and after the examination.
Even as the MRI begins, NICU staff need to be on alert to decide if an examination must be halted. This may be due to the impact of the transport, cold, stress, sedation etc..
MRI-compatible incubators
Since the early 2000s, attention has focused on MRI-compatible incubators. These are equipped with an integrated head coil and accompanied by auditory shielding, temperature and humidity regulators, a ventilation support system and monitors specifically certified for the massive magnetic environment of the MRI.
In February 2004, ‘Pediatrics’ published a report on the imaging of seven non-sedated neonates via the use of an MRI-compatible incubator. The authors noted that the “constant environment reduces the risk of adverse events occurring during the transport and imaging of the neonate.”
Not all problems, however, were mastered by the incubator. For instance, the infant was not easily visible from the control room and required the presence of a staff member in the vicinity. In addition, in spite of temperature and humidity controls, additional monitoring was required for electrocardiography and oxygen saturation.
Nevertheless, interest in MRI-compatible neonatal incubators has continued.
In September 2010, the ‘European Journal of Paediatric Neurology’ published results of a study which found that MRI-compatible incubators reduced the mean gestational age of patients from 44 to 39.7 weeks, and in parallel, more than doubled incubator use from 14.8% to 36% for ventilated neonates.
Advantages of the MRI-compatible neonatal incubator also included halving the time required for handling the infant, a reduction of total procedure time by an average of 20 minutes, and in imaging time by four minutes. Such time savings arose from the fact that there was no need to stabilize the infant. Furthermore, no MRI procedure was terminated due to insufficient sedation or infant instability; previously, one in 10 infants had required additional sedation during the procedure.
Equipment compatibility and safety
In May 2013, researchers from Australia’s Royal Brisbane and Women’s Hospital published results of a three-year review on MRI-compatible incubators in the ‘Journal of Paediatrics and Child Health’. Although the overall conclusions were positive, with no adverse incident reported over the period, the authors drew attention to several “practical issues”.
The first was a 30-45 minute pre-warming period required to reach an appropriate temperature setting for babies. The second consisted of difficulties in reading the incubator’s patient monitor interface, including key data such as cot temperature, pulse rate and oximetry readings. Once again, as with the February 2004 ‘Pediatrics’ study mentioned previously, the Royal Brisbane researchers recommended “that staff remain in the scan room throughout the procedure to monitor the well-being of the baby.”
The biggest challenge, however, concerned compatibility of equipment connected to the incubator. For instance, though the ventilator was MRI-compatible, it was not designed to provide humidified or preheated gas. The researchers also noted the need to improvise very specific procedures, for example, in extending infusion lines from pumps located outside the imaging room, which were not MRI-compatible.
Indeed, the need to use MRI-compatible or MRI-safe accessories, ranging from thermal packs and temperature probes to noise protectors, remains one of the biggest drawbacks with MRI-compatible incubators outside the NICU. The authors of the Royal Brisbane study point to “difficulties in sourcing a gas supplier to refill the portable MRI-compatible air and oxygen cylinders because of their special status outside the usual medical gas cylinder refilling programme.”
The scale of such problems becomes dramatic when intubation or resuscitation is required. In such cases, the infants need to be rapidly removed from the MR system and its magnetic fringe. The only alternative is to ensure that, rather than just accessories, the entire range of medical equipment – from syringes and infusion pumps to laryngoscopes and suction equipment – is MRI-compatible.
More research needed
In February 2015, ‘Advances in Neonatal Care’ published results from a systematic review of 13 research studies, two quality improvement projects, as well as practice guidelines and articles on neonatal MRI imaging by the Norwegian Neonatal Network and Oslo University Hospital.
The authors concluded that although results seemed promising and increasingly consistent, “more research is needed before conclusive recommendations” could be established about MRI-compatible incubators and associated techniques.
Alternatives emerge
Recently, a system from Aspect Imaging known as Embrace Neonatal MRI has sought to close the gap between NICU imaging requirements and the capabilities of current MRI-compatible incubators. Embrace received authorization from United States Food and Drug Administration (FDA) in July 2017, and in November obtained a CE marking for European Union sales.
Unlike conventional MRI machines, the new system does not require a safety zone or a radio-frequency shielded room. Since it is fully enclosed, medical device implants or equipment in the NICU in close proximity are not required to be MRI-compatible. Other advantages include an always-on permanent magnet; it therefore requires no electrical, cryogenic or water cooling (click here for more details on this product).
Other approaches to neonate imaging are also under evaluation.
Cincinnati Children’s Hospital in the US, for example, has installed a commercial 1.5-T MRI system in its NICU, based on an orthopedic system coupled to custom-built components – most significantly, a high-end scanner. The unit’s gradient coil is about 2.5 times shorter than a conventional adult-sized system. In January 2014, the ‘American Journal of Roentgenology’ published results of a study at the hospital on imaging neonates. Although its scope was small (15 infants), the authors concluded that the system was capable of producing “high quality” images of neonates, not only of the brain but also the abdomen and chest.
As with other efforts to date, the modified system also attained several collateral objectives, such as ease of installation and operation in an NICU, improved visual contact and physical access to the infant, along with the use of advanced imaging techniques, ECG and respiratory gating and triggering. One of “the most important benefits”, according to the authors, consisted of “the reduction of risk associated with transport of the neonate to and from the NICU.” As discussed previously, this has been the single biggest challenge for neonate imaging and a driver of most design and technology development for over 25 years.
