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Keywords:

  • critical care outreach;
  • deteriorating patient;
  • nursing practice;
  • observation;
  • rapid response systems

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

Aims and objectives

To audit ward nursing practice in the adherence to an early warning scoring protocol in the detection and initial management of the deteriorating ward patient and investigate factors that may impact on practice.

Background

Hospital inpatients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, misinterpret or mismanage the signs. Rapid response systems have been implemented to address this problem. The rapid response systems consists of two phases: the afferent phase involves monitoring the patient, recognising deterioration and referring to more expert help and the efferent phase involves expert teams assessing and treating the patient. Research has tended to concentrate on the efferent phase of the process and has so far failed to show a significant impact on patient outcome.

Methods

Using cardiac arrest as a surrogate marker for deterioration, patient records were retrospectively reviewed during the 12 hours prior to the cardiac arrest event. Data relating to nursing practice and adherence to the early warning scoring protocol were extracted and analysed.

Findings

The findings suggest that ward nurses' monitoring of patients' observations has improved compared with earlier research, but errors in early warning scoring and nonadherence to referral protocols are still a problem. A number of potentially influential factors on nursing practice were tested, but only deterioration occurring outside normal weekdays was associated with a reduced quality of nursing adherence to protocol.

Conclusions

The implementation of rapid response systems may have been an oversimplified solution to the highly complex problem of undetected patient deterioration. There are a multitude of contributory factors to the problem of noncompliance to early warning scoring protocols, and possible solutions will need to reflect the breadth, depth and complexity of the problem if we are to improve patient experience and outcome.

Relevance to clinical practice

An audit of nursing practice against an early warning scoring protocol based on national recommendations and standards in the recording of and response to physiological deterioration in the ward patient has shown that vital signs recording has improved, but early warning scoring accuracy and referral to more expert help remain suboptimal. By identifying areas of suboptimal practice, strategies for education and training and service development can be better informed. More in-depth evidence on factors that may impact the quality of nursing practice has been identified. Problems with rapid response systems assumptions have been highlighted, which may facilitate the implementation of more realistic solutions for managing the deteriorating ward patient.

What does this paper contribute to the wider clinical community?
  • A study of the afferent arm of the rapid response system.
  • More in-depth analysis of nursing practice in the detection and management of deteriorating ward patients.
  • An evaluation of the factors that may have an influence on nursing practice.
  • An evaluation of the possible strengths and weaknesses of rapid response systems.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

The study reported here was part of a larger investigation into the phenomenon of the deteriorating ward patient. The overall aim was to evaluate nursing practice in the care of deteriorating ward patients and explore factors that might enhance or inhibit that practice. This study describes a clinical evaluation of nursing practice against early warning scoring (EWS) protocols, using predetermined standards of care for the monitoring, detection and initial management of the deteriorating ward patient. The standard of practice was then compared against context elements to determine what organisational, departmental and demographic factors may have had an influence on practice.

Background

Patients in hospital can experience unexpected physiological deterioration that can lead to critical illness, unexpected intensive care unit (ICU) admission, cardiac arrest and/or death (NCEPOD 2005, NPSA 2007a). Much of this deterioration can be signalled in the patients' physiological signs such as changes in respiratory rate (RR) (Goldhill & McNarry 2004), heart rate (Goldhill & McNarry 2004, Cuthbertson et al. 2007) and blood pressure (Hillman et al. 2001, Cuthbertson et al. 2007), or by symptoms such as a deteriorating mental state (Jacques et al. 2006). Although these signs can be monitored and detected by ward nurses as part of routine practice, they can be missed or misinterpreted (NCEPOD 2005, NPSA 2007a).

In an attempt to address this issue, EWS systems and critical care outreach (CCO) teams have been implemented in acute hospital settings in the UK (Department of Health 2003). Similar systems called rapid response systems (RRSs) (DeVita et al. 2004), and medical emergency teams (METs) (Lee et al. 1995) have been introduced across the world (DeVita et al. 2006). However, even when these systems are in place, ward staff do not necessarily comply with the referral criteria protocols and continue to fail to note or address patients' deterioration (Hillman et al. 2005, NPSA 2007a). Early studies tended to paint a negative picture of nursing practice, suggesting that ward nurses are failing to adequately detect and manage the deteriorating ward patient due to inexperience, lack of skill and excessive workloads (Odell et al. 2009). However, more recent research suggests that the process of adherence to rapid response system protocols is highly complex, influenced by many factors that include organisational factors, local cultural rules, staff experience and education, and multidisciplinary team work (Odell et al. 2009, Shearer et al. 2012, Hands et al. 2013).

