Clinical Judgement

ObjectivesTo compare the performance of a validated automatic computer-aided risk of mortality (CARM) score versus medical judgement in predicting the risk of in-hospital mortality for patients following emergency medical admission.DesignA prospective study.SettingConsecutive emergency medical admissions in York hospital.ParticipantsElderly medical admissions in one ward were assigned a risk of death at the first post-take ward round by consultant staff over a 2-week period. The consultant medical staff used the same variables to assign a risk of death to the patient as the CARM (age, sex, National Early Warning Score and blood test results) but also had access to the clinical history, examination findings and any immediately available investigations such as ECGs. The performance of the CARM versus consultant medical judgement was compared using the c-statistic and the positive predictive value (PPV).ResultsThe in-hospital mortality was 31.8% (130/409). For patients with complete bl...

The study sought to assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury. We prospectively enrolled all adult patients (older than 16years) who were considered to have stable blunt chest trauma over a six-month period (May 1-October 31, 2009). We defined the latter as patients who were unintubated, normotensive (systolic blood pressure > 90 mm Hg) and without hypoxia (oxygen saturation> 95% at room air). Patients eligible for the study were sent for anteroposterior (AP) CXRs which were then interpreted by the same consultant radiologist throughout the study period. Both test (clinical judgement) and disease status (CXR) were assigned and correlated as binary measures. We compared the test performance characteristics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) a...

The construction of a screening scale for states of anxiety and depression among primary health care (PHC) patients is described. Most of the scale items were selected from a pool of items chosen from two international screening scales which were validated locally, namely the Self‐Reporting Questionnaire (SRQ‐20) and the Hospital Anxiety and Depression (HAD) Scale. A validity study of a new sample of PHC patients indicated that the scale provided a valid measure of anxiety and depressive states, and was closely correlated with the psychiatrist's clinical judgement. The scale correlated more strongly with the psychiatrist's clinical judgement than the general practitioners' assessments. Two cut‐off points were established, one of which is more appropriate for clinical use and the other for prevalence estimation. The former threshold of the scale could be used to alert the busy general practitioner to the possibility that clinically significant anxiety or depression may be...

Background
Coercion is no longer a valuable practice in conveying good care in French psychiatry. However, the paradoxical consequence of this new consensus is to lock psychiatric practice into a double bind: psychiatric coercion is judged as an “abuse of power” and for its “permissiveness”.
Aims
To analyze this moral anomaly by describing the concrete practice of coercion and its justifications in psychiatry as a solution to the clinical problem of agitation.
Methods
From a medical anthropology perspective on coercion practices in psychiatric hospitals, describe and compare what psychiatrists do and why.
Results
A brief description of a case shows the concrete problem of psychomotor agitation, and its clinical judgment leads to a typology of customary ways of justifying coercion.
Conclusions
The category of violence blurs the clinical meaning of psychomotor agitation as much as it does the practice of physical restraint in psychiatry.

Keywords
Medical anthropology, Clinical Judgment formation, Psychiatry, Coercion, Agitation, Violence

Background: Research suggests that diagnostic procedures for Autism Spectrum Disorder are not consistent across practice and that diagnostic rates can be affected by contextual and social drivers. The purpose of this review was to consider how the content of clinical practice guidelines shapes diagnoses of Autism Spectrum Disorder in the UK; and investigate where, within those guidelines, social factors and influences are considered. Methods: We electronically searched multiple databases (NICE Evidence Base; TRIP; Social Policy and Practice; US National Guidelines Clearinghouse; HMIC; The Cochrane Library; Embase; Global health; Ovid; PsychARTICLES; PsychINFO) and relevant web sources (government, professional and regional NHS websites) for clinical practice guidelines. We extracted details of key diagnostic elements such as assessment process and diagnostic tools. A qualitative narrative analysis was conducted to identify social factors and influences. Results: Twenty-one documents were found and analysed. Guidelines varied in recommendations for use of diagnostic tools and assessment procedures. Although multidisciplinary assessment was identified as the 'ideal' assessment, some guidelines suggested in practice one experienced healthcare professional was sufficient. Social factors in operational, interactional and contextual areas added complexity to guidelines but there were few concrete recommendations as to how these factors should be operationalized for best diagnostic outcomes. Conclusion: Although individual guidelines appeared to present a coherent and systematic assessment process, they varied enough in their recommendations to make the choices available to healthcare professionals particularly complex and confusing. We recommend a more explicit acknowledgement of social factors in clinical practice guidelines with advice about how they should be managed and operationalised to enable more consistency of practice and transparency for those coming for diagnosis.