Antimicrobial resistance – new tools for a growing scourge
In June 2017, the European Commission adopted an Action Plan to tackle Antimicrobial Resistance (AMR) which is responsible for an estimated 25,000 deaths in the EU every year. Worldwide, the death toll from AMR is reported to be as high as 700,000. The World Bank warns that by 2050, the economic impact of drug-resistant infections due to AMR would be on par with the financial crisis in 2008.
Contamination and resistance
Overall, healthcare-associated infections (HAIs) affect up to 15% of hospitalized patients. The main causes are persistent microbial contamination of hospital surfaces, along with a growth of drug-resistant pathogens. Although antimicrobial misuse is believed to be largely responsible for AMR, hospital hygiene has come sharply into focus as traditional cleaning methods begin to encounter limits in their capacity to control infection.
WHO guidelines on hand hygiene
According to the World Health Organization (WHO), good hand hygiene practices could halve the infection level in hospitals. The WHO guidelines are also known as the ‘Five Moments for Hand Hygiene.’ They involve the occasion before a patient is touched, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching the patient’s surroundings. However, much more needs to be done to validate training or control the implementation of the WHO guidelines.
Challenges of compliance
One of the biggest challenges is the time required for the most effective form of hand hygiene, namely alcohol-based hand rubs (ABHR). WHO recommends applying ABHRs for 20 to 30 seconds, while the US Centers for Disease Control and Prevention (CDC) recommends doing so until the hands feel dry, which it states ought to take about 20 seconds. Such time-spans are considered far too long for busy, practising clinicians.
However, it seems that such requirements may be unnecessarily arduous. In Dec 2017 / Jan 2018, a clinical observational study in Germany found that reducing the recommended application time for hand rubs improved compliance rates with no significant difference in efficacy. The researchers at the Institute for Hygiene and Environmental Medicine of the University Hospital of Greifswald focused on nurses who applied ABHRs for either 15 or 30 seconds. The study found ABHRs were “equal or even more effective” within 15 seconds versus 30 seconds for a variety of micro-organisms. The only caveat was that the ABHR needed to have a proven efficacy after 15 seconds. This did not extend to all ABHRs available on the market, and particularly not to gel formulations.
Other researchers are approaching the problem differently. In October 2013, an article in the journal ‘Clinical Infectious Diseases’ published results of a meta-study on hand hygiene, which it called “the critical intervention underlying modern infection prevention efforts.” The authors concluded that, in spite of limited research and evidence, “bundles including education, feedback, reminders, access to ABHR and administrative support” would be the most effective at improving hand hygiene compliance.
Three years before this, the ‘American Journal of Infection Control’ reported results from a project at one hospital, where compliance with hand hygiene was improved and sustained through use of a multi-faceted bundle approach. One aspect of the latter was a violation notice letter sent to non-compliant staff and enforced by managers. This appears to have been the key factor in dramatically raising hand hygiene compliance from a rate of 34% to more than 90% in the space of just two years.
Recent developments in hand hygiene
Recent developments related to hand hygiene include new test methods for evaluating hand hygiene products, improvements in ABHR, novel antisepsis techniques and new strategies for monitoring hand hygiene practices among healthcare personnel. A host of new methodologies is also being explored to implement hand hygiene at hospitals. These range from new digital tools to robotics, artificial intelligence and genetics.
Gesture recognition algorithms
In late 2017, global hand hygiene company GOJO reported results from a ‘smart hospital’ project with two medical technology companies from Ireland, SureWash and MEG Support Tools. The three joined forces with an infection control team at Manchester’s Christie Hospital, to create a live data dashboard using an interactive training kiosk from SureWash, an audit app from MEG and GOJO’s Smartlink dispenser. Analytics were run in real time on the data to provide actionable feedback when hand hygiene standards slipped.
Patients and infection control
During the study, hand hygiene education and compliance were also targeted at patients by means of gesture recognition and camera-based algorithm technology.
Indeed, patients have recently begun to be harnessed as key actors in infection prevention. So far, there were few resources available for such a task, in spite of a growing body of evidence to suggest that patients’ flora too were a primary source of several infections, and that these could be prevented by correct hand hygiene. Most previous work involving patients had simply included them as monitors of hand hygiene practices by healthcare workers.
Clean bots
Germ-killing robots provide a new weapon in the arsenal against health care-associated infections.
One study funded by the CDC in the US showed that germ-killing robots (also being described as Clean Bots) could reduce common healthcare-associated infections by 30 percent.
At the end of 2017, Vanderbilt University Medical Center in Nashville, Tennessee, began deploying robots to protect hospitalized patients from two of the toughest strains of resistant bacteria: methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The first area of application is the burns ward, which hosts some of the most vulnerable patient groups. Rooms are cleaned with traditional liquid disinfectants. After this, hallway doors and curtains are closed, while cabinets and drawers are left open. This is followed by the despatch of a remote-controlled robot, which floods the room with ultraviolet radiation to kill any residual germs. The robot shuts itself down after its sensors detect adequate reflected UV from the room surfaces, which typically takes about 25 minutes. However, longer settings can be used in rooms likely to host hospital-acquired infections.
Nevertheless, authorities at the Vanderbilt Medical Center reiterate that Clean Bots are not a replacement for good hand hygiene.
Vanderbilt now plans to monitor the effects of the robots on infection rates and on workflow, and is developing protocols to optimize use of the robots without delaying patients arriving from the emergency department or the recovery room.