Literature review

Recording vital signs is an established ward nurse function and has been recognised as being a key in the detection of physiological deterioration (Andrews & Waterman 2005, McBride et al. 2005). While nurses acknowledge the value of recording patients' vital signs (Cioffi 2000), recording observations can be infrequently undertaken (Cox et al. 2006, Endacott et al. 2007, Clarke et al. 2010) and delegated to the least skilled staff (Minick & Harvey 2003). The inadequate frequency of RR recording has been highlighted in a number of studies (Endacott et al. 2007, NPSA 2007b, Odell et al. 2007). Even though monitoring vital signs is recognised as a fundamental role of the nurse, the evidence on broader monitoring practice has been sparse. Recent studies have reported that observation activity might be linked to nursing shift patterns rather than patient need, and although sicker patients are more likely to have vital signs measured overnight, there is still a lack of compliance with clinical escalation protocols (Shearer et al. 2012, Hands et al. 2013).

National guidance published in 2007 (NICE 2007) recommended that systems of physiological EWS should be available for all adult patients in acute hospital settings. The guidance highlights which physiological parameters should be regularly monitored, and the frequencies of monitoring that should be guided by patient acuity.

The use of EWS systems has grown in the UK since they were first introduced in 1997 (Morgan et al. 1997). This has resulted in a wide range of system models using varying physiological elements and trigger ranges. There has been little evidence of the systems' reliability, validity or use in identifying at-risk patients (Gao et al. 2007). A more robustly tested EWS has been developed (Prytherch et al. 2010), which has formed the basis for a National Early Warning Score (NEWS) in the UK (Royal College of Physicians 2012).

Even when EWS systems are in place and ward staff have access to rapid response teams, failure to adhere to EWS trigger recommendations continues to be a problem on general hospital wards (NPSA 2007a, Shearer et al. 2012, Hands et al. 2013). Nurses reported that they valued rapid response teams (Cioffi 2000, Andrews & Waterman 2005), but they can be inconsistently used (Hillman et al. 2005, Donohue & Endacott 2010, Shearer et al. 2012, Hands et al. 2013).

A RRSs model was described by DeVita et al. (2006), consisting of an afferent and efferent limb (Fig. 1). The model clearly delineates two processes of rapid response: the afferent arm where the patient is monitored, deterioration recognised and referred to the expert team, followed by the efferent limb where the expert team assesses and treats the patient. Early research in this field tended to concentrate on the efferent limb of the model (Hillman et al. 2005), with little attention being paid to the afferent limb, which is the key first step in the process. This afferent limb failure is now gaining more interest, and effort needs to be concentrated on understanding and improving the systems and processes in the monitoring and recognition of the deteriorating ward patient (DeVita et al. 2010), and the organisational and cultural influences on staff decision-making in using rapid response protocols (Shearer et al. 2012, Hands et al. 2013).

image

Figure 1. Rapid response team structure (DeVita et al. 2006).

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While studies have reported infrequent RR monitoring, inadequate patient assessment and failure to activate rapid response teams, there has been little research into the wider aspects of patient observation and only speculation as to what factors might contribute to suboptimal practices of patient monitoring. These factors include adverse working conditions (NPSA 2007b), heavy workloads (Jones et al. 2009), lack of education and training (Endacott et al. 2007, Jones et al. 2009), lack of experience (Donohue & Endacott 2010), errors in calculating early warning scores (Prytherch et al. 2006, Mohammed et al. 2009), communication difficulties between nurses and doctors (Andrews & Waterman 2005, Cox et al. 2006, NPSA 2007b, Hands et al. 2013), cultural influences and intraprofessional hierarchies (Shearer et al. 2012).

Study aims

The aims of this study were to audit nursing practice against an EWS system protocol and seek whether predetermined contextual factors may have an influence on that practice.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

Ethical approval for the study was granted by the local research ethics committee. The study setting was a single-site 700-bed general hospital situated in the South of England.

The study was an audit of nursing practice against an EWS protocol in the detection and initial management of deteriorating ward patients. Patient deterioration was identified using the surrogate marker of cardio-respiratory arrest (CRA), a marker that has been well used in other deterioration studies (Schein et al. 1990, Bedell et al. 1991, Hodgetts et al. 2002, Jones et al. 2013).

The inclusion criteria were all adult (18 years and above), nonobstetric inpatients who had suffered a CRA on a general ward during one year (1 January–31 December 2007). CRAs were identified through resuscitation department records, switchboard logs, CCO records and patient hospital records. CRA cases were coded to maintain patient anonymity.