Given the recent debates between Giorgi, van Manen, Smith, Morley, and Zahavi with regard to whether or not Husserl's reflective method - with its epoché and reductions - makes sense as a foundation for empirical psychological research, I decided to revisit the methodology of my 1984 doctoral dissertation on "Psychodiagnostic Seeing" and articulate it here in a more pedagogical manner, taking the reader through the intricacies of the phenomenological method as applied to the study of clinical intution. Husserl's method of intentional analysis, also known as "noetico-noematic analysis", is defined and presented here in connection with Gurwistch's discussion of Husserl's constitutive phenomenology and Spiegelberg's elaboration of the three dimension of all phenomenological research: intuition, analysis,  and description. A brief excerpt from the findings of my dissertation (Churchill, 1984b) is presented to illustrate the method. The article aims to demonstrate that there is, in fact and in practice, a viable application of Husserl's method for psychologically focused qualitative research.

This manual was written as a distillation of our training, our experience and our practice as forensic psychiatrists. Between us we have worked in four different countries so we hope that the structured professional judgement instruments contained here will work in a variety of health services and jurisdictions. With this in mind, the definitions, items and scales emphasise patient focused rather than institutional or local legal factors, in so far as possible. It is fashionable to say that a culture speaks through the authors of a text rather than the authors creating anything new. In this sense, any expertise we have drawn on is derived from a shared scientific culture, as described by Collins & Evans (2007). If this is the case then we hope that we are articulating a multidisciplinary forensic mental health culture because many colleagues have contributed to this text through comments, criticisms and feedback, while many more have educated and enculturated us over the years, including many of our patients who are contributors to that culture.. Those we should acknowledge as having directly helped in the drafting of this manual are numerous. We feel we must however acknowledge by name our colleagues at the Central Mental Hospital, Dundrum who have been involved in the development of this manual, including

Acknowledgements This manual was written as a distillation of our training, our experience and our practice as forensic psychiatrists. Between us we have worked in four different countries so we hope that the structured professional judgement instruments contained here will work in a variety of health services and jurisdictions. With this in mind, the definitions, items and scales emphasise patient focused rather than institutional or local legal factors, in so far as possible. It is fashionable to say that a culture speaks through the authors of a text rather than the authors creating anything new. In this sense, any expertise we have drawn on is derived from a shared scientific culture, as described by Collins & Evans (2007). If this is the case then we hope that we are articulating a multidisciplinary forensic mental health culture because many colleagues have contributed to this text through comments, criticisms and feedback, while many more have educated and enculturated us ove...

Objectives:Structured professional judgement is now the most widely accepted approach to clinical risk assessment and risk management. The Suicide Risk Assessment and Management Manual (S-RAMM) is a new structured professional judgement tool closely modelled on the HCR-20. This is the first prospective validation study for this instrument.Methods:Two post-membership registrars jointly interviewed 81 of 83 current inpatients to rate the S-RAMM. Two assistant psychologists independently rated the HCR-20, GAF and PANSS. All incidents of self-harm, attempted suicide, suicide and violence to others were collated from hospital reporting of critical incidents over the next six months supplemented by examination of other records.Results:For combined self-harm and suicide outcomes, the S-RAMM total score using the receiver operating characteristic had an area under the curve AUC=0.89, (95% CI 0.79 to 0.99). The S-RAMM performed as well for the prediction of self-harm and suicide as the HCR-2...

Background: Estimation of the correct depth of insertion of a tracheal tube (TT) in children is extremely important. Insertion of an excessive length may result in endobronchial intubation while an inadequate length of insertion may lead to accidental extubation. Methods: We reviewed TTs commonly used in paediatric practice and also reviewed recommended guidelines for correct depth of insertion. Results: Amongst the different brands of TTs used, there was a wide discrepancy in the placement of the intubation depth marker. This is important as the intubation depth marker is often used as a guideline for intubation. Conclusions: For optimal placement we can rely on various formulae and manufacturers' markings on the TTs. Clinical judgement, however, remains the cornerstone of optimal placement.

Aims and objectives.  To consider the validity and reliability of risk assessment scales for pressure ulcers.Background.  Pressure ulcers are a major problem worldwide. They cause morbidity and lead to mortality. Risk assessment scales have been available for nearly 50 years, but there is insufficient evidence to state with any certainty that they are useful.Design.  A literature review and commentary.Methods.  Bibliographic databases were searched for relevant papers, a critical review was completed on relevant papers.Results.  There is contradictory evidence concerning the validity of risk assesment scales. The interaction of education, clinical judgement and use of risk assessment sakes has not been fully explored. It is not known which of these is most important, nor whether combining them results in better patient care.Conclusions.  There is a need for further work. A study exploring the complex interaction of risk assessment scales, clinical judgement and education and trainin...