Artificial intelligence
Artificial intelligence (AI) is also being utilized to enhance hygiene. The magazine ‘New Scientist’ recently reported efforts by a Stanford University research team, which sought to harness AI to spot behaviour that might contribute to the spread of infection. Towards this, the researchers used video cameras at a hospital in a range of hotspots such as patient rooms, hallways and adjacent to hand sanitizing dispensers. The cameras made recordings over the course of one high activity hour. 80 percent of the video was used to train tracking algorithms, while the rest was used to test the algorithms.
During the hour when the recording was made, 170 people entered patient rooms. However, only 30 followed appropriate protocols for hand hygiene. The researchers found that computer vision algorithms were more accurate in making such a judgement than people in the hospital covertly recording hand sanitation practices.
The researchers are now planning to outfit three hospitals for a year to see how the technology and the observations it reports impact infection rates. One of the researchers, Alexandre Alahi, told ‘New Scientist’ that though it may not be affordable to have a doctor in a room round-the-clock, an AI doctor could well be economically viable, freeing up humans to do other jobs.
Video analytics
Video analytics has also been used for a study by the Division of Infectious Diseases and Hospital Epidemiology at University Hospital Zurich to make in-depth follow-up of hand hygiene practices, in order to systematically document hand-to-surface exposures (HSE) and delineate true hand transmission pathways. The authors of the study, published in the October 30, 2017 issue of ‘Antimicrobial Resistance & Infection Control’ concluded that the “abundance of HSE underscores the central role of hands in the spread of potential pathogens while hand hygiene occurred rarely at potential colonization and infection events.” They aim to propagate their hand trajectory monitoring approach to design more efficient prevention schemes.
The trajectories of infection
One of the newest tools in the fight against infection seeks to provide a first-person view of pathogen transmission. It involves the documentation of hand-to-surface exposures (HSE) by healthcare workers and tracking their trajectories.
The process, which was developed by researchers at Zurich University Hospital in Switzerland, uses a head-mounted camera and commercial coding software to code HSE type and duration based on a hierarchical scheme. It identifies HSE sequences with particular relevance to infectious risks, based on the WHO’s ‘Five Moments for Hand Hygiene.’
The Swiss researchers recorded and studied hand movements of 8 nurses and two physicians and confirmed the central role of hands in the spread of potential pathogens. During the study period of almost five hours, a total of 4,222 HSEs were identified, corresponding to one HSE every 4.2 seconds. Of this, 291 HSE transitions were ‘colonization events’, occurring from outside to inside the patient zone. Hand hygiene occurred rarely at potential colonization and infection events.
According to the researchers, an in-depth analysis of hand trajectories during active patient care may help to design more efficient prevention schemes.
Colour coding bedsheets
While tools such as video analytics and robotics offers new approaches to the challenge of hygiene, others are turning to imaginative, lower tech solutions. In India, health officials in West Bengal’s Raiganj district hospital recently announced that bedsheets of varying colours would be used on different days a week to check cross infection and ensure that the beds and the wards were cleaned every day.
There authorities were responding to complaints that bedsheets were not regularly changed, in some cases even after a patient had been discharged. Using bedsheets of different colours gives an immediate solution to such a problem. The hospital has put up a chart mentioning days of the week and the corresponding colour of the bedsheets, allowing family members of patients to confirm that their beds had been cleaned.
Extremity Cone Beam CT imaging demonstrates value of weight-bearing scans
Commercially launched in early 2017, the Carestream OnSight 3D Extremity System is a Cone Beam Computed Tomography (CBCT) scanner designed for point-of-care extremity imaging in weight-bearing patient position for orthopedic clinics, imaging centres, specialty offices, hospitals and emergency departments. The system uses a high-performance amorphous-Silicon (a-Si(H)) flat-panel detector and a unique three-source X-ray tube design. This detector allows for the rapid acquisition of X-ray projections, which helps minimize the negative impact of patient motion. The three-source X-ray tube was designed to reduce the “cone beam” artifact that has traditionally impacted large volume CBCT reconstructions as reported in scientific literature.
The detector and source rotate around the patient’s anatomy, acquiring a multitude of projections from different angles, axially and rotationally. The images are then reconstructed into a 3D volume using advanced software reconstruction techniques. This produces high resolution volumetric 3D images that have the same spatial resolution in any plane.
Cobalt Health, a leading UK medical charity, has installed the world’s first Carestream OnSight 3D Extremity Cone Beam CT system at their Imaging Centre in Cheltenham, Gloucestershire UK.
Founded in 1964, Cobalt provides a wide range of oncology services across the south-western UK counties of Herefordshire,Worcestershire and Gloucestershire. Cobalt has a history of early investment in new technologies such as MRI and PET/CT. A long-standing Carestream customer, Cobalt was the first facility in the UK and Ireland to implement the Carestream MyVue Patient Portal and currently has both Carestream Vue RIS and Vue PACS installed. Peter Sharpe, CEO of Cobalt Health said: ‘As a charity we’re very used to introducing new technology to support our patients and referring clinicians and this seemed like an ideal opportunity. The Carestream OnSight 3D Extremity CBCT scanner really fitted very nicely, particularly in supporting our orthopedic clinics. It provides something that we couldn’t offer previously, in terms of image resolution and flexibility; it seemed like a really good fit.’ ‘It provides you with true weight bearing images, high resolution and low radiation dose. I think there’s a huge opportunity to embed it in the patIent pathway in A&E and orthopaedic clinics across the UK.’ To introduce the benefits of the OnSight system to the patient pathway, Cobalt held a series of evening seminars where they showed case studies and orthopedic surgeons demonstrated how patients could benefit from the cone beam CT system. ‘It’s the best way of marketing the new technique,’ said Peter Sharpe. ‘The referrers need to come and understand how it works, what the image quality is, and what the benefits are.’
