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1.
Emerg Med J ; 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31719104

RESUMO

BACKGROUND: Emergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk. METHODS: This study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians' estimated risk and ACE. RESULTS: Increasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population. CONCLUSION: Physicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.

2.
Emerg Med J ; 2019 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551289

RESUMO

BACKGROUND: The ED Stressor Scale outlines 15 stressors that are of importance for ED staff. Limited research has identified how commonly such stressors occur, or whether such factors are perceived with similar importance across different hospitals. This study sought to examine the frequency or perceived severity of these 15 stressors using a multicentre cohort of emergency clinicians (nurses and physicians) in EDs in two countries (Australia and Sweden). METHOD: This was a cross-sectional survey of staff working in eight hospitals in Australia and Sweden. Data were collected between July 2016 and June 2017 (depending on local site approvals) via a printed survey incorporating the 15-item ED stressor scale. The median stress score for each item and the frequency of experiencing each event was reported. RESULTS: Events causing most distress include heavy workload, death or sexual abuse of a child, inability to provide optimum care and workplace violence. Stressors reported most frequently include dealing with high acuity patients, heavy workload and crowding. Violence, workload, inability to provide optimal care, poor professional relations, poor professional development and dealing with high-acuity patients were reported more commonly by Australian staff. Swedish respondents reported more frequent exposure to mass casualty incidents, crisis management and administrative concerns. CONCLUSIONS: Workload, inability to provide optimal care, workplace violence and death or sexual abuse of a child were consistently reported as the most distressing events across sites. The frequency with which these occurred differed in Australia and Sweden, likely due to differences in the healthcare systems.

3.
Emerg Med Australas ; 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31268243

RESUMO

OBJECTIVES: The aims of this study were to describe clinical staff perceptions of their ED working environment and to explore associations between staff demographics, coping styles and the work environment. METHODS: A cross-sectional study was conducted in one Swedish ED and two Australian EDs in 2015-2016. Descriptive statistics were used to explore stressors, coping styles and aspects of the working environment for the combined cohort and the cohort split by age, sex, professional role, years of employment in the ED and country. Regression analyses examined the impact of coping style and demographic characteristics on staff perceptions of the working environment. RESULTS: Two hundred and six ED staff completed the survey (response rate: 64%). Factors most stressful for ED staff included death or sexual abuse of a child, heavy workload and poor skill mix. Staff perceptions of the working environment differed based on age, sex, country, tenure and job role. Regression analysis of perceptions of the work environment on demographics and coping strategies revealed that negative coping strategies were associated with low self-realisation, high workload, high conflict and high nervousness. Active coping and positive thinking were associated with increased self-realisation. Positive thinking was associated with lower levels of conflict. CONCLUSIONS: Employees engaging in positive coping strategies had more positive perceptions of the work environment, while those engaging in maladaptive coping strategies reported negative perceptions of the work environment. These data suggest that strategies that promote the use of active coping and positive thinking should be encouraged and warrant further research in the ED.

4.
Australas Emerg Care ; 22(3): 180-186, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31151793

RESUMO

BACKGROUND: Emergency departments (EDs) are stressful workplaces. Limited research explores components ED staff find stressful and how they cope. The aim of this study is to describe ED staff perceptions of their working environment. METHODS: A cross-sectional study was undertaken in 2017 in a public, teaching hospital ED situated in an outer-metropolitan low socio-economic area. ED doctors and nurses completed surveys exploring workplace stressors (the ED stressors tool), coping strategies (Jalowiec Coping Scale), and perceptions of the working environment (Working Environment Scale-10). Descriptive and comparative analyses were undertaken. RESULTS: A 40% response rate (161/400) was achieved. Staff reported high workload, moderate self-realisation, and low levels of conflict and nervousness. Heavy workload, poor skill-mix and overcrowding were ranked as high-stress, high-exposure (daily) events. The death or sexual abuse of a child and inability to provide optimal care were ranked highly stressful but infrequent. Coping strategies most often used included: trying to keep life as normal as possible (90%) and considering different ways to handle the situation (89%). CONCLUSIONS: Impacts of varying degrees of exposure of this young cohort of staff, with limited experience, to modifiable and non-modifiable stressors highlight site-specific opportunities to enhance staff perceptions of their working environment.