The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports.

Arousal status of patient in correlation with anaesthetic effect is the vital consideration for an anaesthesiologist. Recent anaesthesia has proposed hi-tech solutions to deal with it. This review throws a light on practical and realistic approaches prior equipping the O.T. with sophisticated depth of anaesthesia monitors. This review includes information from literature on health technology assessment, Bi-spectral Index (BIS) and anaesthesia’s current practice. It also portrays Indian and UK anaesthesiologist’s perspectives on deployment of BIS and other similar modalities .It is expected that this article will help to save significant amount of overuse of healthcare resources in low resource settings by providing insight on ethical and economical aspects on use of such technology.

A337 satisfaction domains exhibited the strongest signifi cant results amongst all three tests. However, while the convenience domain exhibited strongly signifi cant measurement equivalence for the CTT, it only exhibited signifi cant results for the SEM and DIF. CONCLUSIONS: While all three methods indicated the same overall results, there is some suggestion of differing sensitivity amongst the tests.

Background: Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is currently based on the clinical judgement of the medical team, without de ned indications. This study aims to identify presenting symptoms and physical exam ndings associated with relative positive ndings on neuroimaging studies, Methods: This study was conducted by reviewing the electronic medical records of patients presenting to the Emergency Department (ED) with isolated neuro-ophthalmologic complaints between January 1 st , 2013 and September 30 th 2019. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses. Results: We reviewed the charts of 211 patients of whom 50.7% were females and had a mean age of 41.2 ±21.4 years. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal ndings. Complaining of blurry vision (p=0.038) or visual eld changes (p=0.014) at presentation were associated with having positive ndings on imaging. Physical exam ndings of a visual eld defect (p=0.016), abnormal pupil reactivity (p=0.028), afferent pupillary defect (p=0.018), or abnormal optic disc exam (p=0.009) were also associated with positive ndings on imaging. Conclusion: Neuroimaging is more likely to yield positive ndings in patients presenting to the ED with blurred vision or changes in visual eld and in those found to have visual eld irregularities, afferent pupillary defects or abnormal optic discs on physical exam. These ndings-when combined with the proper clinical settingshould lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making. Key Messages • What is already known about this subject? The advancements in neuroimaging is allowing physicians to distinguish brain lesions. The most commonly used imaging modalities by neuro-ophthalmologists would be the Brain Computed tomography (CT) and Magnetic resonance imaging (MRI). There is overuse of such imaging especially in non-indicated cases. There are however, some ndings on history and physical exam that would suggest positive ndings on imaging. Multiple studies previously commented on those ndings separately. • What are the new ndings? Our study presents grouping of risk indicators in both history and physical exam (mainly ophthalmological) that would suggest an abnormal neuroimaging in the setting of neuro-ophthalmological emergencies. They are blurred vision, or changes in visual eld on history taking. While visual eld irregularities, abnormal pupil reactivity with or without afferent pupillary defect or abnormal optic discs, on physical exam. We nally

The development and evaluation of a brief risk screening instrument for the psychiatric inpatient setting This paper reports on the development and evaluation of a risk screening instrument (RSI) intended for use by nursing sta on general acute psychiatric admission wards. The RSI comprised six questions concerning patient status on admission (e.g. sex, legal status, employment) and 11 items of judgement concerning the presentation of the patient (e.g. threatening behaviour, suicidality, family and social support). The interrater reliability of the RSI was calculated to be 85% overall. The predictive value of the RSI was not con®rmed when tested against harmful incidents subsequent to admission. However, the mean RSI score of that group of patients involved in harmful incidents tended to be higher than that group of patients not involved in such incidents, and all such incidents were found to occur within eight days of admission. Analysis of other data collected in the course of the study revealed discrete patient groups and provided systematic insights into their characteristics, which are potentially valuable when considering the nursing skills required on acute psychiatric inpatient units. It is concluded that the RSI tested has the potential to contribute to the assessment and management of risk within the acute psychiatric inpatient setting, by augmenting and guiding clinical judgement.

Anna-Marie Welman, thank you for all the phone calls and help. Annamarie du Preez, without your diligent searches and help in the library the research would not have seen the light, thank you. Cecilna Grobler, there is no adequate manner in which to thank you for all you have done but do accept my heartfelt thanks. Thank you for the formatting of the dissertation. You are a wonderful friend. Thank you to all my colleagues at the School of Nursing, the many times I received encouragement and words of advice. Among you there is a special person receiving special thanks. Magda Mulder, I am glad you also had a part in the work, thank you for the Afrikaans translation. The two people who did the language editing, Ella and Christo, thank you for patching my quilt. Last but never the least, Yvonne Botma. Thank you for accompanying me on this journey as mentor, colleague and friend. Thank you for coping with my demanding habits and being available to provide the necessary help.