One-stop clinics
Cobalt runs regular one-stop clinics with orthopedic surgeons who refer their patients on the same day for X-rays, MRI or CT scans. Roisin Dobbin-Stacey, PET CT and CT Manager for Cobalt Health explained: ‘The Carestream On-Sight 3D CBCT doesn’t discriminate; it’s not just for sports injuries or for one-stop clinics, it will be available to all patients.’ ‘The weight-bearing feet and ankle exams that we’ve been doing, on people of all ages, have been made considerably easier; it only takes 25 seconds to get these incredible images. They step into the scanner and all they have to do is keep still for 25 seconds.’
‘In the past, when you had a patient who said they had a pain in their foot or ankle when they were walking or running, you would lie them down and do a CT scan and it wouldn’t show anything. You can now put them into the CBCT scanner and see the true condition of a patient who’s got all their weight going through that joint and you can see the difference; you can see why they’ve got that pain.’
‘The dose, of course, is something else that is talked about a lot; referrers ask why they would send their patient for a CT scan when they can have an X-ray; but actually if a patient is having a CBCT scan, the dose is only slightly higher than with an X-ray, and it’s a weight bearing exam. And it’s a lot less than with a CT, so that again is very encouraging.’
Exquisite detail
Consultant Radiologist, Prof. Iain Lyburn, has had a very positive experience with the Carestream OnSight 3D scanner. ‘It’s very high quality, very high resolution,’ he said. ‘The detail is exquisite, so you can see very small bony defects, very small osteophytes, with great clarity. It’s also much quicker than some other investigations, taking less than a minute for many body parts, so you get a cross sectional slice through the area in a relatively quick time.’ ‘We recently examined a young man with hind foot pain and, whereas an MRI scan showed some edema, with the Carestream CBCT image you could see the bony detail wit absolutely exquisite clarity and what we hadn’t appreciated properly was an ill-defined irregularity around the os trigonum, which was the cause of the pain. It was a very small detail that you couldn’t pick up on the MRI, these small fragments of bone causing the pain. It was very helpful. We had another patient with pain below the ankle joint whose MRI showed some edema across the joint in the calcaneum, so we thought that was probably the cause of the pain. Remember the MRI would be done with the patient lying supine with their ankle on the bed, whereas with the CBCT the patient was standing in the functional position, and what it highlighted beautifully was a protuberance in the subtalar joint.We could see the impingement far more clearly demonstrated because of the way the image was taken and realized that it was going to be the cause of the symptoms. There was possibly a suspicion of it on the MRI with the edema, but having the cone beam CT showing it in position clarified that that was the source of the symptoms. And that might change the management of the patient, because many times we would do a plain radiograph, see how the patient gets on then get them back.With the Carestream OnSight CBCT you would get the diagnosis straight away and would see most fractures earlier than you would on an X-ray. In imaging, as with many other aspects of medical technology, you’ll look back in a few year’s and see that the Carestream CBCT is irreplaceable.’
Plug and play
Installing the OnSight 3D Extremity system at Cobalt’s Imaging Centre was straightforward, as Roisin Dobbin-Stacey explained. ‘Planning and getting the room ready for delivery of the equipment was very easy; the room size had to be a minimum of 8 feet by 12 feet (Ed. 2.5m x 3.7m). The equipment arrived, it was brought up in the lift, wheeled in and plugged into a 240 volt socket. It literally is plug and play!’ ‘The Carestream engineers were fantastic, they got it all up and running within a couple of days, and the Apps training was brilliant. I think the system itself, how it’s been designed, is so user friendly. As a radiographer you want something that’s easy to use, and for me it’s fantastic, it’s such good fun to use. Cobalt CEO Peter Sharpe summed up his feelings about the Carestream OnSight CBCT system: ‘we have no regrets. It’s an excellent device, it works well and uptime has been 100 percent. It’s easy to use, patients love it and the image quality is superb so yes, it’s been a great investment.’
Carestream Healthwww.carestream.com
Strong presence of Nordic skills and innovations in life science at Arab Health 2018
Danish, Finnish and Swedish organizations join forces to facilitate business partnering and networking at Arab Health 2018. At the event, 75 Nordic companies bring innovative life science solutions aiming to add sustainable value to the Middle East healthcare sectors and to build lasting relations between the Nordic participants and local stakeholders.
Business Finland, Business Sweden, Danish Health Tech Group and Global Pharma Consulting are coordinating four national pavilions at Arab Health 2018. To kick off the trade fair, the organizations announce an exclusive Nordic Business Partnering and Networking Reception for invited guests on Monday 29 January 2018 at 7-10 pm at the Sofitel Dubai Downtown.
“This is the only opportunity for stakeholders in the MENA region to talk to so many decision makers, officials and experts from the Nordics in one place in a relaxed setting,” explains Senior Consultant Paula Hassoon at Global Pharma Consulting, organizer of The Innovation Pavilion by Sweden.
“Joining forces with our Danish and Finnish colleagues to host a Nordic partnering and networking event brings added value to all of the participating companies,” she says.
Digital health from Finland
At the four national pavilions, the Nordic companies will showcase cutting-edge med-tech solutions and technologies to the MENA region. According to Meria Heikelä, Director at Business Finland and co-organiser of the Finnish pavilion, Finland ranks among the three strongest health technology economies in the world, with digital health being its largest high-tech export.
“Finland’s world-class research and technology competencies are the pinnacle of its health sector and one reason why Finland has one of the most efficient healthcare systems in the world. Preventive healthcare and rehabilitation solutions are among the key focus areas of Finland at Arab Health 2018,” explains Meria Heikelä.