5.
Heart ; 105(20): 1559-1567, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31142594

RESUMO

OBJECTIVE: Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS: We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS: Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION: Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER: APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.

6.
Int Emerg Nurs ; 45: 17-24, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31053392

RESUMO

BACKGROUND: Research exploring multi-disciplinary emergency department (ED) clinicians' perceptions of their working environment is limited, although exposure to occupational stressors is frequent. This study describes ED clinicians' perceptions of their working environment, occupational stressors and their use of coping strategies. METHODS: A cross-sectional descriptive study was conducted in 2017 at two Australian public hospital EDs. Nursing and medical staff completed a print-based survey of 100 items, which included three scales and a demographic questionnaire. Responses were analysed using descriptive statistics and regression analysis. RESULTS: Doctors and nurses (n = 241) completed the survey (response rate 45%). Workload featured as a major factor in perception of the working environment and was a frequently occurring stressor. Death or sexual abuse of a child was the highest rated stressor, despite relative infrequency of exposure. When coping strategies were adjusted for sex, female respondents were more likely to use negative strategies such as blaming themselves (Odds Ratio, OR 4 [1.6-9.7]; p < 0.01) and less likely to use positive strategies such as exercise (OR 0.2 [0.1-0.6]; p < 0.01). CONCLUSIONS: While stressors were similarly rated among the diverse group of clinicians, the ways in which they reported coping varied. Further research is required to facilitate design of staff support strategies.

7.
Emerg Med Australas ; 31(4): 580-586, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30916483

RESUMO

OBJECTIVE: To describe the impact of an educational intervention for ED prescribers on discharge oxycodone prescribing both for the number of oxycodone prescriptions per 1000 discharged patients, and the number of tablets per prescription. Secondary outcomes included the quality of general practitioner communication. METHODS: An interrupted time series assessment was conducted in the ED of a tertiary referral hospital to establish the pre-intervention, peri-intervention and post-intervention prescribing profile of ED medical practitioners. Prescriber numbers were used to obtain drug data for all oxycodone-containing prescriptions from the Queensland Health Medicines Regulation and Quality Unit database. The intervention included education sessions, a staff information email, posters within the ED, and a patient brochure. It was conducted with relevant nurses, pharmacists and prescribing doctors. RESULTS: In the pre-intervention period, 656/17 371 (38 per 1000) discharged patients were prescribed oxycodone, compared to 180/5938 (30 per 1000) during the intervention, and 602/20 505 (29 per 1000) post-intervention. This equated to a decrease of 8 per 1000 (95% CI 5-12 per 1000) and a 22% (95% CI 13-31%) relative prescribing reduction. The mean total number of tablets of oxycodone per prescription decreased from 16.7 (SD 16.5) pre-intervention, to 12.7 (SD 6.0) peri-intervention, to 10.7 (SD 5.2) post-intervention. After the intervention, there was an increase in discharge communications to general practitioners by 15.4% (95% CI 9.7-21.1%). CONCLUSIONS: An ED prescriber-targeted intervention reduced overall prescribing of oxycodone and improved communication at discharge. The prescribing intervention is one strategy that may be used by ED medical staff to improve patient safety and opioid stewardship in Australia.

8.
CMAJ ; 190(33): E974-E984, 2018 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-30127037

RESUMO

BACKGROUND: Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department. METHODS: We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT). RESULTS: For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% CI 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2). INTERPRETATION: The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457.