Background: Research suggests that diagnostic procedures for Autism Spectrum Disorder are not consistent across practice and that diagnostic rates can be affected by contextual and social drivers. The purpose of this review was to consider how the content of clinical practice guidelines shapes diagnoses of Autism Spectrum Disorder in the UK; and investigate where, within those guidelines, social factors and influences are considered. Methods: We electronically searched multiple databases (NICE Evidence Base; TRIP; Social Policy and Practice; US National Guidelines Clearinghouse; HMIC; The Cochrane Library; Embase; Global health; Ovid; PsychARTICLES; PsychINFO) and relevant web sources (government, professional and regional NHS websites) for clinical practice guidelines. We extracted details of key diagnostic elements such as assessment process and diagnostic tools. A qualitative narrative analysis was conducted to identify social factors and influences. Results: Twenty-one documents were found and analysed. Guidelines varied in recommendations for use of diagnostic tools and assessment procedures. Although multidisciplinary assessment was identified as the 'ideal' assessment, some guidelines suggested in practice one experienced healthcare professional was sufficient. Social factors in operational, interactional and contextual areas added complexity to guidelines but there were few concrete recommendations as to how these factors should be operationalized for best diagnostic outcomes. Conclusion: Although individual guidelines appeared to present a coherent and systematic assessment process, they varied enough in their recommendations to make the choices available to healthcare professionals particularly complex and confusing. We recommend a more explicit acknowledgement of social factors in clinical practice guidelines with advice about how they should be managed and operationalised to enable more consistency of practice and transparency for those coming for diagnosis.

Clinical evolution in patients affected by community acquired pneumonia varies from a mild and low risk infectious disease to an extremely severe, life threatening disease. Commonly, immunocompetent adults without co-morbidities or severe risk factors cared for at out patient clinic have low risk of complications and death (mortality below 1-2%); it increases to 5-15% in patients with co-morbidities and/or with specific risk factors that are admitted into the hospital and reaches 20-50% in those patients admitted into ICUs. Evaluation of severity in patients with pneumonia allows the prediction of disease evolution, establishing the proper setting of care, the type-of microbiological tests needed, and to choose the best empiric antibiotic treatment. It is suggested that patients be in three risk categories: low risk (mortality under 1-2%) susceptible to ambulatory treatment; high risk patients (mortality 20-30%) that need specialized wards; and intermediate risk patients, with co-morbidities and/or risk factors for complicated clinical evolution and death, but cannot be classified in a specific category. In the ambulatory setting, without availability of complete laboratory exams, it is recommended to evaluating the severity of pneumonia considering the following clinical variables: age over 65 years, presence of co-morbidities, sensorial compromise, vital signs alteration, degree of radiological involvement: multilobar, bilateral findings, cavitations), pleural effusion and arterial oximetry < 90%. However, clinical judgement and the physician´s experience must predominate over predictive models, which are not infallible.

While research generally demonstrates the efficacy of attachment-based interventions for supporting families and children, less is known about the constituent elements of these interventions and their effects. Existing tools for extracting information about these elements from psychosocial intervention studies do not differentiate between techniques used in attachment-based interventions. Therefore, a novel extension of the PracticeWise coding system was developed for attachment-based interventions. This paper describes the development of this new extension. A systematic literature search of randomized controlled trials of attachment-based interventions (1998-2018) identified 66 publications. This led to N = 49 unique attachment-based interventions. Study authors were requested to share the intervention manuals for these trials. Publications or, if available, manuals were initially coded using the standard PracticeWise coding system. Techniques falling under the general definition of a practice element, but not captured by the standard system, formed the basis for a novel set of subcategories. To identify and develop definitions for this novel subset of practice elements, the publications and manuals were carefully examined and initial codes were developed inductively for each intervention, and then discussed to reach consensus. These codes were then applied across all interventions. Through an iterative process, 16 unique practice elements were identified and defined, and clustered into five thematic groupings: Modelling; Parent-Child Interaction (Behavior-focused); Mental Representations (Representation-focused); Education & Guidance; Other. As an illustration, the Attachment and Biobehavioral Catch-up intervention is described using the novel supplemental practice elements coding system.