Data were collected using a predesigned data collection pro forma. The patients' hospital records and charts were scrutinised for evidence of documentation and recording of the elements of the predefined protocol standards during the 12 hours prior to the CRA, deemed the deterioration phase. The 12-hour study phase was based on the maximum length of a ward nurse's' shift and the recommended maximum time that should be between patients' vital signs recordings (NICE 2007, DeVita et al. 2010). The demographic and event details of all included CRA cases were entered and analysed using a Microsoft® Excel database (Microsoft Excel. Redmond, Washington: Microsoft, 2003.).

The protocol included eleven standard elements that were derived from recommendations from the literature and national guidance and were identified as follows:

  1. Vital signs recorded within 4 hours.
  2. Vital signs recorded within 6 hours.
  3. *Vital signs recorded within 12 hours.
  4. Temperature recorded.
  5. *Heart rate recorded.
  6. *Blood pressure recorded.
  7. *Respiratory rate recorded.
  8. Oxygen saturation (SpO2) recorded.
  9. *EWS recorded.
  10. *EWS accurate.
  11. *Referral made according to EWS trigger threshold.

*Denotes essential practice standards.

Of the 11 elements, seven were considered essential and are identified by an asterisk. Data relating to these 11 elements were sought in the patients' records. Nursing practice was audited by documented evidence of adherence to the protocol elements as outlined above and was categorised as such:

  • Good - All 11 elements of the protocol were met.
  • Basic - <11 elements of the protocol were met, but including the seven essential elements*.
  • Poor - Failure to meet the seven essential protocol elements*.

The three categories of protocol adherence by ward nurses were then statistically analysed against the predefined context elements relating to the CRA event using Pearson's chi-square test. Statistical significance was set at p ≤ 0·05. The aim was to explore which context elements may have an influence on the degree to which nurses adhered to the protocol.

While adherence to the protocol was under the control of the nurse, the context elements were not. The predetermined context elements emerged from the literature, hospital and departmental statistics and personal clinical experience.

Eight context elements were evaluated as follows:

  1. Admission route type: emergency or elective.
  2. patients' age: below 65 years or 65 years and above.
  3. Patient gender.
  4. Time of day of CRA: social: 07:00–20:59 hours, and unsocial hours.
  5. Day of week of CRA: week days, and weekends and bank holidays.
  6. Ward where CRA occurred.
  7. Speciality of care: medical, surgical or elderly care.
  8. Nursing staff levels: locally agreed recommended level, under the recommended level and over the recommended level.

Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

During the study year, 214 adult CRAs on the general wards met the inclusion criteria, and the hospital records for these CRA cases were examined. The final analysis involved 123 (57·5%) CRA events involving 120 patients. Ninety-one (42·5%) cases were excluded due to no information about the CRA event, not a CRA when records examined, incomplete records, duplicate event record or records not found in storage.

The 123 CRA cases occurred on all 26 general wards in the hospital. The wards comprised 13 medical, eight surgical and five elderly care wards. The number of CRAs on the ward ranged from one CRA on five wards to 13 CRAs on two wards. The demographic and event details of the cardiac arrest cases are outlined in Table 1.

Table 1. Demographic and event summary of 123 cardiac arrest cases
 Number (%)
Emergency admission117 (95·1)
Speciality
Medical81 (65·8)
Surgical33 (26·8)
Elderly care9 (7·3)
Male71 (57·7)
Age 65 and above97 (78·8)
Left hospital alive8 (6·5)
Occurred during unsocial hours (21:00–06:59 hours)56 (45·5)
Occurred on weekdays (excluding bank holidays)88 (71·5)
Length of stay1–73 days

Nursing practice

Nurses' adherence to the EWS protocol was graded according to the predetermined criteria and categorised as previously described.

The number of cases in each category is reported in Table 2.

Table 2. Ward nurses' adherence to early warning scoring protocol
Standard of practiceNumber (%)
Good25 (20·3)
Basic36 (29·3)
Poor62 (50·4)

Twenty-five (20·3%) cases scored maximum for adherence to the protocol where all 11 elements were evident in the records. Just over half (50·4%) failed to reach the minimum standard of practice.

When the 11 elements were individually measured as shown in Fig. 2, the frequency and completeness of physiological observations were more consistently recorded than EWS recording, EWS accuracy and referring for more expert help.

image

Figure 2. Early warning scoring protocol elements documented in 123 cardio-respiratory arrests.