9.
Clin Chem ; 64(7): 1044-1053, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29760219

RESUMO

BACKGROUND: Increased cardiac troponin I or T detected by high-sensitivity assays (hs-cTnI or hs-cTnT) confers an increased risk of adverse prognosis. We determined whether patients presenting with putatively normal, detectable cTn concentrations [> limit of detection and < upper reference limit (URL)] have increased risk of major adverse cardiovascular events (MACE) or all-cause mortality. METHODS: A prospective 5-year follow-up of patients recruited in the emergency department with possible acute coronary syndrome (ACS) and cTn concentrations measured with hs-cTnI (Abbott) and hs-cTnT (Roche) assays. Cox regression models were generated with adjustment for covariates in those without MACE on presentation. Hazard ratios (HRs) for hs-cTn were calculated relative to the HRs at the median concentration. RESULTS: Of 1113 patients, 836 were without presentation MACE. Of these, 138 incurred a MACE and 169 died during a median 5.8-year follow-up. HRs for MACE at the URLs were 2.3 (95% CI, 1.7-3.2) for hs-cTnI and 1.8 (95% CI, 1.3-2.4) for hs-cTnT. Corresponding HRs for mortality were 1.7 (95% CI, 1.2-2.2) for hs-cTnI and 2.3 (95 % CI, 1.7-3.1) for hs-cTnT. The HR for MACE increased with increasing hs-cTn concentration similarly for both assays, but the HR for mortality increased at approximately twice the rate for hs-cTnT than hs-cTnI. Patients with hs-cTnI ≥10 ng/L or hs-cTnT ≥16 ng/L had the same percentage of MACE at 5-year follow-up (33%) as patients with presentation MACE. CONCLUSIONS: Many patients with ACS ruled out and putatively normal but detectable hs-cTnI concentrations are at similar long-term risk as those with MACE. hs-cTnT concentrations are more strongly associated with 5-year mortality than hs-cTnI.

10.
Emerg Med Australas ; 30(4): 538-546, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29609223

RESUMO

OBJECTIVE: To assess community-acquired pneumonia severity scores from two perspectives: (i) prediction of ICU admission or mortality; and (ii) utility of low scores for prediction of discharge within 48 h, potentially indicating suitability for short-stay unit admission. METHODS: Patients with community-acquired pneumonia were identified from a prospective database of emergency patients admitted with infection. Pneumonia severity index (PSI), CURB-65, CORB, CURXO, SMARTCOP scores and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) minor criteria were calculated. Diagnostic accuracy statistics (sensitivity, specificity, predictive values, likelihood ratios and area under receiver operating characteristic curves [AUROC]) were determined for both end-points. RESULTS: Of 618 patients admitted with community-acquired pneumonia judged eligible for invasive therapies, 75 (12.1%) were admitted to ICU or deceased at 30 days, and 87 (14.1%) were discharged within 48 h. All scores effectively stratified patients into categories of risk. For prediction of severe pneumonia, SMARTCOP, CURXO and IDSA/ATS discriminated well (AUROC 0.84-0.87). SMARTCOP and CURXO showed optimal sensitivity (85% [95% confidence interval (CI) 75-92]), while specificity was highest for CORB and CURB-65 (93% and 94%, respectively). Using lowest risk categories for prediction of discharge within 48 h, only SMARTCOP and CURXO showed specificity >80%. PSI demonstrated highest positive predictive value (31% [95% CI 24-39]) and AUROC (0.74 [95% CI 0.69-0.79]). CONCLUSIONS: Community-acquired pneumonia severity scores had different strengths; SMARTCOP and CURXO were sensitive with potential to rule out severe disease, while the high specificity of CORB and CURB-65 facilitated identification of patients at high risk of requirement for ICU. Low severity scores were not useful to identify patients suitable for admission to short-stay units.

11.
Emerg Med Australas ; 30(3): 375-381, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29363265

RESUMO

OBJECTIVE: Clinical staff in EDs are subject to a range of stressors. The objective of this study was to describe and compare clinical staff perceptions of their ED's working environment across two different Australian EDs. METHODS: This was a cross-sectional, descriptive, research design that included distribution of three survey tools to clinical staff in two Australian EDs in 2016. Descriptive statistics were reported to characterise workplace stressors, coping styles and the ED environment. These data were compared by hospital and the employee's clinical role (nurse or physician). RESULTS: In total, 146 ED nurses and doctors completed the survey (response rate: 67%). Despite geographical variation, the staff at the two locations had similar demographic profiles in terms of age, sex and years of experience. Staff reported moderate levels of workload and self-realisation but low levels of conflict or nervousness in the workplace. Nurses and physicians reported similar perceptions of the work environment, although nurses reported slightly higher median levels of workload. Staff rated the death or sexual abuse of a child as most stressful, followed by workplace violence and heavy workload. Staff used a large range of coping strategies, and these were similar across both sites. CONCLUSION: These findings are the first multi-site and multidisciplinary examinations of Australian ED staff perceptions, improving our understanding of staff stressors and coping strategies and highlighting similarities across different EDs. These data support the development and implementation of strategies to improve ED working environments to help ensure professional longevity of ED staff.