A retrospective review of 1900 road accident victims attending the emergency departments of two Melbourne hospitals was undertaken fo identify lnjuy Severi@ Score levels which could distinguish between nlinor, moderate, severe and critical inju y. Injuries scoring 1SS 6 or below were designated 'minor' because they were associated with a low risk of requiring admission to hospital. Case notes of patients scoring above ISS 6 were then reviewed by a panel of clinicians, who independently rafed each pafienb's overall injury severi/y as moderate, severe or c&al according to what was recorded in the notes and their 'clinical' judgement. I.% values were compared with clinicians' ratings. Measures of each clinician's individual rating conk&my, and correlation between pairs of clinicians wifh respect to inter-rater consistency, were made. By combining data from both hospituls it emerged that 'moderate' injury corresponded to ISS 8-13, 'severe' to IS!? 74-20 and 'critical' to 15521 and above. These 1% breakpoints will be useful in selecting groups of injured patients for future trauma audit studies.

Three groups of ten professional psychologists were provided with differing types of information about an actual counseling client: one group received minimal, or stereotype, information about the client (Stereotype Group); a second group received minimal information and viewed videotaped excerpts from a counseling session with the client (Stereotype-Video Group); and a third received both of these types of information plus test protocols from a standard test battery administered to the client (Stereotype-Video-Diagnostics Group). All subjects then made a number of clinical judgments about the client. These included: (1) predicting how the client described herself on a personality checklist (Predictive Task), (2) evaluating the client on a number of clinical dimensions (Evaluative Task), and (3) diagnosis of the client. Judges were also asked to rate their confidence in the accuracy of each judgment made.It was concluded that type of information may have complex differential effects...

Summary: The Lasater Clinical Judgement Rubric (LCJR) is frequently used in clinical judgement assessment in education, but there are few clinical studies to illustrate its validity or identify predictors of clinical judgement scores. This study validated the LCJR and found years of nursing experience to be predictive of higher LCJR scores. Content Outline: Introduction A. Importance of Clinical Judgement in Nursing B. Measurements of Clinical Judgement C. Impact questions of stress in a simulation D. Purpose of the study

Background: The accuracy of General Practitioners' (GPs') clinical judgement for diagnosing dementia is uncertain. Aim: Investigate the accuracy of GPs' clinical judgement for the diagnosis of dementia. Design and Se ing: Diagnostic test accuracy study, recruiting from 21 practices around Bristol. Method: The clinical judgement of the treating GP (index test) was based on the information immediately available at their initial consultation with a person aged over 70 years who had symptoms of possible dementia. The reference standard was an assessment by a specialist clinician, based on a standardised clinical examination and made according to ICD-10 criteria for dementia. Results: 240 people were recruited, with a median age of 80 years (IQR 75 to 84 years), of whom 126 (53%) were men and 132 (55%) had dementia. The median duration of symptoms was 24 months (IQR 12 to 36 months) and the median ACE-III score was 75 (IQR 65 to 87). GP clinical judgement had sensitivity 56% (95% CI 47% to 65%) and specificity 89% (95% CI 81% to 94%). Positive likelihood ratio was higher in people aged 70-79 years (6.5, 95% CI 2.9 to 15) compared to people aged ≥ 80 years (3.6, 95% CI 1.7 to 7.6), and in women (10.4, 95% CI 3.4 to 31.7) compared to men (3.2, 95% CI 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups. Conclusion: GP judgement is more likely to under identify rather than over identify dementia.

A 4-year-old border collie who participates in agility, is presented to you for poor performance and consistently missing weave polls. You find pain with manipulation of the shoulder joint and suspect medial shoulder instability. How do you best treat this patient?

Aims. To review, discuss and compare nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks. Background. Scope of practice in professional nursing and midwifery is an evolving process which needs to be responsive to clinical, service, societal, demographic and fiscal changes. Codes and frameworks offer a system of rules and principles by which the nursing and midwifery professions are expected to regulate members and demonstrate responsibility to society. Design. Discussion paper. Data sources. Twelve scope of practice and associated decision-making frameworks (January 2000-March 2014). Implications for nursing. Two main approaches to the regulation of the scope of practice and associated decision-making frameworks exist internationally. The first approach is policy and regulation driven and behaviour oriented. The second approach is based on notions of autonomous decision-making, professionalism and accountability. The two approaches are not mutually exclusive, but have similar elements with a different emphasis. Both approaches lack explicit recognition of the aesthetic aspects of care and patient choice, which is a fundamental principle of evidence-based practice. Conclusion. Nursing organizations, regulatory authorities and nurses should recognize that scope of practice and the associated responsibility for decisionmaking provides a very public statement about the status of nursing in a given jurisdiction.