Danish innovations in med-tech
With the annual Pavilion of Denmark at Arab Health and a recent business delegation visit to UAE and Saudi Arabia healthcare sectors, Danish Health Tech Group is committed to share the Danish med-tech strengths with stakeholders in the MENA region.
“In Denmark, we prioritize design and quality, and innovate through an inherent focus on public-private sector cooperation and by proactively involving patients and staff in the healthcare sector,” says Thomas Andersen, Head of Danish Health Tech Group.
Swedish world-class healthcare
While all the Danish companies are exhibiting with Danish Health Tech Group, Sweden offers two different pavilions.
The Innovation Pavilion by Sweden and the official Swedish pavilion each has representatives from 20 Swedish healthcare and life science companies.
“Sweden is known for its world-class’ innovations within the healthcare sector. Much of this success derives from the tradition of entrepreneurship through the close collaboration between the government, academia and industry,” says Fredrik Bodin, Trade Commissioner of Sweden to the UAE, co-organizer of the official Swedish pavilion.
The national pavilions at Arab Health 2018
- The Innovation Pavilion by Sweden, organized by Global Pharma Consulting, located at Za’abeel Hall 6 Z6.E30
- The Finnish Pavilion, co-organized by Business Finland and Business Oulu, located at Hall H3 A10
- The Pavilion of Denmark, organized by Danish Health Tech Group, two pavilions located at Trade Center Arena SA.F50-59 and Za’abeel Hall 6 Z6.E30
- The official Swedish pavilion, organized by Business Sweden and the Embassy of Sweden in Abu Dhabi, located at Za’abeel Hall 1, Z1.G50
More information to be obtained from:
Business Finland (Finpro) at www.finpro.fiBusiness Sweden’s at www.business-sweden.seDanish Health Tech Group at www.dk-healthtech.comGlobal Pharma Consulting at www.globalpharma.se
The future for radiologists is also interventional
Interventional radiology is a subspecialty providing minimally invasive image-guided diagnosis and treatment of disease. The number of procedures performed by interventional radiologists is extensive, ranging from the purely diagnostic such as angiography and cholangiography to the therapeutic, covering vascular and ablative applications. In recent years there has been a shift away from diagnostic angiography with the arrival on the market of high performance CT and MRI angiography systems which provide reliable and non-invasive alternatives.
Radiologists are by no means the only medical specialty performing interventional techniques as cardiologists and vascular surgeons have been quite successful in developing interventional skills, so much so that interventional cardiology has grown into a discipline of its own. In fields such as peripheral arterial disease treatment for example, it would seem that interventional radiologists have lost out to other specialties even though in some European countries like Germany they still have a significant share of this work. There is, however, a wide range of other areas, especially in interventional neuroradiology and oncology where interventional radiologists hold a quasi-monopoly.
In Europe, the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) established in 2013 the first edition of the European Curriculum and Syllabus for Interventional Radiology which aimed at harmonizing training across European countries while supporting the European Board of Interventional Radiology (EBIR) examination in interventional radiology. CIRSE also works together with the European Society of Radiology (ESR) to attract more clinically-oriented medical students to interventional radiology. The steady growth of the ageing population in Europe and other industrialized countries and the resulting higher incidence of strokes and cancer cases combined with the multiplication and development of interventional techniques will boost the demand for interventional radiologists in the near future. Already now, there is a shortage of interventional radiologists in some countries, notably the UK where 25% of hospitals cannot provide minimally invasive procedures to their patients on a 24/7 basis because of a lack of recruitment of interventional radiologists in the National Health Service (NHS). This situation is having a clearly detrimental effect on patient care in some parts of the country. According to the Royal College of Radiologists (RCR), there are just 414 interventional radiologists in the NHS whereas 735 of them would be needed to provide 24/7 on-call service everywhere. In comparison, France has about 1,250 interventional radiologists while Germany totals over 1,000. In emerging countries, the shortages can be huge, such as in India where there are only 596 registered interventional radiologists, i.e. one per every 2,18 million population. The challenge for radiologists is to recognize the value of being close to the patient and embrace clinical care.
Big data and imaging – algorithms and analytics aid clinical decision making
A fluid, game-changing combination of mathematical tools and Big Data seems ready to disrupt the field of radiology. However, it also promises to pave the way for what may turn out to be potentially-dramatic advances in healthcare.
There is some irony here. Data was once seen as a liability, to maintain and pay for. It is now being considered a potentially major asset. The key to this turnaround in perspectives lies in increasingly sophisticated, deep learning algorithms, advanced analytics and artificial intelligence which interpret the Big Data and make it usable.
Explosion in image numbers and volume
There is no hyperbole in the use of the term Big Data, as far as radiology is concerned. In recent years, there has been a veritable explosion in the stock of medical images. Emergency room radiologists often examine up to 200 cases a day, and each patient’s imaging studies can be around 250 GB of data. At the upper end, a ‘pan scan’ CT of a trauma patient can render 4,000 images. Currently, about 450-500 petabytes of medical imaging data are generated per year, but this is accelerating. Decisions are made on the basis of small parts of imaging data, the proverbial tip of the iceberg. Much of the information in this data has still to be deciphered and used.
Medical imaging and disease
Medical imaging provides important information on anatomy and organ function as well as detecting diseases states. Its analysis covers a gamut of areas from image acquisition and compression, to transmission, enhancement, segmentation, de-noising and reconstruction.