Assuntos
Adaptação Psicológica , Pessoal de Saúde/estatística & dados numéricos , Moral , Percepção , Adulto , Atitude do Pessoal de Saúde , Estudos Transversais , Serviço Hospitalar de Emergência/classificação , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Pessoal de Saúde/psicologia , Humanos , Satisfação no Emprego , Masculino , Pessoa de Meia-Idade , Queensland , Estresse Psicológico/complicações , Inquéritos e Questionários , Recursos Humanos , Local de Trabalho/psicologia , Local de Trabalho/normas
12.
Emerg Med Australas ; 30(1): 47-54, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29232768

RESUMO

OBJECTIVE: To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain. METHODS: A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values). RESULTS: Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s-TIMI) including four variables: age ≥65 years, three or more risk factors, high-sensitivity troponin (hs-cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g-TIMI). s-TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g-TIMI had a sensitivity of 98.90% and specificity of 14.90%. CONCLUSIONS: Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g-TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s-TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s-TIMI may be useful as part of an accelerated chest pain protocol.


Assuntos
Infarto do Miocárdio/classificação , Infarto do Miocárdio/diagnóstico , Medição de Risco/normas , Índice de Gravidade de Doença , Idoso , Biomarcadores/análise , Biomarcadores/sangue , Dor no Peito/complicações , Dor no Peito/diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/terapia , Estudos Prospectivos , Medição de Risco/métodos , Fatores de Risco , Triagem/métodos , Troponina I/análise , Troponina I/sangue
13.
Ann Emerg Med ; 71(4): 439-451.e3, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29248334

RESUMO

STUDY OBJECTIVE: This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS: High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS: Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION: In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Medição de Risco/métodos , Troponina I/sangue , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/epidemiologia , Biomarcadores/sangue , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/epidemiologia , Estudos Prospectivos , Queensland/epidemiologia , Reprodutibilidade dos Testes , Fatores de Risco
14.
Eur J Emerg Med ; 25(2): 97-104, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27547885

RESUMO

OBJECTIVE: Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock. METHODS: Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined. RESULTS: A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival. CONCLUSION: Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Ressuscitação/métodos , Índice de Gravidade de Doença , Choque Séptico/terapia , Adulto , Gerenciamento Clínico , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Choque Séptico/mortalidade
15.
Emerg Med J ; 35(3): 169-175, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28784608

RESUMO

OBJECTIVE: To identify differences in prevalence, demographics, clinical features and outcomes for type 1 myocardial infarction (T1MI) and type 2 myocardial infarction (T2MI) in a cohort of patients presenting to the Emergency Department (ED) with chest pain. METHODS: This was a post hoc analysis of data collected from two prospective studies. Data were collected between November 2008 and February 2011 for the first study, and between February 2011 and March 2014 for the second. Participants were patients presenting to the ED with symptoms suggestive of acute coronary syndrome (ACS). The outcome was 30-day diagnosis; classified into T1MI, T2MI or non-MI. Descriptive statistics were used to compare the demographics, clinical history and presenting symptoms across diagnoses (T1MI, T2MI and non-MI). Cumulative mortality over 1 year was compared for T1MI and T2MI. RESULTS: 147 patients (6.3%; 95% CI 5.3% to 7.3%) were classified as T1MI and 52 (2.2%; 95% CI 1.7% to 2.9%) were classified as T2MI. T2MIs were more likely to be female (OR 4.71, 95% CI 2.28 to 9.76), have an abnormal but non-ischaemic ECG (OR 2.95, 95% CI 1.45 to 6.00), report prior hypertension (OR 2.83, 95% CI 1.35 to 6.12), have tachycardia (OR 9.26, 95% CI 3.08 to 30.77) and pain at rest (OR 3.04, 95% CI 1.28 to 8.02) compared with T1MI. One-year mortality was similar between T1MI and T2MI (9% and 14.6%, respectively, p=0.37). CONCLUSIONS: T2MIs comprised one quarter of all MIs diagnosed in the ED. Among patients presenting to the ED with symptoms of ACS, symptoms do not allow clinicians to reliably differentiate patients with T1MI and T2MI. Prior hypertension, tachycardia and abnormal non-ischaemic ECGs are seen more often in T2MI compared with T1MI. One-year mortality was substantial in patients with T1MI and T2MI, but low power precludes conclusions about mortality differences between groups.


