The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life. When an emergency care system matures, the scope of emergency medicine (EM) expands. Most emergency department care is provided by specially trained physicians. There is a mature academic professional organization that can advance the field, which can now sustain fellowships and subspecialization, national databases, and peer reviewed journals. Emergency medical services systems are developed and run on city, regional, and even national levels. Internationally, two different systems have been developed for the delivery of emergency medical care. The first is the Anglo-American model that is familiar within the United States and the other is the Franco-German model. The Anglo-American model provides prehospital care. Paramedic and emergency medical technicians extend the role of the physician, caring for, stabilizing, and transporting the patient. On the other hand, in the Franco-German model, care is brought to the patient. Emergency systems used to provide out-of-hospital urgent care and to screen the patients to decide who needs to be transferred. The physician and the technology are sent to the scene in the hope of providing an immediate high level of care when most needed. Management systems are currently in place for process improvement, quality assurance, and cost controls. Countries that can be described as having mature emergency care systems include Australia, Canada, the United Kingdom, Germany, Switzerland, and the United States .Rapid assessment of injuries and life-preserving therapy is required, but defining the optimal strategy can be complicated when multiple organ systems are involved . The impAlthough the gadgets and tools that the neurosurgeon uses today in emergencies give him important help in diagnosing and treating the patient, we still need new technology. This should accelerate diagnosis and treatment. Moreover, it must be user-friendly, so that it can be used even by a junior physician and still give excellent results. Furthermore, modern technology concentrates on avoiding misdiagnosis, as this can lead to disastrous results for the patient. Additionally, rapid and specific diagnosis can always help to improve the patient's quality of life.Another very important instrument that has to be developed for neurosurgical emergencies is the telemedical emergency neurosurgical network. Teleeducation, teleconferencing, and teleconsultation have flourished, albeit mainly as a showcase between a number of emergency units within leading institutes , 4.With advances in information and imaging technology, the application of robotic systems to the health sector has become a burgeoning field in assisting surgeons in manipulating, monitoring, and/or guiding operations, with the advantages of high targeting precision, reliable support during protracted operations, and the possibility of preoperative planning based on patients' images. In 2001, around 270,000 image-guided robotic operations were conducted annually worldwide , 4.In the developing countries, telemedicine holds promises increasingly balanced access to health care services. To this end, collaboration with the developed countries will increase and will help to ensure that expertise, knowledge, and experience are more rapidly and more cheaply available .There have recently been rapid developments in medical technology in emergency departments. The present paper presents a spectrum of neurosurgical tools that have been developed in the last two years.Researchers at UC Berkeley have been working on developing a new brain injury detector that is cheap, easy to use, and can provide nearly immediate results. This device sends radio signals that pass through the brain and are detected using a special antenna. The underlying technology is known as “Volumetric Electromagnetic Phase Shift Spectroscopy (VEPS)” and can detect changes in tissue properties inside the body through noncontacting, multifrequency electromagnetic measurements from the exterior of the body, thus providing rapid and inexpensive diagnostic testing  5, 6]. , 6. 5, 6The updated infrascanner model 2000 intracranial haematoma detector is another tool for the neurosurgeon that has received FDA approval . This isThe Clotbust ER is another important ultrasound system that has received the CE mark and that is potentially an important tool for the emergency department . This isThis seems to be an essential tool for the physician in the emergency department. With this tool, the physician  can noninvasively deliver ultrasound energy to a patient who has just been diagnosed with an ischaemic stroke in the ER. The thrombus starts to dissolve and can be then treated with a standard intravenous thrombolytic agent. That is extremely important, since this can provide a better outcome and better quality of life for the patient with ischemic stroke, without the need for specialised personnel. For stroke treatment and monitoring in the emergency department, attention must be drawn to the new device called Fore-sight from Casmed of Branford, CT, USA  22]. A . A 22]. Another tool of significant importance for the neurosurgeon specialist in emergencies is the Presto, which monitors cranial blood flow without a sonographer . This isAn essential device for emergencies in neurological surgery is the HeadSense intracranial pressure monitor . In thisFurthermore, the portable full body CT scanner—BodyTom—has been awarded the CE mark and is another important device for the emergency department . This isBy providing real-time updates as the surgery unfolds, the scanner eliminates the need to move patients between operating room and radiology suite and makes surgery safer. BodyTom can obtain images of the entire spine in one pass, providing detailed three-dimensional images of both bone and soft tissue that is unavailable using the flat-panel fluoroscopic imaging that is typically found in most operating suites. This enables the surgeon to assess any developing complications before the patient leaves the operating room .The importance of this device is (more than) obvious. You do not have to be a specialist to support its usefulness in emergencies. With this portable CT scanner, you can always have immediate neuromonitoring, even in the smallest medical centres. Moreover, the scanner is cost-effective, as it can be used by all the departments of the institute, especially if we are dealing with a small capacity medical centre.Remaining with the theme of diagnostic testing and computed tomography monitoring, the IMRIS CT  should bThe FDA has given clearance to IMRIS for its ceiling-mounted intraoperative CT system, the VISIUS iCT. This is the world's first and only such system that rides on a ceiling-mounted track and can be deployed around the patient within 30 seconds when necessary. Because the system does not touch the ground, there are many fewer things to keep in mind when deploying the scanner, and the operation can be resumed quickly once the scan is done . It is oDeveloped for cranial and spinal neurosurgery, VISIUS iCT is a specialized multifunctional surgical theatre that brings state-of-the-art image quality directly to patients in the OR. The first and only ceiling-mounted intraoperative CT travels on-demand to the patient—without introducing additional risks by moving the patient or having anything touch the floor—and preserves the OR protocols, including optimal surgical access and techniques . VISIUS iCT is a state-of-the-art surgical theatre that provides personalized dose management together with diagnostic quality imaging during the surgical procedure, in order to assist surgeons in critical decision-making. The 64-slice scanner effortlessly moves into and out of the operating room during surgery, using ceiling-mounted rails to ease workflow. This enables multiple room configurations to meet both clinical requirements and increased utilization without compromising image quality or exam speed.Patient transport and the need for the floor-mounted rails used in other systems are eliminated, opening up valuable OR space and allowing unimpeded movement of surgical equipment and simplified infection control. The system also offers the longest scanner travel range on the market today.In addition, VISIUS iCT features a suite of software applications, such as 3D volume rendering, in order to aid surgical planning and dose reduction. This considers each patient's unique characteristics and needs to maximize image quality and minimize dose. “State-of-the-art dose management is one of the keys to driving the adoption of iCT to guide surgical procedures,” Graves said.The system software allows healthcare practitioners to visualize dosage prior to scan and adjust settings based on the specific clinical need, with detailed dosage reports produced after each scan .Finally, another new device that would be a great assistance to the specialist in the ED is the new angiography system from Siemens , which has been awarded FDA approval . The devSiemens claims that the new combination of tube and detector provides visibility of small vessels at a rate that is 70% higher than with the previous generation technology. If this is proven to be clinically valid in everyday use, the promise of better resolution at lower power and lower dose levels will be a significant step, as interventional procedures become more and more complex with longer times. This may translate into the potential for extended exposure to radiation during the procedure .In addition to the hardware innovations, there are several new software applications. The Artis Q and Q. zen will be the first angiography systems to feature IVUS map, integrating intravascular ultrasound (IVUS) with angiographic images. With the simultaneous views of the vessels' interior wall via IVUS with precise location on the angioimage, IVUS map efficiently supports physicians in diagnostic testing and stent placement. CLEARstent Live enhances the visibility of stents in real time during therapy whilst simultaneously stabilising the image, resulting in a clear image of the intervention without time lag. Other new 3D applications, such as syngo DynaCT micro, provide substantial improvements in spatial resolution, by enhancing the smallest details in crucial areas such as imaging of intracranial stents or other miniscule structures, such as the cochlea in the inner ear. Organs such as the lungs can be imaged in 3D in less than three seconds with syngo DynaCT Highspeed, reducing the number of motion artefacts and the amount of contrast agent required. For oncological procedures, personalised therapy is the key to improve the access to the disease and to improve patient outcomes. A new 3D functional imaging protocol, syngo DynaPBV Body, shows blood distribution by means of colour coded cross-sectional blood volume maps, along with quantitative measurement of blood volume in lesions, in order to assess changes in perfusion over the course of treatment . The last twenty years have been the rise of neuroscience, molecular biology, and brain imaging technologies, which have changed our understanding of the human brain. Neuroscientists are currently working on the development of an array of therapeutic cognitive enhancements for humans. These technologies are in the pioneering stage and promise further insights into our understanding of the brain. Some scientists consider that the twenty first century will be to neuroscience as the twentieth century was to physics . The sheer size of the brain's neural network, comprising approximately 100 billion neurons and over 100 trillion synaptic connections, will represent an enormous challenge for NBIC in the future. Fantasies about mind control will remain elusive, since science has yet to determine how the brain encodes memory and more fundamentally how mind works . DevelopEpisodes of neurosurgical care are associated with the expenditure of huge health system resources and have tremendous impact on quality of life and clinical outcomes, disproportionate to the size of our specialty and to the number of individual encounters. The complex medical, social, and ethical dimensions of these interventions preclude substituting mid-level providers, such as physician assistants and nurse practitioners, for the neurosurgeon. Many neurosurgical care episodes are concentrated at the extremes of age , focus on an unforgiving nervous system, and/or require continuous subspecialty coverage for stroke, hydrocephalus, and neurotrauma, and thus have tremendous impact on both healthcare and health system outcomes. For these reasons, neurosurgical practitioners have passionately embraced the modern era of medical education, training, and innovation as a method of improving the outcomes of our patients and for advancing our specialty. Neurosurgery has emerged as a leader and innovator, and is therefore an area of medical practice that should be targeted for additional support and enhanced attention to educational best practices, rather than cuts in economic support .ICT will no longer mean only intracranial tension. It will signify an even more important term—“Information and Communication Technology”. Distance today has become meaningless and geography has become history. Advances in medical technology and surgical techniques have dramatically improved diagnosis and treatment of most disorders, saving and extending lives. Yet the technology revolution has to bypass certain difficulties for urgent medical care in different hospital establishments. Tomorrow's neurosurgeon will be part of digital health, digital hospitals, EMR, HIS, telemedicine, telemonitoring, and mHealth. With a mini iPad or equivalent low cost tablet, he/she will be able to work with anyone, anytime, anywhere. Professor Google and Dr. Facebook will ensure that the patient is truly empowered, with real time access to almost the same exabytes of information as the neurosurgeon. “Caveat emptor”—let the buyer beware—the neurosurgeon of 2020 could very well be on the receiving end . Ultimat


Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach. Emergency care is one of the most sensitive areas of health care. This sensitivity is commonly based on a combination of factors such as urgency and crowding . UrgencyThe Australasian College for Emergency Medicine (ACEM) defines ED overcrowding as the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting to leave exceeds the physical and/or staffing capacity of the ED . ED overThe inappropriate use and/or misuse of ED services is one of the common problems leading to overcrowding . SociodeWhen existing needs cannot be met by the available resources a system is needed to cope with the situation and many hospitals use a triage system in order to do this . The aimtrier (to sort) which was originally used to describe sorting of the agricultural products. Today, "triage" is almost exclusively used in specific health care contexts [The term "triage" is derived from the French word contexts .Iserson and Moskop  describe1. At least modest scarcity of resources exists.2. A health care worker  assesses each patient's medical needs based on a brief examination.3. The triage officer uses an established system or plan, usually based on an algorithm or a set of criteria to determine a specific treatment or treatment priority for each patient.ethical theories, triage is commonly seen as a classic example of distributive justice, which addresses the question of how benefits and burdens should be distributed within a population [From the perspective of pulation . It is tpulation  the prinpulation .The fundamental point of triage is the following: not everyone who needs a particular form of health care, such as medicine, therapy, surgery, transplantation, intensive care bed, can gain immediate access to it. Triage systems are designed to assist allocation decisions in this regard. These decisions are more difficult when a condition is life-threatening and the scarce resource potentially life-saving. In life threatening conditions, the question can become: "Who shall live when not everyone can live?" The crux of the matter is the seeming inappropriateness of abstract allocation principles at the level of face-to-face relationships. The general utilitarian concerns of the system, which in the context of scarcity comes down to calculating and choosing between patients on the basis of abstract reasoning , seems to collide with the Hippocratic duty of doing as much as you can for the patients who need care  .Ethical issues are hardly considered in emergency department setting. A study by Anderson-Shaw et al has suggested that patients hospitalized through ED often present with ethical dilemmas significantly impacting their inpatient care and overall health outcomes . There imedical literature, the controversies relating to the ethics of triage in medical practices predominantly date back to the early eighties [Within existing eighties . Recent eighties , underlyeighties , evolutieighties  and theieighties , update eighties  and posieighties .Currently, the existing literature on triage is deficient in two ways. Either there is a predominant focus, from a medical perspective, on the practical elements of triage and on clinical-based guidelines. Or there is a focus, from an ethical perspective, on the domain of distributive justice, with its conflicting principles, as such remaining on the abstract level of reasoning. The aim of this paper is to bring the two strands together.The central question is the following: how can triage systems in emergency care be ethically assessed, so as to realize optimal use of scarce resources in an ethically just way without remaining on the abstract level, that is by taking the effect of triage on the individual patients and caregivers into account?In order to do this, we will focus on ED triage. We aim at complementing existing literature on ED triage with an ethical framework that can help ED management teams in planning and executing triage for the care of emergency patients in the daily practice.Common contexts of triage in contemporary health care practices are pre-hospital care , emergen1. First, pre-hospital triage in order to dispatch ambulance and pre-hospital care resources.2. Second, triage at the scene by the first clinician attending the patient.3. Third, triage on arrival at the hospital ED.During the last decade, the issue of pandemic triage has entered the discussion of triage -23. The Triage is a system of clinical risk management employed in emergency departments worldwide to manage patient flow safely when clinical needs exceed capacity. It promulgates a system that delivers a teachable, auditable method of assigning clinical priority in emergency settings .In contemporary emergency care, triage is regarded as an essential function not only during massive influx of patients as in disasters, epidemics and pandemics but also in regular emergency care departments. The burden in emergency care is increasing and so are the expectations of patients . In hospTriage guidelines score emergency patients into several categories and relate it to the maximum waiting time based on specific criteria of clinical urgency. Initial versions of triage guidelines had three levels of categorization mostly termed as emergent, urgent and non-urgent . StudiesThe Manchester Triage Score [The Canadian Triage and Acuity Scale [The Australasian Triage Scale [Emergency severity Index [The most commonly used guidelines for ED triage on the international literature are ge Score ,28,29, Tty Scale , The Ausge Scale  and Emerty Index ,29. In Ety Index ,33.how to sort a patient among one of the five levels, we can apply The Manchester Triage Score [general discriminators for triage: life threat, haemorrhage, pain, conscious level, temperature and acuteness. These have to be practiced at each level of priority and it is essential for the triage officer to understand the triage method. For example: Pain can be severe pain, moderate pain and recent pain. Specific discriminators are applicable to individual presentations or to small groups of presentations, which tend to relate to key features of particular conditions. For example: cardiac pain or pleuritic pain. Thus, the specific criteria of triage are based on clinical urgency.When reflecting on the question whether these triage systems say anything about ge Score  as an exThough terminology of categorization differs slightly between the various guidelines, their practical meaning is more or less the same. Triage is a brief encounter between triage officer and patient, which takes two to four minutes . SubsequThe Canadian Triage and Acuity Scale (CTAS) consist of separate guidelines for adult  and chilThe Sacco Triage Method  is an evidence based outcome driven triage which considers the resources to maximize the expected survivors. Triage decisions are based on a simple age adjusted physiological score  that is computed routinely on every trauma patient and are correlated to survival probability .ED triage introduces several ethical questions, which have received less attention in the general literature on triage. Below, we will carry out an ethical analysis by firstly applying the four principles of biomedical ethics developed by Beauchamp and Childress . Then, waction, not merely a respectful attitude [Respect for autonomy is a pivotal criterion for decision-making in health care and provides that competent persons have the right to make choices regarding their own health care. Respect for patient autonomy became especially important with the emancipation of the patient in the socio-political context of democracy and the human rights movement. It resulted in the decline of the paternalistic relationship between a doctor and patient and encouraged individuals to protect their personal values. To respect an autonomous agent is, at a minimum, to acknowledge the person's right to hold views, to make choices, and to take actions based on personal values and beliefs. As Beauchamp and Childress state, such respect involves attitude . It invoWhile considering ED triage, autonomy is very difficult to assess especially when urgent situations arise. Here, it is important to find out who decides about the emergency of a situation in the first place.Let us first look at the viewpoint of the patient. The American College of Emergency Physicians defines emergency services as follows: "Emergency services are those health care services provided to evaluate and treat medical conditions of recent onset and severity that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that urgent and/or unscheduled medical care is required."According to this definition, urgency is determined by a lay person and emergency services have two components; firstly evaluation and then, treatment. Most of the patients who come to an emergency department believe they have a problem requiring immediate medical care. In such cases, ED triage raises ethical questions particularly when the emergency service is being denied. One can consider triage as an evaluation, although technically it is not a complete medical evaluation. Refusal to provide emergency treatment to a patient presenting to the ED contradicts to the principle of respect for autonomy. The triage officer takes the decision without consent of the patient which can be regarded as the paternalistic approach of decision making. A study  publisheWhen looking at the viewpoint of the care provider, we see that the decisions are being made by the triage officer or the concerned authority of the ED. Triage is the initial step in the evaluation of a patient's complaint(s) before initiating medical evaluation and management and generally, informed consent is not considered as a part of triage process . In addiNevertheless, the fact that informed consent cannot factually be realized in many ED situations does not mean that respect for autonomy cannot be taken into account at all here. Davis et al reported that even acutely ill emergency patients preferred respect for autonomy in medical decision making and increasing acuity of illness at presentation does not predict a decreased desire for autonomy .An important way of respecting autonomy as much as possible here is by focusing on good and clear ED communication. To exercise respect for autonomy, health care workers must be able to communicate well with their patients. However, the emergency department (ED) presents unique