Technology has enabled often-dramatic leaps in image resolution, size and availability. Sophisticated picture archiving and communications systems (PACS) have allowed for the merger of patient images from different modalities and their integration with other patient data for analysis and use in a clinical setting.
Limits to vision – from digital to analogue
So far, radiology information to identify disease or other clinical conditions is presented in the form of images. Although scanners digitize data into pixels, this is reconstructed into shapes and shades or colours for display in a form that can be understood by the human brain.
This is where the ‘tip of the iceberg’ statement above comes into play. Medical scanners encode an image pixel in 56 bits, equivalent to 72,000 trillion ‘shades’. However, the scanner reduces the data amount to 16 bits, just 65,536 shades, for the human eye. As a result, 40 bits of information is lost, in just one pixel.
At some point in the future, it seems likely that radiologists use numbers rather than images to numerically define and detect patterns of diseases. The process may in fact have already begun.
Imaging analytics and deep learning
Such trends are being fuelled by rapid advances in imaging analytics. Smart, deep learning (DL) algorithms, which analyse pixels and other digital data bytes within an image, have the capacity to detect specific patterns associated with a pathology and provide conclusions in terms of a numerical metric.
One example of the use of numbers as a diagnostic definition concerns the use of algorithms in CT images to calculate bone density. The result is compared to a reference number, which au tomatically trigger alerts on low bone density. Avoiding the need for another dedicated examination, a physician can determine if a patient needs calcium supplements or another preventative measure.
Such algorithms also learn over time, and become better at what they do, resulting in even greater speed and more confidence in the future. Such a process has been driven by the steady acceleration, over the years, in computer processing speed. Indeed, while training an algorithm at the turn of the century took 2-3 months, the same results can now be achieved and iterated within minutes.
Neural systems and algorithms
Technically, deep learning produces a direct mapping from raw inputs to outputs such as image classes. Many DL algorithms are inspired by biologic neural systems. They are different from traditional machine learning, which requires manual feature extraction from inputs, and face limitations to use in the face of the large volumes of information associated with Big Data.
Big Data’s virtuous circle
Many DL algorithms directly seek to harness Big Data in radiology. Gigantic (and fast-growing) image libraries are being accessed for investigation to develop, test, validate and continuously refine algorithms, with the aim of covering a whole range of pathologies.
For radiologists, analytic results from an examination can be comprehensively evaluated against similar data obtained over a long period of time and evaluated to suggest appropriate diagnosis in current scenarios.
Such a virtuous cycle of algorithms and Big Data have become the focus for a host of major medical technology vendors as well as start-ups. However, the key enabling players are radiology departments, who own the data repositories and are uniquely placed to curate the data, in other words, organize it from fragments and make it available for running analytical algorithms.
The above process has, in some senses, been jump-started by previous efforts to data mine reports from radiology departments as they transitioned from PACS to enterprise imaging. The next step in this Big Data-driven opportunity will consist of linking information in radiology reports to the pixels of medical images.
The pixel goldmine
Few doubt any more that pixels are a goldmine, holding wholly new insights into a medical image and how best they could be utilized, not just by radiologists but other clinicians offering patient care. Alongside data mined from electronic medical records, quantitative pixel-based analysis algorithms are increasingly likely to be used to find patterns in images.
Big Data-based screening algorithms, for example, can be used to highlight subtle, multi-dimensional changes in a nodule or a lesion. This can be followed by applications such as curved planar or 3D multi-planar reconstructions, or dynamic contrast enhancement (DCE) texture analysis on highly targeted data subsets, instead of making the time-consuming effort of querying a complete imaging dataset.
Specific examples of such an approach might include diagnosis of lesions in the liver and identification of disease-free liver parenchyma. Another would be volume analysis of lung tumours and solitary pulmonary nodules to decide temporal evolution of lesion. Big data based pattern analysis modules can detect areas of opacities, honeycombing, reticular densities and fibrosis, and thereby provide a list of differentials, using computer aided diagnostic tools.
For tumours, in general, radiologists can run algorithms to check contrast enhancement characteristics, and such metrics can be compared to prior results as well as other pathology data to provide a specific differential list.
Decision support systems
One decision support system based on Big Data assists physicians in providing treatment planning for patients suffering from traumatic brain injury (TBI). The algorithm couples demographic data and medical records of the patient to specific features extracted from CT scans in order to predict intracranial pressure (ICP) levels.
Google’s entry into this field seeks to address real world limitations – not just in terms of human capacities but also trained medical personnel. Its first deep learning imaging algorithm sought to recognize diabetic retinopathy, the fastest growing cause of blindness in poor countries, where a shortage of specialists meant many patients lost their sight before diagnosis.
The promise of AI
Google’s algorithm is based on artificial intelligence (AI), seen as an especially promising catalyst for advances in such areas.
AI-based algorithms, for example, can calculate the volume of bleed on the basis of multiple brain CT slices in stroke patients, with the size of bleed volume indicating urgency as well as care pathway. Another recent algorithm assesses recent infarcts on CT, which can be missed if they are hyper-acute (less than 8-12 hours old), and is therefore relevant to all patients with sudden onset weakness. The University of California in San Francisco has been testing an algorithm to identify pneumothorax in chest radiographs of surgery patients, before they exit the OR (operating room). The aim is to not only avoid the huge costs of a collapsed lung but also ensure that the OR is freed from being used for an otherwise-avoidable procedure.
AI is also being considered for workflow management and triaging. In the near future, it is almost certain that images are screened as data is acquired by a scanner, to distinguish between ‘normal’ and ‘abnormal’ images, prioritize cases according to the likelihood of disease and alerting radiologists to conditions that require urgent attention. The results are tangible and impressive. One algorithm has helped physicians to shrink the time for cardiac diagnoses from 30 minutes to 15 seconds.