Background: Patients' satisfaction is a useful measure to provide an indicator of quality in healthcare and thus needs to be measured frequently. The aim of the study was to analyse and compare the level of satisfaction of patients attending the Outpatient Department of a Hospital. Methods: Study was conducted by using a pre-structured questionnaire with 120 samples. Samples were further stratified into sub-populations of Officers, Junior Commissioned Officers (JCOs) and Other Ranks (ORs) including dependents as study population. Results: JCOs predominantly expressed lower satisfaction judgement with several attributes. Overall satisfaction judgement with Outpatient Department services were rated lower by JCOs (2.56) when compared with Officers and ORs (3.10), the difference being statistically significant. Conclusion: Statistically significant differences have been identified by this study against various study attributes as well as overall impression towards OPD services among the study groups, which need to be addressed by the hospital leadership to achieve consumer delight.

Patients&#39; satisfaction is a useful measure to provide an indicator of quality in healthcare and thus needs to be measured frequently. The aim of the study was to analyse and compare the level of satisfaction of patients attending the Outpatient Department of a Hospital. Study was conducted by using a pre-structured questionnaire with 120 samples. Samples were further stratified into sub-populations of Officers, Junior Commissioned Officers (JCOs) and Other Ranks (ORs) including dependents as study population. JCOs predominantly expressed lower satisfaction judgement with several attributes. Overall satisfaction judgement with Outpatient Department services were rated lower by JCOs (2.56) when compared with Officers and ORs (3.10), the difference being statistically significant. Statistically significant differences have been identified by this study against various study attributes as well as overall impression towards OPD services among the study groups, which need to be addres...

show that pre-encountered data and knowing the patient are important factors. Expert nurses mobilise their knowledge to discriminate between pain-related agitation and agitation caused by other factors by generating hypothesis. They perform analgesic tests to confirm or refute pain. Counterbalancing the benefits and adverse effects of analgesia and sedation is also part of their clinical judgement when making decision about pain management. Conclusions The clinical context of the patient plays an important part in nurses' judgment about pain. To facilitate this difficult task, pain assessment should be combined with sedation assessment in critically ill children.

Aims. To review, discuss and compare nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks. Background. Scope of practice in professional nursing and midwifery is an evolving process which needs to be responsive to clinical, service, societal, demographic and fiscal changes. Codes and frameworks offer a system of rules and principles by which the nursing and midwifery professions are expected to regulate members and demonstrate responsibility to society. Design. Discussion paper. Data sources. Twelve scope of practice and associated decision-making frameworks (January 2000-March 2014). Implications for nursing. Two main approaches to the regulation of the scope of practice and associated decision-making frameworks exist internationally. The first approach is policy and regulation driven and behaviour oriented. The second approach is based on notions of autonomous decision-making, professionalism and accountability. The two approaches are not mutually exclusive, but have similar elements with a different emphasis. Both approaches lack explicit recognition of the aesthetic aspects of care and patient choice, which is a fundamental principle of evidence-based practice. Conclusion. Nursing organizations, regulatory authorities and nurses should recognize that scope of practice and the associated responsibility for decisionmaking provides a very public statement about the status of nursing in a given jurisdiction.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

The present research aimed to investigate the effects of attribution on expert clinical judgment in comparison to semi-experts and lay-people. Two research questions were addressed. Firstly, would experts be less subject to attributional manipulations, in terms of their perceived ratings of dangerousness, than would semi-experts or lay-people? Second, would experts be less subject to attributional manipulations, in terms of their assessments of offender responsibility, than would semi-experts or lay-people? Method: A 3x3x2 mixed groups design was implemented. Participants read nine crime scenarios that had been internally or externally manipulated. For each scenario, participants were asked to rate offender dangerousness, offender responsibility and the seriousness of the crime and to suggest a suitable sentence length. Targeted recruitment was employed, yielding 12 experts, 21 semi-experts and 22 lay-people. Results: Offenders were considered to be more responsible for their actions and more dangerous to others in the internal manipulations than in the external ones across all crime types and by all levels of expertise. Findings indicate that semi-experts are less subject to the influence of attributional manipulations than both experts and lay-people. Marked similarities in the pattern of expert and lay-person judgments can be observed from the present analyses. Conclusions: The current findings lend support to previous research in the area in that similarities between expert and lay-person judgment were observed. However, through

L'objectif de la formation est d'identifier les procédures de conversions de l’expérience clinique et non clinique en repères théoriques pour améliorer le jugement clinique. La séance 1 montre comment modéliser un jugement clinique en anthropologie médicale. La séance 2 montre comment analyser des jugements cliniques.