challenges to effective provider-patient communication, such as lack of privacy, noise, frequent interruptions, and lack of an established medical relationship. A study on ED communication concluded that the physician-patient encounter was brief and lacking in important health information such as specifying symptoms that should prompt return to the ED . Good coHowever, the common triage guidelines have not considered communication skills and informed consent as part of triage procedure ,27. EffeThe principle of nonmaleficence can be described as "do no harm". The Hippocratic Oath mentions this obligation as "I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them" . One ougWaiting long for a consultation can increase pain and suffering and, at times, worsen the outcome and thus, result in indirect harm. Psychosocial harm includes stress, fear, feeling neglected or not being taken care of.Triage guidelines aim to avoid harm to the patient by sorting the patients as quickly and efficiently as possible. However, in emergency care, especially in situations of overcrowding, treating one patient might threaten the welfare of another patient by not being able to take care of both. Studies in different centres have found an association between overcrowding and reduced access to care, decreased quality measures, and poor outcomes .Sometimes, referral to other centres can result in more quick and effective service and thus, harm in the form of excessive delays may be avoided . FurtherEkwall et al. suggest the importance of addressing the psychosocial needs of patients of varying levels of urgency through their social interactions at triage . ExistinBeneficence is a moral obligation of contributing to the benefit or well-being of people and thus is a positive action done for the benefit of others instead of not merely refraining from harmful acts. The norms of the principle of beneficence are as follows :1. One ought to prevent evil or harm.2. One ought to remove evil or harm.3. One ought to do or promote good.Health care providers in the ED have an ethical obligation to attempt to provide benefits to the patients by taking their complaints seriously and by managing their problems according to prevailing standards of care. By applying a system of triage, they seek to improve the quality of care by using the available resources as effectively and efficiently as possible. The ultimate goal of triage is to preserve and protect endangered human lives as much as possible by assigning priority to patients with an immediate need for life-sustaining treatment. Though due consideration should be given to the available resources, the life and health of patients is priority.In triage, tendency of overtriage particularly in patients with trauma may be a tendency for beneficence. However, it is an "err on the side of caution". Overtriage not only increases the cost of medical care  but alsoNevertheless, this has to be done in a context characterized by urgency, overcrowding, and limited medical resources , which increases the pressure upon health professionals in the ED. In the same line of reasoning, triage officers mention the fear that an incorrect triage category allocation may lead to a delay in treatment and at worst, the death of a patient, particularly when waiting times are long .fairly, and that benefits and burdens are distributed in a just and fair way [appropriate criteria and principles (equity) [Justice, more specifically understood as distributive justice, requires that given limited resources, allocation decisions must be made fair way . Triage fair way . This do(equity) .principle of equality. It is based on the idea that each person's life is of equal worth and holds that everyone should have an equal chance to receive the necessary care. A triage system based on this principle would presumably operate on a first-come, first served basis [Generally, the criteria and principles relevant for triage in emergency care can be classified into three general categories, among which a balance has to be created ,64. The ed basis , giving ed basis . The reled basis . Howevered basis  care sitprinciple of utility, on the other hand, holds that actions should be judged by their consequences and how far they produce the greatest net benefit among all those affected. Or put simply, to do the greatest good for the greatest number. In fact, utilitarianism is the rationale for triage systems, insofar as they seek to use the available but scarce medical resources as efficiently as possible [The possible . In itsepossible . In ordepossible ,23. To mthe principle of priority to the worst-off. Here, much depends on how one defines the worst-off group. Are they the most needy? The most urgent cases? Or the ones with the lowest prospects? Or even the poor and disenfranchised people who most often use the emergency departments because they have no other choice of receiving health care? [One particular criterion, however, is being reflected in the third principle of justice, i.e. th care?  Suppose th care? . Accordith care? .Let us take stock. How can good-quality care be given in urgent situations, with limited resources, in an overcrowded ED? By applying a triage system, one can quickly and efficiently sort patients according to clinical priority, thus aiming to manage patient flow safely when clinical needs exceed capacity. The triage process happens during the period between the time patients first present in the ED and the time at which they are first seen by a doctor . Even th(1) The principle of respect for autonomy, especially in ED situations, is very difficult to assess, most particularly when urgent situations arise, as often is the case. Special attention is needed for particular ways of respecting autonomy as much as possible, for instance by appropriate and adequate communication during the triage process.(2) The principle of nonmaleficence is under pressure since triage can reinforce the physical  and psychological harms  that come with the underlying pathological conditions.(3) Aggression and violence are common phenomena in the ED. They aggravate the working conditions, impair staff morale and complicate people's abilities to make proper decisions. The principle of beneficence is compromised by the pressure upon health professionals, which in turn reinforces their feelings of fear for making wrong decisions .(4) With regard to the principle of justice, it is finally a continuous assignment to check whether the system realizes a fair balance between the principle of equal respect for all and efficient use of resources. Here, it is important to see whether the just situation can be realized in a human way.comprehensive ethical view for two reasons: (1) they only offer fragmented pieces of the triage puzzle; and (2) they do not provide a view on the dynamics of the care process. To address the ethical issues of ED triage as seen from a more comprehensive ethical view, the care ethics perspective might offer additional insights.The results from this ethical analysis, based on the four principles of biomedical ethics, are interesting but insufficient since they do not offer a Care ethics is an ethical theory that evolved out of the Kohlberg-Gilligan debate on moral psychology and from the work done by social scientists, such as Joan Tronto in the USA and Selma Sevenhuijsen in the Netherlands ,44,67. AIn this paper, we will apply the care ethics perspective to the issue of ED triage because we are convinced that the care ethics perspective offers important ethical insights into the dynamic character of triage within the setting of emergency care. By focusing on the dynamic aspects of delivering acute medical care, it provides an important addition to the predominantly fragmented principle-based approach. Here, we opt for an ethical analysis according to the four dimensions of care, as developed by Joan Tronto .Moral Boundaries (1993), Joan Tronto distinguishes four dimensions of care, each comprising a corresponding ethical attitude [In her pioneering book attitude ,77. The 'caring about', is the starting point of care and refers to being concerned about the condition of a person and paying attention to the vulnerability of this person confronted with. The corresponding ethical attitude is attentiveness and refers to the actual recognition of a need that should be cared about.The first dimension, In triage, the ethical attitude of attentiveness to the needs of people, respecting their autonomy, even within the brief examination by the triage officer, is the starting point of the process and is important for ensuring that people are not being neglected. This is also a continuous attitude, for a patient may need re-triaging due to worsening or improvement of condition, or may suffer from psychological distress, due to long waiting times and lack of information.'taking care of'. It refers to assuming the responsibility for providing the necessary care. The challenge to improve the patient's condition is recognised. Here, responsibility is the corresponding ethical attitude.The second dimension is The triage officer takes up the responsibility to improve the patient's condition as much as possible. This means that he tries to make the right decisions in order to guarantee that the patient will be cared for as well as possible, given the circumstances of scarcity of resources.'Actual care giving' is the third dimension of care and refers to the effective and adequate way to meet the patient's needs. This dimension of care requires the necessary competence to provide the actual care in a professional way.By sorting patients competently, triage functions as a necessary part of good-quality emergency care. From a care ethics perspective, competent triage not only comprises the medical competence of sorting patients according to criteria of clinical urgency, but also includes attention to proper communication and respect for the patient's privacy, thus avoiding psychological harm.'care receiving' and the corresponding attitude of responsiveness, which refers to the response of the patient to the given care.Good care requires feedback and verification that the patient's needs are actually being met. This brings us to the final dimension of care, namely that of The dimension of care receiving is mostly lacking in the practice of triage and at times leads to conflict. Nevertheless, checking to see how the given care is being received is very important since the decisions made by the triage officer can have potential negative impact on patient's condition (e.g. patient's safety may be endangered or their condition may deteriorate) and on their experiences . The result is not merely inconvenience but rather a degradation of the entire care process. As such, and in combination with the attitude of attentiveness, the triage officer needs to seek the responsiveness of the patient, which helps to address ethically relevant issues like respect for autonomy and the issue of informed consent, lack of communication, lack of privacy and psychological harm.Care practices always take place within a framework of interpersonal relationships, where the caregiver(s) and the care receiver are reciprocally involved in a dynamic interaction of giving and receiving care . ReciproIn his theoretical study, Gastmans points at the fact that the characteristics of relatedness and reciprocity should also be understood against the background of a very particular social context ,77. ApplIn general, care ethics is mainly considered as an ethics of individual relationships . HoweverAccordingly, a careful interpretation of ED triage makes clear that a relationship between care professionals and patients cannot be seen as isolated interactions. They are always situated in a broader care process, which is enacted in the teamwork of caregivers, being part of a particular health care institution, which may have (or may not have) a carefully developed policy on ED triage .Moreover, the process and outcome of ethically sensitive decision-making processes in ED triage is influenced, not only by institutional factors, such as the presence of policies, but also by the ethical culture of the hospital as organization , as it mas part of a hospital-wide strategy for fixing ED overcrowding [Ethical problems in hospitals often occur in an atmosphere of powerlessness, (in)efficiency, problems of cost-effectiveness, pressure, (in)competence, scarcity of human and financial resources, etc. It is this institutional and professional atmosphere, which determines what ethical problems are being expressed and how they are being dealt with in the hospital. Hence the importance of developing ED triage crowding . Such a In this paper, we have identified the ethical dimensions of ED triage, which provide the moral framework for decisions made by triage officers. In order to carry out their task effectively, it is essential that hospitals engage in emergency department triage planning. Different from triage systems, that are exclusively clinical-based and narrowly focused on the ED, it is important to opt for an integrated clinically and ethically based form of triage planning, as seen from a comprehensive ethics perspective that incorporates both the above-described principles and care-oriented approach. Such a way of ED triage planning would incorporate the following characteristics.