Certain vendors are leveraging AI to correlate findings on properties like morphology, cell density or physiological characteristics to expert radiologist’s reports, while taking additional clinical data such as biopsy results into account. Others use reasoning protocols as well as visual technologies such as virtual rendering to analyse medical images. This is then combined with data from a patient’s medical record to offer radiologists and clinicians decision-making support.
AI and the radiologist
So far, algorithms and emerging metrics are expected to be largely used as a complement to decisions made by radiologists.
However, at some point in the future, it seems plausible that radiologists no longer need to look at images at all. Instead, they would simply analyse outcomes of the algorithms.
Once again, AI is at play here. Apart from deep learning algorithms, radiology can claim to be witness to the first successes with the emerging science of ‘swarm’ AI, which helps form a diagnostic consensus by turning groups of human experts into super experts. Swarm AI is directly based on nature, which sees species accomplishing more by participating in a flock, school or colony (a ‘swarm’) than they can individually. One report, published in ‘Public Library of Science (PLOS)’, stated that swarm intelligence could improve other types of medical decision-making, ”including many areas of diagnostic imaging.”
In December 2015, a study in ‘IET Systems Biology’ reported about a swarm intelligence algorithm which assisted “in the identification of metastasis in bone scans and micro-calcifications on mammographs.” The authors, from universities in the UK and India, also reported about the use of the algorithm in assessing CT images of the aorta and in chest X-ray. They proposed a hybrid swarm intelligence approach to detect tumour regions in an abnormal MR brain image.
The future: human-machine symbiosis
AI is unlikely to become a replacement for radiologists, but a tool to help them. According to Curt Langlotz, MD, PhD, professor of radiology and biomedical informatics at Stanford, the “human-machine system always performs better than either alone.”
Geriatric emergency medicine – growing patient numbers drive demand
Just like pediatric emergency units were developed to serve children, healthcare experts are recognizing that older adults require specialized forms of emergency care, which differ from the general population. Indeed, emergency rooms can be unforgiving for the elderly, many of who are often traumatized by the experience.
New geriatric emergency departments have recently begun to emerge, led by the US. They not only provide more appropriate care for older people, but can bring cost savings to a hospital, too.
A major and growing challenge
In the US, up to 25% of ED patients are aged 65 years or older. Indeed, geriatric ED patients represent 43 percent of all admissions, including 48 percent admitted to the intensive care unit (ICU). Geriatric patients in the ED also have an average length of stay that is 20 percent longer than younger populations.
There are no consolidated figures for Europe. However, there are both similarities and differences vis-a-vis the US. In the UK, a Nuffield Trust report in 2009 found nearly 40 percent of all ED admissions being for the over-65s and 10 percent for people aged 85 and above. However, it also observed that “at most, 40 percent of the increased number of emergency admissions” over a four-year period could be explained by the effects of population ageing.
The numbers of elderly are not insignificant.
In the US, the 2010 Census found 13 percent of the population, corresponding to over 40 million people, were over 65 years in age. Their numbers too showed a sharper increase than other population groups, with people in the 85+ age group growing at almost three times the rate of the general population.
The situation in Europe is even more demanding, with 19.2 percent of the population in the 65+ age group in 2016, up from 16.8 percent a decade previously.
Benefits for both elderly and hospitals
There are several benefits which the elderly can derive from a geriatric ED. The most important is optimization of care. This is achieved by focusing resources, attention and capability to their most common risks and needs; the latter differ in several respects from other age groups.
Conversely, a geriatric ED can also provide benefits to a hospital. Improved standards of care for a large patient population are a useful marketing or public relations tool. In the US, hospitals have been marketing the geriatric ED to attract older patients who utilize higher reimbursing programmes. Finally, the case for special geriatric attention has become compelling due to the Affordable Care Act. This reduces reimbursement, should a patient return to the hospital due to iatrogenic complications such as infections and wounds.
Paradigm change for both emergency and geriatric care
Traditionally, ED teams were not provided with training for the care of older people. The ED environment was instead organized according to single organ management. For elderly ED admissions, a more holistic approach was considered as best practice, especially in terms of frailty and geriatric syndromes. Several such attitudes continue to this day.
In parallel, geriatric medicine (GM) has historically avoided paying attention to emergency care contexts, and competencies specifically associated with the elderly (e.g. management of falls, confusion, dementia, delirium, the risk of adverse drug-drug or drug-food interactions); these are as important in an acute care setting as in a geriatric ward. Indeed, various studies have pointed out that underlying vulnerabilities which led to an ER visit may go undetected and unaddressed by emergency room staff.
Compelling evidence
However, it has also become clear that dedicated geriatric EDs can make a major difference in delivering quality care to the elderly. One study used Medicare data from 2012 and 2013 to study falls by the elderly, a significant cause of morbidity – leading to hip fractures and nursing home admissions. The researchers found that less than 4 percent received a physical therapy (PT) consult. On the other hand, they also discovered that readmission rates for another fall within 60 and 180 days dropped significantly in patients who had a PT consult.
A brief history of the geriatric ED
The concept of a geriatric ED took root in the US in 2008. Since then, such facilities have become increasingly common in the country. Figures from the non-profit ECRI institute state there were 50 geriatric EDs in operation in the US in early 2014, with another 150 in development.