Research on human judgment has now extended well beyond the issue of the clinician versus the actuary. To the detriment of psychology, the application of the judgment findings to clinical diagnosis and treatment has not grown accordingly. In this article, what have been separately addressed aspects of the judgment research are combined, and their broader implications are examined. The unsatisfactory performance levels typical on judgment tasks are reviewed, and two underlying causes-problematic judgment habits and human cognitive limitations-are discussed. Problematic habits and judgment limitations may be of central relevance to longstanding puzzles and difficulties within psychology, which include low diagnostic reliability and validity, the comparative success of psychometric instruments and diagnostic strategies, problems in uncovering specific treatment effects, and the minimal gains accrued through experience. Corrective measures that are likely to improve judgment accuracy arc discussed.

One of the responsibilities of a consultant is to identify the clinical competence of trainees by observing them at work. The attributes of clinical competence in anaesthesia were defined by interviewing a group of consultants and trainees. Observation of practice was believed to be important in monitoring competence and the supervising consultants all believed that they could recognize competent performance. The account of the structure of observation provided by the anaesthetists is used as the basis of advice on how to conduct an assessment of trainees' developing professionalism by use of the specialist's professional judgement.

Objective The Paediatric Admission Guidance in the Emergency Department (PAGE) score is an assessment tool currently in development that helps predict hospital admission using components including patient characteristics, vital signs (heart rate, temperature, respiratory rate and oxygen saturation) and clinical features (eg, breathing, behaviour and nurse judgement). It aims to assist in safe admission and discharge decision making in environments such as emergency departments and urgent care centres. Determining the inter-rater reliability of scoring tools such as PAGE can be difficult. The aim of this study was to determine the inter-rater reliability of seven clinical components of the PAGE Score. Design Inter-rater reliability was measured by each patient having their clinical components recorded by two separate raters in succession. The first rater was the assessing nurse, and the second rater was a research nurse. Setting Two emergency departments and one urgent care centre in the North West of England. Measurements were recorded over 1 week; data were collected for half a day at each of the three sites. Patients A convenience sample of 90 paediatric attendees (aged 0-16 years), 30 from each of the three sites. Main outcome measures Two independent measures for each child were compared using kappa or prevalence-adjusted bias-adjusted kappa (PABAK). Bland-Altman plots were also constructed for continuous measurements. Results Inter-rater reliability ranged from moderate (0.62 (95% CI 0.48 to 0.74) weighted kappa) to very good (0.98 (95% CI 95 to 0.99) weighted kappa) for all measurements except 'nurse judgement' for which agreement was fair (0.30, 95% CI 0.09 to 0.50 PABAK). Complete information from both raters on all the clinical components of the PAGE score were available for 73 children (81%). These total scores showed good' inter-rater reliability (0.64 (95% CI 0.53 to 0.74) weighted kappa). Conclusions Our findings suggest different nurses would demonstrate good inter-rater reliability when collecting acute assessments needed for the PAGE score, reinforcing the applicability of the tool. The importance of determining reliability in scoring systems is highlighted and a suitable methodology was presented.

Patient monitoring on low acuity general hospital wards is currently based largely on intermittent observations and measurements of simple variables, such as blood pressure and temperature, by nursing staff. Often several hours can pass between such measurements and patient deterioration can go unnoticed. Moreover, the integration and interpretation of the information gleaned through these measurements remains highly dependent on clinical judgement. More intensive monitoring, which is commonly used in peri-operative and intensive care settings, is more likely to lead to the early identification of patients who are developing complications than is intermittent monitoring. Early identification can trigger appropriate management, thereby reducing the need for higher acuity care, reducing hospital lengths of stay and admission costs and even, at times, improving survival. However, this degree of monitoring has thus far been considered largely inappropriate for general hospital ward settings due to device costs and the need for staff expertise in data interpretation. In this review, we discuss some developing options to improve patient monitoring and thus detection of deterioration in low acuity general hospital wards.