(1) From the complementary dialogue between the principle-based approach and the care-oriented approach, we can conclude that a clinically and ethically based ED triage process is not only based on a momentary decision made by one person. It also takes relevant ethical principles as respect for autonomy, nonmaleficence, beneficence, and justice into account, as well as the fact that triage is a part of dynamic care process incorporating the four dimensions of care.(2) Based on the essential importance of a supportive institutional framework, it is essential to opt for a hospital-wide strategy of triage planning with a broad involvement of relevant people. Hospital management, ED management and staff, triage officers, directors and staff of other departments are important stakeholders in the process ,10. As t(3) Just as triage itself is a dynamic process, and in itself part of the dynamic process of overall patient care, it is important to consider triage planning as a phenomenon that is susceptible to change. Hence, it is important to carry out regular reviews of the hospital's ED triage protocol, based on experiences of staff and patients, and on evolutions in care . Propose(4) ED staff has to operate in highly stressful, ethically sensitive, and sometimes even traumatic circumstances. Providing sufficient support on educational , psychological (feedback) and ethical level, is essential for realizing a clinical-ethical based process of triage planning. A good and supportive hospital culture is a crucial determinant for this.As such, the various ethical aspects that are intrinsically related to ED triage, and which we have identified by our ethical analysis, can help to create a supportive clinical-ethical framework for ED triage.ACEM: Australasian College for Emergency Medicine; ATS: Australasian Triage Scale; CTAS: Canadian Triage and Acuity Scale; ED: Emergency Department; ESI: Emergency Severity Index; LSI: Life Saving Interventions; SALT: Sort, Assess, Life-saving interventions, Treatment and/or transport; SARS: Severe Acute Respiratory Syndrome; SORT: Strategy for Off-Site Rapid Triage; START: Simple Triage and Rapid Treatment;The authors declare that they have no competing interests.RPA conceptualised the topic, designed ethical analysis, collected documents and wrote major parts of the manuscript. CG linked the ethical analysis of emergency triage with care ethics and also revised the manuscript. YD guided to design the ethical analysis, contributed on the distributive justice and revised the manuscript at several stages of preparation. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/11/16/prepub


The predictD study developed and validated a risk algorithm for predicting the onset of major depression in primary care. We aimed to explore the opinion of patients about knowing their risk for depression and the values and criteria upon which these opinions are based.A maximum variation sample of patients was taken, stratified by city, age, gender, immigrant status, socio-economic status and lifetime depression. The study participants were 52 patients belonging to 13 urban health centres in seven different cities around Spain. Seven Focus Groups (FGs) were given held with primary care patients, one for each of the seven participating cities.The results showed that patients generally welcomed knowing their risk for depression. Furthermore, in light of available evidence several patients proposed potential changes in their lifestyles to prevent depression. Patients generally preferred to ask their General Practitioners (GPs) for advice, though mental health specialists were also mentioned. They suggested that GPs undertake interventions tailored to each patient, from a “patient-centred” approach, with certain communication skills, and giving advice to help patients cope with the knowledge that they are at risk of becoming depressed.Patients are pleased to be informed about their risk for depression. We detected certain beliefs, attitudes, values, expectations and behaviour among the patients that were potentially useful for future primary prevention programmes on depression. Unlike other medical problems such as cancer or cardiovascular disease These three studies Our research team conducted the predictD studies We undertook the study in the primary care setting of seven Spanish cities, from both northern  and southern Spain . Primary Care in Spain is organized in health centres, which each cover a population of 15,000 to 30,000 inhabitants from a geographically defined area. GPs in each health centre work as a group, with extensive primary care teams. The Spanish National Health Service provides free medical cover to 95% of the population. Patients can visit their doctors as often as they want without having to pay for it, even when they do so for preventive reasons. Each patient is assigned to only one GP, who has gatekeeper functions.The study population comprised primary care patients living in one of the seven cities mentioned above. The selection of participants was based on maximal variation to obtain as many perspectives as possible The exclusion criteria were an inability to understand and speak Spanish, age younger than 18 or older than 75 years, the presence of psychosis, bipolar disorder or dementia, and suffering, according to their GPs, from major depression at the time of the study. These exclusion criteria are very similar to those of the predictD studies We used Focus Groups (FGs) with patients as a way of collecting data from several people simultaneously No patient knew any of the other patients participating in their FG. All the participating patients received 20 Euros at the end of the FG as an expression of gratitude for their participation.The group moderators (facilitators) were experts in qualitative techniques. Moreover, these personnel were independent and not part of the staff of the health centres. Patients were selected and invited to participate by their GPs. Research assistants contacted the patients who were informed of the date, time and place of the meeting. Patients were only told that the purpose of the meeting was to hear their views on various aspects of health to avoid they prepared the topic before focus groups and thus were more spontaneous.The topic guide used in the FGs consisted of a brief introduction and three general questions, as detailed in The FGs were conducted between April and August 2009 and lasted between 60–105 minutes. The FGs were all conducted in quiet areas of health centres and were audio-recorded digitally and transcribed verbatim by the same person (PMP). In the preparation of this manuscript were followed the ‘Consolidated Criteria for Reporting Qualitative Research (COREQ)’ We used thematic analysis as suggested by Guest et al. In order to guarantee the trustworthiness of this research The predictD-qualitative study was approved by the relevant ethics committees in each participating Spanish city: Ethics Committee on Human Research of the University of Granada, Ethics and Research Committee of Primary Health District of Malaga, Ethics Committee for Clinical Research of Sant Joan de Deu Foundation (Barcelona), Ethics Committee for Clinical Research of Aragon (CEICA), Ethics Committee for Health Research of the Jaen Hospital, Ethics Committee for Clinical Research of Euskadi (CEIC-E), Ethics Committee for Clinical Research of the Rio Hortega Hospital of Valladolid. We were aware that patients in the focus groups would be asked to discuss sensitive personal issues with regard to depression (a stigmatized condition) with others in the groups who were relative strangers. Thus, before focus groups were audio-recorded, all participants were informed about the study purpose, its confidentiality and that study findings would be published in academic congress and journals. They could ask questions about it and the group moderators responded to them. They then gave their written informed consent to participate. Participants’ anonymity was kept using personal codes in transcripts.The participants comprised 52 patients from 13 urban health centres in seven Spanish cities; 52 of the 70 (74%) patients invited to participate in the FGs consented to take part. The distribution among cities and the characteristics of the patients are shown in We obtained three main types of response, which were placed within three broad categories: 1) Interest in the intervention, 2) Imparting information, and 3) Consequences for life.Opinion on the possibility of being informed about their risk of depression and possible risk factors.In general, the respondents had a positive attitude towards knowing their level and risk profile in order to initiate changes in their lifestyle that could prevent the onset of depression, either on their own initiative or originating from the doctor:Well, I’d like you to put yourselves in this situation: before depression starts you go to your health centre and someone tells you that you have a high risk of having depression in the next few months. You haven’t got depression now but you have a risk of getting it and there are a few things that will influence this risk. These are such and such and so and so. What do think about that if it were possible? Patient 13 (P13): Very good. P10: I think it’s a good idea. P15: Anything to do with prevention is great. P12: At least you know about it, and then you can start taking precautions].. The patients also questioned whether knowing their risk for depression was worthwhile if it failed to help them reduce it: .Nevertheless, a few patients had doubts about wanting to know the information concerning their risk for depression. The first doubt refers to considering depression a “special” disease: [FG Malaga. P34: This may pose a problem for weaker persons]. Less commonly, some responses were negative: [FG Malaga. M: Imagine someone wants to give you that information. P35: Not to me!]. . Or responses that were indifferent or sceptic: .Finally, some patients considered that other persons (not themselves) may be alarmed by the information, with undesired effects: .With regard to who is the best person to provide information, patients generally preferred their GP, though mental health specialists were also mentioned: . [FG Valladolid. P43: these are diseases with an important psychological factor. I think the psychologist…]..Receiving the information from the GP but seeking solutions oneself, with or without the GP’s help: . Face to face, with visual-facial contact and a coping attitude: . So that they can understand, simply and directly: [FG Bilbao. P15: To my face and plainly. P12: Naturally]. Tailored to each patient, bearing in mind the personality of the patient and the negative impact it can have on them, but trying to motivate them: .Indirectly, using the third person as a more subtle approach, in addition to availability of time for the doctor-patient interview: .Involving the family, considering the family resources and the possibility of involving other family members in coping with the risk of depression: . A few specific activities were also mentioned, like physical exercise, diet, spending time doing hobbies, going out and walking around with people: .This category mainly includes strategies related to lifestyle and carrying out an “active life”, in the sense of outside activities and relating with people: .