Assuntos
Infarto do Miocárdio/classificação , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Adulto , Idoso , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Estudos Prospectivos
16.
Clin Biochem ; 52: 161-163, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29054440

RESUMO

OBJECTIVE: To externally validate a clinical decision rule incorporating heart fatty acid binding protein (h-FABP), high-sensitivity troponin (hs-cTn) and electrocardiogram (ECG) for the detection of acute myocardial infarction (AMI) on presentation to the Emergency Department. We also investigated whether this clinical decision rule improved identification of AMI over algorithms incorporating hs-cTn and ECG only. DESIGN AND METHODS: This study included data from 789 patients from the Brisbane ADAPT cohort and 441 patients from the Christchurch TIMI RCT cohort. The primary outcome was index AMI. Sensitivity, specificity, positive predictive value and negative predictive value were used to assess the diagnostic accuracy of the algorithms. RESULTS: 1230 patients were recruited, including 112 (9.1%) with AMI. The algorithm including h-FABP and hs-cTnT had 100% sensitivity and 32.4% specificity. The algorithm utilising h-FABP and hs-cTnI had similar sensitivity (99.1%) and higher specificity (43.4%). The hs-cTnI and hs-cTnT algorithms without h-FABP both had a sensitivity of 98.2%; a result that was not significantly different from either algorithm incorporating h-FABP. Specificity was higher for the hs-cTnI algorithm (68.1%) compared to the hs-cTnT algorithm (33.0%). The specificity of the algorithm incorporating hs-cTnI alone was also significantly higher than both of the algorithms incorporating h-FABP (p<0.01). CONCLUSION: For patients presenting to the Emergency Department with chest pain, an algorithm incorporating h-FABP, hs-cTn and ECG has high accuracy and can rule out up to 40% of patients. An algorithm incorporating only hs-cTn and ECG has similar sensitivity and may rule out a higher proportion of patients. Each of the algorithms can be used to safely identify patients as low risk for AMI on presentation to the Emergency Department.


Assuntos
Proteína 3 Ligante de Ácido Graxo/análise , Infarto do Miocárdio/diagnóstico , Idoso , Algoritmos , Biomarcadores , Dor no Peito/diagnóstico , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência , Proteína 3 Ligante de Ácido Graxo/sangue , Proteínas de Ligação a Ácido Graxo/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/metabolismo , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , Troponina/análise , Troponina/sangue , Troponina I/sangue , Troponina T/sangue
17.
Acad Emerg Med ; 25(1): 26-32, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29044739

RESUMO

OBJECTIVES: The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients. METHODS: A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre- and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients. RESULTS: A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to -12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23). CONCLUSIONS: The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