Rationale: To analyze if body mass index (BMI) was related to 5-yr mortality and if mortality predicting capacity of BMI differed if calculated by current height (CH) or by middle age height (MH), in old males. Methods: 512 men of the Uppsala Longitudinal Study of Adult Men (ULSAM) were analyzed. BMI was calculated using weight at age 82 yrs, and measured height at either age 50, i.e. at the first visit of the ULSAM Study, or 82 yrs resulting in BMI MH and BMI CH (kg/m 2). Various BMI cutoff values were tested in order to possibly identify a BMI value discriminating for increased risk of mortal outcome after 5 yrs. Mortality data was obtained from the Swedish population records. Results: There was an average reduction in body height of 3.5±1.9 cm (p < 0.05) from age 50 to 82 yrs. Mean BMI CH was 26.1 and BMI MH was 25 kg/m 2 (p < 0.05) at age 82. Analyses for BMI CH indicated that <23 kg/m 2 was associated with increased risk of dying, i.e. 39% had passed away after 5 years, as compared to 24% in the group of old men with BMI CH 23 kg/m 2 , respectively (p < 0.05). Analyses for BMI MH indicated a corresponding cutoff value of 21 kg/m 2 , i.e. 44% had died after 5 years, as compared to 25% of those with BMI MH 21 kg/m 2 (p < 0.05). Obesity (BMI > 30) by BMI CH and BMI MH was observed in 7% and 4% respectively, and not associated with excess 5-year mortality. Conclusion: In Swedish 82 yr old healthy communitydwelling men, the use of current height for calculating BMI (BMI CH) defined a cutoff at 23 kg/m 2 for underweight associated with increased 5-year mortality, whereas corresponding cutoff for BMI calculated by height at 50 yrs (BMI MH) was <21 kg/m 2. Thus, the BMI cutoff value for defining underweight should be adapted to the method used for body height determination. In this small sample of old men obesity was not related to excess mortality.

This manual was written as a distillation of our training, our experience and our practice as forensic psychiatrists. Between us we have worked in four different countries so we hope that the structured professional judgement instruments contained here will work in a variety of health services and jurisdictions. With this in mind, the definitions, items and scales emphasise patient focused rather than institutional or local legal factors, in so far as possible. It is fashionable to say that a culture speaks through the authors of a text rather than the authors creating anything new. In this sense, any expertise we have drawn on is derived from a shared scientific culture, as described by Collins & Evans (2007). If this is the case then we hope that we are articulating a multidisciplinary forensic mental health culture because many colleagues have contributed to this text through comments, criticisms and feedback, while many more have educated and enculturated us over the years, including many of our patients who are contributors to that culture.. Those we should acknowledge as having directly helped in the drafting of this manual are numerous. We feel we must however acknowledge by name our colleagues at the Central Mental Hospital, Dundrum who have been involved in the development of this manual, including

Background and methods: Abdominal trauma poses a diagnostic challenge to most trauma surgeons. This study evaluates a clinical scoring system in 476 blunt abdominal trauma patients treated by the author over a period of 92 months. Patients were sorted into three groups according to the score results. Priority I group (160 patients) was subjected to an immediate laparotomy. Priority II group (200 patients) was treated according to the results of auxiliary investigations. Priority III group (116 patients) was kept under observation. The treatment outcome was used as a gold standard for the evaluation of the results. Results: In priority I and III groups (276 cases) the management was only dependent on the proposed clinical score with a 100% specificity, 88% sensitivity, 90% positive predictive value, 100% negative predictive value and an overall accuracy of 94%. Conclusions: This scoring system (CASS) is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality that may result from improper and/or delayed diagnosis.

Background: Laparoscopic cholecystectomy (LC) has become the gold standard treatment for gallstone disease. Though mostly safe occasionally it can be difficult due to various problems faced during surgical procedure. Anticipation of likely difficulty can help in avoiding complications. Methods: With the aim of identifying various predictors of difficulty and their correlation with likely difficulty this prospective study on 50 adults undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis was undertaken. Various clinical, radiological and biochemical predictors and frequency and type of intraoperative difficulty was recorded. Results: In present study adverse clinical factors only showed significant predictive value (p value-0.005). Adverse radiological predictors although showing trend towards, did not achieve statistical significance (p value 0.065). In clinical predictors duration of symptoms >1yr, History of acute cholecystitis and BMI >30 showed statistically significant association. Age >50yrs, Male gender, radiological predictors (Thickened gall bladder wall, small contracted gall bladder, Single large impacted stone) and deranged LFT did not show significant predictive value. Conclusions: Clinical predictors are most reliable factors. Use of good clinical judgement regarding possibility of and likely difficulty along with understanding of available resources is important in making decision in each case.

This paper reviews the clinical judgement literature and discusses its applicability to the practice of couples and family therapy. Key findings and conceptual foundations are highlighted. A contextual perspective is advocated to guide future investigations and to enhance the generalizability of the literature to the real-life experiences of therapists. Suggestions for theory development and future research are provided.

This paper reviews the clinical judgement literature and discusses its applicability to the practice of couples and family therapy. Key findings and conceptual foundations are highlighted. A contextual perspective is advocated to guide future investigations and to enhance the generalizability of the literature to the real-life experiences of therapists. Suggestions for theory development and future research are provided.