[FG Malaga: P34: Looking at things positively. P51: Seeing things positively. P49: Being positive…].Finally, certain cognitive and emotional control strategies were identified: . Many patients would ask their health care professional for some way to prevent the depression. The request, maybe even demand, that they be given solutions: . . Others would think about participating in informal support groups to help them restructure their lives: . Seeking support from family and friends: . Or going to the mental health specialist to learn about coping strategies in difficult situations: .It should be noted that (some) other patients mentioned keeping off medication, though they would consider taking them, but not without some reservations. [FG Malaga. P34: In general, the patients showed a positive attitude to receiving information about their risk of future depression. They suggested interesting ideas about how to share information on their risk level and risk profile. They also proposed various different but appropriate attitudes and behaviour to decrease the risk of depression, some of which included asking their GP for advice. This study enabled us to identify proposals and indications to help develop the predictD interventions with the patients’ acceptance, as well as to determine a few barriers and precautions to be taken into account. As far as we are aware, this is the first study to consider patients’ opinions on primary prevention programmes of depression based on their understanding of their risk for depression.One of the strengths of this study is the great variability of the sample, which is a result of the selection criteria used and the cultural variability found in the different regions of Spain included in the study. Our results mirror some aspects (a positive attitude towards prevention of depression and the beliefs about certain preventive behaviour) of the three studies  so far carried out related to this topic, in Germany The research team was multidisciplinary , the approach was oriented (study methods), and the data were analyzed and interpreted from different professional focuses. In addition, the triangulation between the four analysts for the elaboration of categories was optimal.Nonetheless, a number of limitations should be mentioned. The first is that the opinions of the patients reflected in this study are based on a potential future predictD intervention and not on a post-intervention evaluation. These results, therefore, will need to be confirmed or rejected after the intervention is applied in practice.No attempt was made at “respondent validation” as part of a process of error reduction to establish the level of correspondence between researcher and research subjects. Concerning the presence of depression at the time of the study as an exclusion criterion, this was defined by the GP and may, therefore be liable to diagnostic error When the patients were asked about who was the most suitable person to give them information about the risk of depression, the responses may have been slightly skewed towards the GP, as the interviews were conducted in health centres and the study was designed in the context of primary care. However, the persons who carried out the interviews or who chaired the FGs did not belong to the staff of the respective health centres and only one was a GP.Our wish as researchers was that the patients should favour the establishment of the predictD interventions. This may have influenced by the FGs (interviewer bias) as well as the analysis and interpretation of the data. However, even though most of the opinions of the patients were favourable towards knowing their risk for depression, the analysis of the dissenting opinions was still relevant.Several health behavior theories have been used to inform health intervention designs, such as the ‘Theory of Planned Behavior’ The favourable attitude of the patients to primary prevention of depression coincides with other studies Certain aspects relating to those patients who were less positive about knowing their risk of depression deserve consideration. The first is the need to have the patient’s consent to receive the information about the risk for depression, both from the ethical point of view and for the safety of the patient. There were suggestions that the information be adapted to the personal and clinical characteristics of each patient, and that professionals communicating the risk should be sufficiently skilled. Thus, from the practical viewpoint, before starting to communicate the risk of depression, the professionals involved should undergo training in both communication aspects (such as giving the information) and in factors related to patient-centred medicine Various studies have shown that patients believe psychological and social interventions are more effective than pharmacotherapy for the treatment of depression The participants suggested a number of attitudes, values, and behaviour to help prevent depression, including undertaking pleasing activities, cognitive restructuring, emotional control, improving social and family support, and physical exercise. Similar results have been found in other studies Even though patients may have a favourable attitude to knowing their risk, GPs’ attitudes towards the intervention may present barriers to its implementation. Indeed, this situation has already been seen both with other prevention programmes This study provides key information on which to build, and later evaluate, interventions that reduce the incidence of a costly and disabling condition, such as depression. A summary of the key information is shown in


The study of individual risk factors is inadequate to address the current public health challenges associated with HIV/AIDS. Rather, an ecological epidemiological study of HIV/AIDS is needed to address these challenges. A socioecological framework has been proposed for HIV/AIDS, including influences at the individual level, the interpersonal level, the neighborhood level, and the societal level. This framework provides the basis for a conceptual model with specific risk factors at each of these levels and cross-level associations. The nature of the associations also is important, in particular the assumption that the neighborhood alcohol environment exerts its effect on HIV risk through both direct and indirect pathways. It has been widely recognized that an epidemiological study limited to individual risk factors will not be adequate to address the current public health challenges of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) . HIV, alThe idea of an ecological epidemiology of HIV implies that there are measurable constructs at each of the levels of influence and that cross-level connections are involved in the occurrence of HIV, both at the individual  and population  levels. Statistically, this implies a multilevel framework in which connections between constructs at different levels are modeled as cross-level interactions. This article highlights the empirical research that has been conducted, which provides evidence for each of the connections and the areas in which future research is needed.The multilevel framework does not hold that social and environmental constructs are directly related to health outcomes. Rather, as proposed by The authors’ conceptual model of HIV risk within an alcohol environment begins at the individual level, continues though the interpersonal level into the neighborhood level, and finishes at the societal level. It is a spatial hierarchy in which individuals are nested within interpersonal networks and neighborhoods, which are nested within societal structures . Interpersonal social networks and neighborhoods tend to be misaligned with regard to this spatial hierarchy. For example, several studies have geo-referenced sexual networks, and the geographic distribution typically varies with the definition of the relationship  . On the An ecological epidemiology of HIV risk implies a multilevel structure, with individual-level risk factors at the base. This discussion specifically relates to those factors that appear to be affected by the neighborhood alcohol environment: alcohol consumption and high-risk sexual behaviors . In the model, HIV infection is the final impact of these behaviors. For simplicity, the model does not include the links between the alcohol environment and intravenous drug use and other individual factors  that also play a role in these complex relationships.The interpersonal level refers to the social and sexual networks in which individuals are imbedded. Considerable evidence exists to suggest that network structure determines the propagation of STIs like HIV and that position in the network, in terms of embedded-ness, is associated with individual risk . Sexual The interpersonal level in this model encompasses the role of alcohol outlets in shaping social and sexual networks. Members of a sexual network, especially core group members, tend to be geographically clustered. Estimates of the median distance between partners in a network range from 0.34 km to 1.3 km, depending on the study, which emphasizes the importance of the local neighborhood in STI transmission dynamics . ScribneThe neighborhood level includes factors that define the neighborhood alcohol environment . According to the conceptual model presented here, the neighborhood alcohol environment influences HIV risk along two separate pathways. First, alcohol outlets, including both on-premise outlets such as bars and clubs and off-premise outlets such as liquor stores, affect risk of HIV and other STIs through their moderating effect on alcohol consumption. Higher densities of alcohol outlets have been geographically associated with increased consumption of alcohol at the neighborhood level , which iThe societal level encompasses the policies that shape the neighborhood alcohol environment described above. For example, a number of studies have demonstrated higher densities of alcohol outlets (particularly liquor stores) in poor and minority neighborhoods  as well The framework and conceptual model presented here suggest that exposures to alcohol and the alcohol environment play an important role in regulating the risk of acquiring HIV/AIDS. This effect is played out in the neighborhood and social contexts in which an individual is embedded, thereby regulating the risks to which they are exposed. Societal structures also play a role in shaping these neighborhood and social contexts. The policies affecting how alcohol is made available and the nature of the alcohol environment tend to reflect the social structure of greater society. For example, in a segregated city where Blacks tend to be governed by representatives of the White majority, the interests of the Black community may not be appreciated. In such a situation, formal and informal policies may result in situations where poorly run liquor outlets tend to proliferate in predominantly Black neighborhoods, thereby increasing situational risks for substance abuse and high-risk sexual behaviors. Poorly run alcohol outlets also influence the types of social and sexual networks that exist in a neighborhood and characteristics such as network density. Because Black minorities in a segregated society tend to be seen as “other,” the problems associated with a poorly run alcohol outlet are typically viewed as Black problems rather than problems associated with an alcohol outlet. In any case, exposure to these networks increases an individual’s risk of acquiring HIV/AIDs.Demonstrating these types of relationships is part of the challenge in developing an ecological epidemiology for HIV/AIDS. Fortunately, a convergence of research methods and theory has made progress in this area possible. Ultimately, this approach holds promise for advancing efforts in HIV/AIDS prevention by addressing modifiable factors in the environment at the individual, interpersonal, neighborhood, and societal levels. ?