18.
J Head Trauma Rehabil ; 33(4): E47-E60, 2018 Jul/Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29084098

RESUMO

OBJECTIVE: To determine the contribution of demographics, injury type, pain, and psychological factors on postconcussive symptoms. SETTING AND PARTICIPANTS: Recently injured (n = 54) and noninjured (n = 184) adults were recruited from a hospital emergency department or the community. Thirty-eight individuals met the diagnostic criteria for a mild traumatic brain injury and 16 individuals received treatment for a minor traumatic non-brain injury. MAIN MEASURES: Standardized tests were administered to assess 4 postconcussion symptom types and theorized predictors including a "physiogenic" variable (injury type) and "psychogenic" variables (symptoms of anxiety, depression, and stress) within 1 month of the injury. RESULTS: In the injured sample, after controlling for injury type, demographics, and pain (chronic and current), a hierarchical regression analysis revealed that the combination of psychological symptoms predicted affective (F10,42 = 2.80, P = .009, Rchange = 0.27) but not other postconcussion symptoms types. Anxiety (ß = .48), stress (ß = .18), and depression (ß = -.07) were not statistically significant individual predictors (P > .05). Cognitive and vestibular postconcussion symptoms were not predicted by the modeled factors, somatic sensory postconcussion symptoms were predicted by demographic factors only, and the pattern of predictors for the symptom types differed for the samples. CONCLUSIONS: Traditional explanatory models do not account for these findings. The predictors are multifactorial, different for injured versus noninjured samples, and symptom specific.

19.
JAMA ; 318(19): 1913-1924, 2017 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-29127948

RESUMO

Importance: High-sensitivity cardiac troponin I testing is widely used to evaluate patients with suspected acute coronary syndrome. A cardiac troponin concentration of less than 5 ng/L identifies patients at presentation as low risk, but the optimal threshold is uncertain. Objective: To evaluate the performance of a cardiac troponin I threshold of 5 ng/L at presentation as a risk stratification tool in patients with suspected acute coronary syndrome. Data Sources: Systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases from January 1, 2006, to March 18, 2017. Study Selection: Prospective studies measuring high-sensitivity cardiac troponin I concentrations in patients with suspected acute coronary syndrome in which the diagnosis was adjudicated according to the universal definition of myocardial infarction. Data Extraction and Synthesis: The systematic review identified 19 cohorts. Individual patient-level data were obtained from the corresponding authors of 17 cohorts, with aggregate data from 2 cohorts. Meta-estimates for primary and secondary outcomes were derived using a binomial-normal random-effects model. Main Outcomes and Measures: The primary outcome was myocardial infarction or cardiac death at 30 days. Performance was evaluated in subgroups and across a range of troponin concentrations (2-16 ng/L) using individual patient data. Results: Of 11 845 articles identified, 104 underwent full-text review, and 19 cohorts from 9 countries were included. Among 22 457 patients included in the meta-analysis (mean age, 62 [SD, 15.5] years; n = 9329 women [41.5%]), the primary outcome occurred in 2786 (12.4%). Cardiac troponin I concentrations were less than 5 ng/L at presentation in 11 012 patients (49%), in whom there were 60 missed index or 30-day events (59 index myocardial infarctions, 1 myocardial infarction at 30 days, and no cardiac deaths at 30 days). This resulted in a negative predictive value of 99.5% (95% CI, 99.3%-99.6%) for the primary outcome. There were no cardiac deaths at 30 days and 7 (0.1%) at 1 year, with a negative predictive value of 99.9% (95% CI, 99.7%-99.9%) for cardiac death. Conclusions and Relevance: Among patients with suspected acute coronary syndrome, a high-sensitivity cardiac troponin I concentration of less than 5 ng/L identified those at low risk of myocardial infarction or cardiac death within 30 days. Further research is needed to understand the clinical utility and cost-effectiveness of this approach to risk stratification.


Assuntos
Síndrome Coronariana Aguda/sangue , Infarto do Miocárdio/diagnóstico , Troponina I/sangue , Síndrome Coronariana Aguda/mortalidade , Adulto , Biomarcadores/sangue , Morte , Humanos , Masculino , Infarto do Miocárdio/sangue , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos
20.
Med J Aust ; 207(5): 195-200, 2017 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-28987132

RESUMO

OBJECTIVE: To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain. DESIGN, SETTING AND PARTICIPANTS: IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS. INTERVENTION: High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing. MAIN OUTCOME MEASURES: The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS). RESULTS: The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients. CONCLUSIONS: The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000206921.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Ensaios Clínicos Controlados não Aleatórios como Assunto/métodos , Medição da Dor/métodos , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Nova Zelândia , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Medição de Risco , Centros de Atenção Terciária , Resultado do Tratamento , Troponina/análise
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