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Early warning scoring was completed in 103 (83·7%) cases, but nearly a quarter (24·3%) of these were inaccurate. Sixteen of the inaccuracies were scored below the trigger of 3 so would not have generated a referral, but 15 of these had actual EWS score of 3 or more, which should have triggered a referral. The rate and details regarding inaccuracies are outlined in Fig. 3. Of all 123 CRA cases, lack of observations (n = 3), lack of EWS recorded (n = 17) and inaccurate EWS calculations (n = 25) meant that 45 CRA cases (36·5%) had an ineffective recording of an EWS, which probably contributed to suboptimal referral decisions. The protocol for referring the patient for more expert help when the EWS trigger threshold was reached was not adhered to in 39% of the total number of CRA cases, due to the absence of EWS recording (n = 20) and not referring according to protocol (n = 28).

image

Figure 3. Rate and details of accuracy of early warning scores.

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The three categories of nurses' adherence to the EWS protocol were evaluated against the predetermined context elements, and their statistical probabilities are shown in Table 3. Due to the very large majority (95·1%) of patients being emergency admissions, it was inappropriate to apply probability statistical analysis for this context element. Ward location was analysed against the degree to which nurses adhered to protocol to see whether there were any consistencies that might point to cultural influences, but due to the small numbers of CRAs on some wards, statistical analysis was not possible. Overall, there appeared to be no discernible patterns of EWS protocol adherence related to individual wards.

Table 3. Comparison of ward nurses' adherence to early warning scoring (EWS) protocol with context elements
Context elementNo.Adherence to EWS protocol (total no. of cases = 123)p-Value
GoodBasicPoor
patients' age
Below 65 years26510110·496
65 years and above97202651
Time of day
Social (07:00–20:59 hours)671618330·537
Unsocial (21:00–06:59 hours)5691829
Day of week
Weekdays881533400·0006
Weekends and  bank holidays3510322
Speciality
Medical811723410·673
Surgical3361215
Elderly care9216
Gender
Male691722300·192
Female5481432
Staffing levels (staffing levels were determined using computerised rotas which were available in 83 cases, for the shift during and immediately preceding the cardio-respiratory arrest event)
Recommended level3077160·327
Understaffed4271124
Overstaffed11164

Of all the context elements analysed for statistical significance, only the day of the week showed that patients who suffer a CRA event at the weekend or bank holidays were more likely to have had a poorer adherence to the EWS protocol in the hours preceding their CRA.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

The audit of the EWS protocol has shown that ward nurses' adherence to the minimum accepted standards of practice was achieved in less than half of the patients included in this study. Only one-fifth of patients received the optimum standard of practice outlined in the EWS protocol. As these patients represented some of the most acutely unwell in the hospital, the results are of some concern.

The frequency and completeness of observation recording were better when compared with previous findings (McBride et al. 2005, NPSA 2007a,b, Odell et al. 2007). This may be due to the increased interest in the field, the influence of national policy and patient safety initiatives over the last 10 years. The main issue of concern was the inaccuracies of early warning scores and, coupled with the small number of missing EWS, meant that over a third of cases had an ineffective EWS. These findings resonate with those from other studies (Hillman et al. 2005, NCEPOD 2005, NPSA 2007a), and it seems further research needs to be carried out with RRSs if we are to realise their full potential. The problems this study has shown with elements of the afferent phase, such as inaccuracies and absence of EWS, might be a significant reason that studies to date have failed to adequately show effectiveness of rapid response teams (Hillman et al. 2005).

Seventy-six cases had an appropriate referral decision, but of these, 15 were based on inaccurate calculations of EWS. Therefore, in 62 cases, the referral decision was not optimal. Referral decisions are not only influenced by the protocol elements identified for this study, but also affected by complex factors such as the nurses' confidence, knowledge, skill, communication and relationships with members of the wider healthcare team. In an Australian study using structured interviews with 91 staff, Shearer et al. (2012) identified a number of sociocultural factors that were barriers in the activation of a rapid response team. One of the main factors was that ward staff felt that they had the experience and skill to manage the patients themselves even though they recognised that the patients met the rapid response trigger criteria. It was speculated that ward staff may feel that rapid response trigger criteria lack the necessary sensitivity and specificity, as few patients who triggered had a subsequent adverse event (Shearer et al. 2012).

In hindsight, the implementation of EWS systems and rapid response teams might have been an oversimplified solution to a very complex and multifaceted problem, and as pointed out by Hands et al. (2013), future work is needed to help us understand the local social, cultural and professional issues that influence individual practice.