Disease management programmes (DMPs) have been shown to reduce hospital readmissions and mortality in adults with heart failure (HF), but their effectiveness in elderly patients or in those with major comorbidity is unknown. The Multicenter Randomised Trial of a Heart Failure Management Programme among Geriatric Patients (HF-Geriatrics) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity.Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain. Each patient should meet at least one of the following comorbidty criteria: Charlson index ≥ 3, dependence in ≥ 2 activities of daily living, treatment with ≥ 5 drugs, active treatment for ≥ 3 diseases, recent emergency hospitalization, severe visual or hearing loss, cognitive impairment, Parkinson's disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), anaemia, or constitutional syndrome. Half of the patients will be randomly assigned to a 1-year DMP led by a case manager and the other half to usual care. The DMP consists of an educational programme for patients and caregivers on the management of HF, COPD , diabetes  and depression . It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance. The main outcome variables are quality of life, hospital readmissions, and overall mortality during a 12-month follow-up.The physiological changes, lower life expectancy, comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF. The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty, and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients.NCT01076465).(ClinicalTrials.gov number,  Ninety percent of persons with incident heart failure (HF) are age 65 or over; moreover, the prevalence of HF increases with age, rising from 5-10% in persons aged 65-79 years to 10-20% in those 80 years or over  and is tHF produces physical and cognitive impairment as well as reduced quality of life -9. AnnuaTreatments are available to modify the course of HF with left ventricular systolic dysfunction (LVSD) ,14, but There is good evidence in patients with HF and high risk of hospitalisation that multidisciplinary strategies based on coordination and continuity of care can reduce mortality by 25%, hospital admissions for HF by 26-44%, and admissions for any cause by 19-27%, without increasing length of stay . Thus, iIn Spain, several DMPs have been evaluated in elderly HF patients. Morcillo et al. randomised 70 patients with severe HF and major systolic dysfunction (NYHA III or IV and left ventricular ejection fraction < 35%), previous hospitalisation for HF and mean age 79.1 years to "usual care" versus intervention by a case manager. At 6 months follow-up there were fewer deaths, emergency department visits and hospital readmissions in the intervention group . HoweverThe mean age of patients included in studies that have evaluated the effectiveness of DMPs in HF is 73 years, which is substantially lower than that of patients hospitalised for HF in geriatric services . Most clFor all these reasons, we do not know the effectiveness of DMPs or of their main components in geriatric patients with HF. Specifically, it is unclear whether systematic assessment and intervention on psychosocial factors can improve these patients' vital prognosis and quality of life. It is particularly important to test whether interventions useful in younger HF patients are also useful in elderly patients with predominantly preserved systolic function and some level of comorbidity .Finally, little information is available on the long-term outcomes of DMPs in HF. Although the effects are maintained up to 6 months , it has The main objective of the HF-GERIATRICS study is to assess the effectiveness of a DMP in elderly patients with HF and major comorbidity over 12 months. Effectiveness will be based upon hospital readmission, health-related quality of life, and mortality from any cause.The secondary objectives are to assess the impact of the DMP on some intermediate variables such as knowledge of the disease by patients and family members, and improved HF care, which includes compliance with recommendations on lifestyles and drug treatment. This study also aims to measure the impact of the DMP on length of hospital readmissions and to identify the clinical, demographic and psychosocial characteristics of patients who benefit most from the DMP.The HF-GERIATRICS study is a trial in elderly patients who are admitted with a primary diagnosis of HF in acute care units of eight geriatric services in Spain. Patients are assigned randomly to a DMP (intervention group) or to receive usual care (control group). Randomisation is stratified by hospital and is conducted with concealment of the randomisation list. The two trial groups are followed for 12 months.The project has been approved by the clinical research ethics committee of all participating hospitals (Comité de Etica y Ensayos Clínicos (CEIC) de Galicia, CEIC del Complejo Hospitalario de Caceres, CEIC del Hospital Universitario La Paz, CEIC del Complejo Universitario de Albacete, CEIC del Hospital Universitario de Guadalajara, CEIC del Hospital Central de Asturias, CEIC del Hospital Universitario de Getafe, CEIC del Hospital Universitario de San Carlos, Spain).The study will include patients aged 75 years or over who are admitted with a primary diagnosis of HF according to the European Society of Cardiology and Framingham criteria ,27. EachExclusion criteria are terminal or rapidly fatal disease and life expectancy of less than 6 weeks, severe functional or cognitive impairment preventing patients from understanding their illness and lack of a caregiver who agrees to participate in the study, patients waiting for cardiac surgery, those who cannot be followed up , and institutionalised persons for whom a primary caregiver cannot be identified.In each hospital a case manager with a degree in health sciences and special training in HF will identify and register cases admitted for HF each day by reviewing the diagnoses of those aged ≥ 75 years admitted in the acute care unit of the geriatric service. The case manager will then assess each patient and carry out the following activities:i- Verify the study inclusion and exclusion criteria.ii- Inform patients  and their caregivers (when considered necessary and with the patient's consent) of the characteristics of the DMP and confirm their agreement to participate by asking them to sign the informed consent document.iii- Assign the patient to the intervention or control group. Randomisation will be conducted independently in each centre. Consecutively numbered envelopes, containing the group to which each patient should be assigned, will be used for this purpose. The envelope will be opened only at the time of patient assignment, to assure concealment of the randomisation list.iv- Coordinate patient assessment, record the information in the case report form, and transcribe the information to a computerized database.The DMP, which will be carried out by the case manager, has three main components: education of the patient and the main caregiver to improve disease knowledge and self-management, monitoring of the patient's clinical condition, and monitoring of treatment compliance.DMP components to be conducted by the case manager during the hospital staya) i- Provision of information to patients and their caregivers or family members. An individual session will be held to teach the characteristics, causes and prognosis of HF. Emphasis will be given to recognition of symptoms of decompensation, precipitating factors, and treatment (drug knowledge and treatment compliance).ii- Provision of written and graphic educational materials with the foregoing information.iii- Health education on warning signs and symptoms and information on drugs for the most common comorbidities: diabetes, COPD and depression.iv- Coordination of hospital discharge with ward nursing staffv- Development of a follow-up plan. A date for an outpatient appointment will be set, and a telephone contact number will be provided to patients so they can ask questions or report any incidents.Components of the DMP to be conducted by the case manager after hospital dischargeb) The case manager will devote 2 days/week to the clinical assessment of outpatients. The first contact with the patient will be by telephone, in the second week after hospital discharge: during this call, the case manager will verify the patient's knowledge of HF, reinforce the information provided during hospitalisation, and strengthen compliance with recommended lifestyles and pharmacological treatment. Control of minor symptoms of decompensation by use of diuretics will be emphasized. The first visit will take place at the hospital outpatient clinic 4 weeks after discharge. Future visits will be agreed according to the patient's clinical and treatment needs, but some minimum controls will be established at months 1, 2, 3, 6, 8 and 12 after discharge  in the intervention and control groups. These curves will be compared using univariate methods. The effectiveness of DMP will be summarized with hazard ratios  for readmission and mortality obtained by Cox regression, using the hospital as stratification variable. Finally, if the DMP is shown to be effective, we will estimate the number of patients needed to treat (NNT) to prevent one outcome event.For health-related quality of life, the MLWHFQ score at baseline, 6 months and 12 months will be calculated for each group in the trial. The effect of the DMP on quality of life will be estimated as the difference between groups in the change in MLWHFQ scores during the study. These differences will be accompanied by their respective 95% confidence intervals.The analyses of the effect of DMP will be performed according to the intention-to-treat principle.To our knowledge, this is the first evaluation of a DMP in HF targeting elderly patients with major comorbidity. Elderly patients should be included in evaluations of DMPs because they have specific clinical characteristics. First, the elderly have a lower life expectancy than younger adults; thus, the interventions must be successful in the short or medium term. In addition, their health status is more heterogeneous, and the expectations and preferences of these patients are different from what they were at younger ages. Second, the effect of interventions on outcomes like quality of life and functional status should receive as much attention as the "hard" endpoints