The first American hospital to develop a geriatric ED model was Holy Cross Hospital in Silver Spring, Maryland, part of the St. Joseph Mercy Health Systems. The geriatric practice was inspired by the fact that nearly one of five of its ED patients was 65 or older. Moreover, its CEO made a more prosaic observation – that the hospital’s ED was not well suited to take care of his mother.
The Holy Cross Hospital was used to pilot the concept of a geriatric ED. Since then, other St. Joseph Mercy’s hospitals have developed geriatric EDs, as have other hospital groups.
In 2012, the Icahn School of Medicine at Mount Sinai received an award from the US government’s Department of Health and Human Services to implement a geriatric ED model at three major urban hospitals, namely Mount Sinai Medical Center in New York City, Northwestern Memorial Hospital in Chicago and St. Joseph’s Regional Medical Center at Paterson, New Jersey.
Common sense innovations
The practices prescribed by Holy Cross for its pioneering geriatric ED involved simple environmental standards such as natural glare-free lighting, soothing colours, beds rather than gurneys equipped with better mattresses and non-skid flooring. Posters and scales were equipped with larger print, and reading glasses made available. The designers also ensured that rooms/units were large enough to accommodate family members, whose role in care delivery of the elderly is now widely acknowledged.
Staff training
However, the most important developments at the Holy Cross ED concerned staff training and responsibilities. ED staff were given special training in geriatrics, while pharmacists were charged with reviewing medications of every elderly patient, to monitor and analyse them as causative factors for a medical emergency. Lessons from Holy Cross, including the maxim that geriatrics care is the ‘ultimate team environment’, have been transferred to other US healthcare facilities and to hospitals in Europe and elsewhere too.
The expertise a well-trained ED team bring to interactions with a geriatric patient directly impact the latter’s condition. Studies have shown that trained ED staff also lead to the use of relatively less expensive outpatient treatments.
The advantage of training nurses for an ED role was highlighted by the ‘Journal of the American Geriatrics Society’ in January 2018. The article, which studied 57,287 patients over 65, reported that an ED-based transitional care nurse (TCN) programme focused on geriatric care was able to reduce the number of unnecessary hospitalizations by 33 percent. Its co-author, Scott Dresden, MD, an Assistant Professor of Emergency Medicine at Northwestern University wrote that the programme “created an otherwise non-existent safety net for this vulnerable population.”
Holy Cross’ first ED also ushered in a full-time, trained geriatric social worker, dedicated to emergency rooms. According to some estimates, geriatric ED patients are 400% more likely to require social services than the general population. Indeed, social workers play a key role in advising and assisting elderly patients to get post-ED care, after discharge. They also seek to know the patients and discover underlying reasons for their coming to the ED.
Reducing re-admissions and penalties
Overall, US hospitals are being compelled by the Affordable Care Act to reduce iatrogenic complications in the elderly. One study showed that 40 percent of emergency room patients older than 65, who had been denied admission, returned to EDs with conditions which had worsened. An article in ‘Modern Physician’ found that 27 percent of elderly patients either returned to the ED for admission or died, in the first three months after a hospital visit.
The ‘Modern Physician’ article, however, observed that 30-day readmission rates for the elderly at Holy Cross Hospital halved after it set up a geriatric ED, from 10.9 percent to 5.2 percent. Results at another geriatric ED, at St. Joseph Regional Medical Center in Paterson, New Jersey, were even more dramatic: returns of elderly ED patients dropped from 20 percent to just over 1 percent.
Guidelines
Geriatric ED practices are the target of new guidelines in the US, developed by The American College of Emergency Physicians (ACEP), the American Geriatrics Society (AGS) and the Society for Academic Emergency Medicine (SAEM). These call for education and training of medical staff, making specific risk-assessments of senior patients and screening those considered to be vulnerable for co-morbidities such as cognitive problems, falls, etc., performing a comprehensive review of medication, and providing a comprehensive discharge plan.
As part of their geriatric risk management, some hospitals are emphasizing the screening and triaging of elderly patients beyond their primary complaint. One popular tool here is the Identification of Seniors at Risk (ISAR), a simple patient checklist to be completed at the point of entry.
Another innovation is the use of telemedicine as part of ED discharge plans, with a typical 72 hours of coverage at home via video monitoring, and then transitioning care to a primary care physician.
Accreditation
On its part, ACEP has recently launched an accreditation programme for emergency rooms, with three levels of accreditation — basic, intermediate and advanced.
All ACEP accredited facilities must provide elderly patients with walkers, canes and reading glasses. Intermediate accreditation requires provision of suitable lighting and non-slip floors, along with hearing aids, thicker mattresses and warm blankets. Advanced accreditation targets physician-supervised improvement initiatives, such as limiting the use of urinary catheters in older patients.
Europe launches GEM curriculum
In Europe, too, efforts are being made by professional societies to develop a validated curriculum on geriatric emergency medicine (GEM). The curriculum is thorough and covers a full spectrum of activity: pre-hospital care, primary clinical assessment and stabilization, secondary clinical assessment, medication, pain management, palliative care and transitional care, along with continuous attention to typical co-morbidities in the elderly and to differences in care paradigms and challenges vis-a-vis younger age groups.
Geriatric friendly – a new standard?
In the long run, we may well witness some major re-thinking about the impact of geriatric ED. Mark Rosenberg, who heads geriatric emergency medicine at St. Joseph’s – one of the three hospitals that received US government funding in 2012 for implementing a geriatric emergency practice – suggests that if an ED is designed for the most vulnerable patients, it will work for the strongest patients as well. In other words, he argues that all EDs should be designed to be geriatric-friendly, as a baseline standard.