Of all the context elements that were tested for their influence on adherence to the EWS protocol, the only one with a significant statistical association was those CRA cases that occurred during weekends and bank holidays. All the context elements tested in this study have been suggested as contributory factors to suboptimal care in other studies, and by investigating them in more depth, we can understand more about what might influence nurses' adherence to defined standards of care. While staffing levels may not appear to have an effect on the standard of nursing practice in this study, the weekend influence may be due to the presence of less senior nursing staff and the use of more bank and agency staff. While the numbers of nursing staff are unaffected, the experience and expertise of the staff may be diluted at those times. Other weekend effects may be lower numbers, or less experienced medical staff, as well as reduced availability of other support services. The weekend effect has been reported in other studies: an increased risk of death associated with emergency admission at the weekend (Aylin et al. 2010, Freemantle et al. 2012) and increased mortality for patients having elective surgery towards the end of the week and at weekends (Aylin et al. 2013). More research into the weekend effect would be of benefit.

There were particular challenges in the audit process. The considerable number of missing records and data within those records was a drawback to the completeness of data analysis. The problems with storage, care and retrieval of patient records are common and are unlikely to be restricted just to the study hospital. The advent of the electronic patient record is likely to make a positive impact on this problem, but the quality of data entry and record keeping will continue to depend on the professionalism, skill and the meticulousness of healthcare staff. While it might be argued that documentary evidence may not reflect practice, the documentation of the identified elements was in itself a measure of adherence to the defined standard of care. The use of records can minimise the inherent bias that might be evident in questionnaires and interview methods.

The use of CRAs as a surrogate marker of deterioration was necessary in the absence of a satisfactory objective definition of deterioration. Some of the CRAs could have been sudden events with no previous physiological deterioration signposted in the patients' observations. However, the focus of the study and the data that were analysed were not dependent on whether the patient had signs of deterioration, as the standard outlined in the EWS protocol should be applied to all acute inpatients. It could be argued that some of the patients should have had treatment limitation decisions, and this may have affected nursing practice decisions for that patient (either positively or negatively). This was not included in study remit but might be a useful focus for further research.

The choice of standards for the EWS protocol in the detection and immediate management of the deteriorating patient is open to challenge, but were developed from the literature and national recommendations. The standards and audit tool can be used by others to measure adherence to early warning systems protocols and can be added to and updated as new practice evidence becomes evident.

Lastly, the data for this study were collected in 2007, and the data may be considered out of date. However, to date, there have been very few published studies detected in this area. Two recent literature reviews on RRSs and vital signs monitoring (Massey et al. 2010, Kyriacos et al. 2011) have highlighted the paucity of research in this area and the need for more research on vital signs recording on general wards and the effective use of RRSs. Hands et al. (2013) reviewed patterns of vital signs recording on a large electronic system and assessed compliance with the escalation protocols using data collected during 2010/2011 and reported similar findings to the study reported here. This demonstrates the ongoing and widespread problem of inconsistent observation recording and lack of risk score documentation that were highlighted in the recently published enquiry into the Mid-Staffordshire hospital (Department of Health 2013). The report related to patient care issues between 2005–2009.

In reviewing the literature from the last 30 years, it has become apparent that changes in practice take many years to embed into culture, and the findings in the study by Hands et al. (2013) demonstrate that it is unlikely that there have been major changes in the intervening time that will make the findings from this study out of date.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

The aims of the study were to audit nursing practice against a standard of care in the monitoring and use of an EWS system protocol and examine possible influences of predetermined contextual factors on that practice.

The findings suggest that ward nurses' monitoring of patients' vital signs has improved compared with earlier research, but errors in EWS and nonadherence to EWS protocols were still a problem.

In seeking factors that might influence nursing practice decisions in adhering to EWS protocols, a number of contextual elements were tested for their effect, and the only factor found to have a significant association with the quality of nursing practice was in those CRA events that occurred during weekends or bank holidays. Auditing nursing practice from documentary evidence adds to the knowledge gained from nursing interviews and questionnaires in areas such as ward culture, poor staffing numbers and poor night-time care. Issues to do with nurses' skills and knowledge, communication and relationships with other healthcare personnel have all been highlighted in the literature. Further research into the afferent phase of the rapid response system would provide valuable insight into how we might shape future system development, improve clinical practice and positively affect patient experience and outcome.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Sources of support

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

The author's hospital supported the time and funding to undertake a PhD, during which this study was conducted.

Conflict of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References

There was no conflict of interest in the conduct of this study or in producing this manuscript, other than being employed by the organisation within which the study was set.

References

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  2. Abstract
  3. Introduction
  4. Methods
  5. Findings
  6. Discussion
  7. Conclusion
  8. Disclosure
  9. Sources of support
  10. Conflict of interest
  11. References
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