traditionally studied . Third, the prognostic importance of comorbidity in the elderly is similar to or even greater than that of HF itself. Thus, control of comorbidity should be an important target of DMPs. In other words, DMPs for HF in the elderly should "look beyond the heart" . DesigniThe main strengths of this study are random assignment to the intervention, concealment of the randomisation list, intention-to-treat analysis, and the very nature of the DMP designed. This DMP follows the recommendations of the major scientific societies in this field  and has been refined through a literature search for successful interventions. In addition, the intervention will be adapted to the educational level and visual limitations of most patients with the following measures: a) selection of a limited number of self-care skills to manage HF, COPD, diabetes mellitus and depression, to identify the warning signs of decompensation, and to comply with treatment ; b) implWe plan to conduct specific training and certification of the case managers in the coordinating centre and to develop protocols for each of their activities. This ensures that the same intervention will be applied similarly in all participating centres and that, if the efficacy of the DMP is shown, it can easily be expanded to other health care settings.The main challenges of the project are recruitment of study participants, avoidance of contamination of the intervention between the two trial groups, and minimization of losses to follow-up. To ensure sufficient recruitment, we have reviewed the basic hospital discharge dataset for each participating hospital, and have found that they each admit at least 100 patients with the characteristics needed for the project every 6 months. To avoid contamination, the case manager will conduct the DMP in a separate consultation, at a time of day other than when patients usually receive care. Finally, to minimize losses to follow-up, the intervention will be brief and will include only a small number of hospital visits. In addition, patient access to the case manager will be facilitated (by telephone or in person) so that any questions or problems that arise during the intervention can be addressed.The authors declare that they have no competing interests.CRP is the scientific coordinator of the study. CRP and FRA drafted the manuscript. All authors contributed to the study concept and design, revised the manuscript for important intellectual concept, and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/627/prepub


One of the challenges to implementing clinical practice guidelines is the need to adapt guidelines to the local context and identify barriers to their uptake. Several models of framework are available to consider for use in guideline adaptation.We completed a multiphase study to explore the implementation of maternal health guidelines in Kosovo, focusing on determinants of uptake and methods to contextualize for local use. The study involved a survey, individual interviews, focus groups, and a consensus meeting with relevant stakeholders, including clinicians , managers, researchers, and policy makers from the national Ministry of Health and the World Health Organization office in Pristina, Kosovo.Participants identified several important barriers to implementation. First, lack of communication between clinicians and ministry representatives was seen as leading to duplication of effort in creating or adapting guidelines, as well as substantial mistrust between clinicians and policy makers. Second, there was a lack of communication across clinical groups that provide obstetric care and a lack of integration across the entire healthcare system, including rural and urban centers. This fragmentation was thought to have directly resulted from the war in 1998 – 1999. Third, the conflict substantially and adversely affected the healthcare infrastructure in Kosovo, which has resulted in an inability to monitor quality of care across the country. Furthermore, the impact on infrastructure has affected the ability to access required medications consistently and to smoothly transfer patients from rural to urban centers. Another issue raised during this project was the appropriateness of including guideline recommendations perceived to be ‘aspirational’.Implementing clinical practice guidelines in low- and middle-income countries (LMICs) requires consideration of several specific barriers. Particularly pertinent to this study were the effects of recent conflict and the resulting fragmentation of healthcare and communication strategies among relevant stakeholders. However, as Kosovo rebuilds and invests in infrastructure after the conflict, there is a tremendous opportunity to create comprehensive, thoughtful strategies to monitor and improve quality of care. To avoid duplication of effort, it may be beneficial for LMICs to share information on assessing barriers as well as on guideline implementation strategies. Around the world, health systems fail to optimally use evidence, which results in inefficiencies and reduced quantity and quality of life -6. RecogGuideline development, Research priorities, Evidence synthesis, Applicability of evidence, and Transfer of knowledge), this initiative includes integration of WHO recommendations into national guideline adaptation processes to expand access to effective practices at healthcare facilities and thus to improve maternal and perinatal health. The key goal of this initiative is to use evidence-based clinical practice guidelines to transfer high-quality evidence about maternal and perinatal health to stakeholders across the healthcare system. A rigorous process for guideline development, including representation from relevant stakeholders, has been used, including use of the GRADE  approach for appraising the quality of evidence and determining the strength of recommendations [One of the most challenging KT problems is to reduce high rates of maternal and perinatal mortality and morbidity, especially in low- and middle-income countries (LMICs). At the global level, the maternal mortality rate has decreased at an average of less than 1% annually between 1990 and 2005, far below the 5.5% annual decline that would be necessary to achieve United Nations (UN) Millennium Development Goal 5, which focuses on improving maternal health. The Special Program of Research, Development, and Research Training in Human Reproduction (HRP) is a joint effort of the United Nations Development Program, the United Nations Population Fund, the United Nations Children’s Fund, the World Health Organization (WHO) and the World Bank. The HRP and its partners have developed a collaboration to tackle this challenge, adopting the ‘knowledge to action’ framework  to outlindations . To dateRather than focusing on the implementation of a single practice guideline, this initiative is tackling the development and evaluation of a broader implementation strategy that will include a multi-component intervention targeting the reduction of maternal and perinatal deaths. The strategy will span community- and hospital-based care and will consider improvements in access to care and in the referral process. The goal is to test this framework in a specified setting and to build local KT capacity to facilitate future initiatives.The pilot site for this program is Kosovo. In that country, more than 95% of mothers give birth in a healthcare facility, but maternal morbidity and mortality remain greater than in many other European countries. The perinatal mortality rate in 2009 was 19.3%, and maternal mortality increased from 28.4 per 100,000 in 2005 to 43.3 per 100,000 in 2009 [The UN agencies in Kosovo are collaborating with local health authorities to achieve Millennium Development Goals 4  and 5  . It is eOne of the key challenges in implementation work is the need to adapt guidelines to the local context. By adapt we mean the process used to modify the guideline; it requires consideration of the local context. Work by the ADAPTE Collaboration  and the To explore implementation of guidelines, including determinants of uptake and methods of contextualization, we performed a multiphase project encompassing a survey, individual interviews, focus groups, and an in-person consensus meeting. The guidelines selected for this project were the WHO guidelines on prevention and management of postpartum hemorrhage ,17. We uThis study was focused in Kosovo and was conducted within the GREAT initiative framework, and represents a partnership with the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, the WHO headquarters in Geneva and its Kosovo office.Using the approach suggested by CAN-IMPLEMENT, we developed a survey, including questions about respondents’ awareness of guidelines on the prevention and management of postpartum hemorrhage and the induction of labor created by various organizations (including the WHO), and asked respondents to rate the relevance and importance of these guidelines on a seven-point Likert scale [Additional file The survey was sent to various stakeholders, including obstetricians and midwives, using two methods: direct email to 50 people identified through the local WHO office in Pristina, the capital of Kosovo ; and thWe completed a series of telephone interviews with local stakeholders in Kosovo to develop key messages from the WHO guidelines and to understand local barriers and facilitators to their implementation. We used the results of the survey to inform development of the interview guide [Additional file Healthcare managers, healthcare professionals, lay healthcare workers, and policy makers were purposively sampled for inclusion. Snowball sampling was used to identify additional participants. Participants were initially identified through the WHO Liaison Office for Kosovo (Dr. Sami Uka), the Ministry of Health and the Kosovo Obstetrics and Gynecology Association (Prof. Dr. Shefqet Lulaj).The interviews were conducted in English by an experienced interviewer. Each interview was digitally recorded, the recordings were transcribed, and the recording for each interviewee was assigned a unique identifier. Content analysis of the transcripts began after the first interview was completed ,21. Two We completed two 90-minute, in-person focus groups in Pristina in October 2012. The goal was to explore the barriers and facilitators to implementing WHO guidelines for postpartum hemorrhage. Once informed consent was obtained, participants were sent a package containing a summary of the guidelines (translated into Albanian) and the goals of the focus group.Participants were identified through the same process as was used for the interviews. The focus groups were facilitated by experienced researchers  from Toronto, Canada, who also took field notes during the sessions. Two Albanian translators were in attendance. The focus groups were digitally recorded, and the recordings were transcribed and analyzed according to a process similar that used for the interviews. The researchers’ field notes were also analyzed thematically.We held an in-person meeting based on a nominal group process  to revie, University Clinical Center and non-governmental organizations). Participants consisted of family physicians and general practitioners (47%), obstetricians (22%), midwives (16%), nurses (6%), a pediatrician (3%), a biochemist (3%), and a medical student (3%). Participants had been in practice for an average of 11.6 years (range 1 to 31 years). Results of the survey are available in Table A total of 39 responses to the survey were received. One-half (50%) of the respondents worked in a community setting, 22% in a hospital, and the remaining 28% in other settings , lack of ability to monitor guideline implementation, lack of access to relevant medications (including oxytocin and magnesium sulphate), and lack of ability to smoothly and appropriately refer and transfer patients to large urban centers.In addition, many barriers to implementation were identified at the level of the healthcare system, mostly attributed to the post-conflict situation. The war occurred in 1998 – 1999, and Kosovo declared its independence from Serbia in 2008, although this status is not universally recognized by other countries. Kosovo includes several Serbian-majority areas, and Serbia does not recognize Kosovo as an independent country. The conflict and its aftermath have significantly and adversely affected the infrastructure in Kosovo, including healthcare, and this situation was one of the most prominent themes revealed by the interviews. For example, since the conflict there has been no consistent mechanism for collecting healthcare data across the country. Similarly, respondents felt that healthcare has not been funded adequately in the post-conflict period and that this lack of funding has affected quality of care. For example, certain medications and equipment mentioned in the guidelines are not available to clinicians in Kosovo. There has been a growth in the development of privately insured healthcare, but the data from this insurance system are not publicly available and the quality of care provided under the system is unclear. The conflict also led to disintegration of healthcare across rural and urban centers, which has affected transitions in care and the communication between clinicians and policy makers. For example, participants emphasized fragmentation and lack of integration within the healthcare system since the conflict. Other challenges to implementation included high turnover of staff both within healthcare organizations and within the Ministry of Health, which has impaired clinicians’ ability to develop ongoing relationships with policy makers.A total of 19 people participated in the two focus groups. Participants’ demographic characteristics are presented in Table Several barriers at the level of the healthcare provider were discussed. For example, some clinicians were not aware of the methods used to develop the WHO guidelines  and therefore did not find them ‘trustworthy’. Similarly, clinicians were concerned that the recommendations had been created without the involvement of relevant clinicians. Participants questioned whether recommendations that could not currently be implemented in Kosovar facilities (because of a lack of resources or equipment) should be included in the development of care pathways. For example, the WHO guidelines recommend a procedure that is currently not available in Kosovo, but several obstetricians suggested that it should be retained in the contextualized guidelines because it may become available as healthcare infrastructure improves. This issue relates to the ‘aspirational’ nature of guideline recommendations:‘Sometimes you don’t, you cannot perform that, so I don’t see that like to exclude the embolization…. but I see that as an opportunity for you that you see that you have to do this and you don’t have conditions, and you have to ask for fulfilling this, in the training, in the equipment, in the materials.’Other participants said that retaining such recommendations in local guidelines could be confusing for clinicians and might foster disengagement from implementation efforts if they feel the guidelines are not relevant to their practice.Participants were very concerned about their lack of ability to document and monitor current practice:‘We come to the problem of how to collect this information that whether the protocol is being implemented and what to do with those not implementing the protocol.’Many participants stated that ‘without measurement, improvement in care cannot be done’.Additionally, deliveries in Kosovo are handled by both obstetricians and midwives, and communication across these groups was perceived as a challenge and a limitation to guideline implementation: ‘communication between the professionals is, is, uh, lacking...’.However, there was keen interest from participants to continue engaging with each other on educational initiatives to meet this challenge.Capacity building was identified as a further challenge to guideline implementation. Participants noted a lack of undergraduate training  and continuing education relating to guideline use and implementation. Strategies to incorporate these topics in undergraduate curricula were discussed, including integration throughout the training period:‘I think that there is enough space to, to, uh, to, to introduce this into our regular teaching program, or curricular, regular curricular, or, uh, inside some, uh, trainings and, uh, continual professional developing of the staff, medical workers and co-workers.’. The Ministry of Health recently established a quality improvement portfolio, including a Kosovo Guidelines Advisory Committee with a mandate to develop and/or adapt guidelines. Representatives of this committee attended the focus groups, but none of the clinicians at the consensus meeting was involved with or aware of the committee’s efforts. The focus groups and subsequent consensus meeting represented the first time that representatives of this committee were able to engage with relevant clinicians, and this opportunity stimulated substantial discussion on how to continue such engagement. These discussions also highlighted a lack of clarity about who should be responsible for developing and implementing guidelines, the Ministry of Health or professional associations :Several barriers at the level of the healthcare system were identified, including lack of communication between clinicians and policy makers‘The Ministry of Health should manage health policies at the Kosovo level … the professional associations should deal with the professional side, drafting, formulation of protocols and then monitoring of implementation for its own, its own field.’Subsequently in the meeting, suggestions were made that the professional groups should work in partnership on implementation of guidelines, and a strategy for developing a small working group was discussed. However, participants in the focus groups also identified a lack of trust between clinicians and policy makers. As a result, the clinicians were not convinced by the methods outlined by the Guidelines Advisory Committee and expressed concerns about the motives and capacity of the Ministry of Health and the Kosovo Guidelines Advisory Committee.All participants identified the need for access to data describing the quality of care, including diagnoses, use of medications, and adverse events. However, Kosovo has no national or regional system that can be used to document or audit care. As a result, the impact of guidelines cannot be adequately evaluated, and the effectiveness of implementation efforts may therefore be unknown:‘That’s why there is a need to have a mechanism which measures, uh, the impact and then reports back on, on the outcomes, and then you get to the revision.’Lack of consistent access to relevant medications and equipment was identified in the focus groups:‘It would be better to say that there is, there is access, some access, but it’s not regular and it’s not quality access.’For example, the WHO guidelines recommend use of oxytocin to prevent postpartum hemorrhage, and this drug is on the list of ‘essential medications’ in Kosovo. However, several clinicians mentioned that oxytocin is not consistently available in all hospitals, such as those in smaller, more rural cities: ‘then there are time ranges we don’t have, uh, not even oxytocin’. Representatives of the Ministry of Health agreed to prioritize this issue.Several participants (both clinicians and policy makers) suggested that punitive measures could be initiated to facilitate implementation of guidelines. For example, it was suggested that:‘Implementation can be best, uh, best, uh, required, or the best means is the punitive measures at least for the, for the initial, uh, for the initial peers so that the others, uh, follow suit.’The use of punitive measures was explored in detail, as were legal mandates to implement guidelines. Other participants expressed concern about the potential to ‘game’ the system if punitive strategies were used., oxytocin), lack of integration of healthcare resources  across the system, lack of healthcare/clinical data , and lack of ability to monitor implementation of guidelines ; GREAT: SES is an associated editor for Implementation Science but was not involved with any decisions regarding this manuscript.SES conceived the study, completed the data collection and its analysis and drafted the manuscript. JM participated in data collection and analysis, and in drafting and revising the manuscript. CM participated in data collection and analysis. SU and AMG provided input into the study design and draft manuscript. All authors reviewed and approved the final manuscript.Survey. Interview guide.Click here for file