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1.
Clin Chem ; 65(11): 1437-1447, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31570634

RESUMO

BACKGROUND: We aimed to derive and externally validate a 0/2-h algorithm using the high-sensitivity cardiac troponin I (hs-cTnI)-Access assay. METHODS: We enrolled patients presenting to the emergency department with symptoms suggestive of acute myocardial infarction (AMI) in 2 prospective diagnostic studies using central adjudication. Two independent cardiologists adjudicated the final diagnosis, including all available medical information including cardiac imaging. hs-cTnI-Access concentrations were measured at presentation and after 2 h in a blinded fashion. RESULTS: AMI was the adjudicated final diagnosis in 164 of 1131 (14.5%) patients in the derivation cohort. Rule-out by the hs-cTnI-Access 0/2-h algorithm was defined as 0-h hs-cTnI-Access concentration <4 ng/L in patients with an onset of chest pain >3 h (direct rule-out) or a 0-h hs-cTnI-Access concentration <5 ng/L and an absolute change within 2 h <5 ng/L in all other patients. Derived thresholds for rule-in were a 0-h hs-cTnI-Access concentration ≥50 ng/L (direct rule-in) or an absolute change within 2 h ≥20 ng/L. In the derivation cohort, these cutoffs ruled out 55% of patients with a negative predictive value (NPV) of 99.8% (95% CI, 99.3-100) and sensitivity of 99.4% (95% CI, 96.5-99.9), and ruled in 30% of patients with a positive predictive value (PPV) of 73% (95% CI, 66.1-79). In the validation cohort, AMI was the adjudicated final diagnosis in 88 of 1280 (6.9%) patients. These cutoffs ruled out 77.9% of patients with an NPV of 99.8% (95% CI, 99.3-100) and sensitivity of 97.7% (95% CI, 92.0-99.7), and ruled in 5.8% of patients with a PPV of 77% (95% CI, 65.8-86) in the validation cohort. CONCLUSIONS: Safety and efficacy of the l hs-cTnI-Access 0/2-h algorithm for triage toward rule-out or rule-in of AMI are very high. TRIAL REGISTRATION: APACE, NCT00470587; ADAPT, ACTRN1261100106994; IMPACT, ACTRN12611000206921.

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.
N Engl J Med ; 380(26): 2529-2540, 2019 06 27.
Artigo em Inglês | MEDLINE | ID: mdl-31242362

RESUMO

BACKGROUND: Data regarding high-sensitivity troponin concentrations in patients presenting to the emergency department with symptoms suggestive of myocardial infarction may be useful in determining the probability of myocardial infarction and subsequent 30-day outcomes. METHODS: In 15 international cohorts of patients presenting to the emergency department with symptoms suggestive of myocardial infarction, we determined the concentrations of high-sensitivity troponin I or high-sensitivity troponin T at presentation and after early or late serial sampling. The diagnostic and prognostic performance of multiple high-sensitivity troponin cutoff combinations was assessed with the use of a derivation-validation design. A risk-assessment tool that was based on these data was developed to estimate the risk of index myocardial infarction and of subsequent myocardial infarction or death at 30 days. RESULTS: Among 22,651 patients (9604 in the derivation data set and 13,047 in the validation data set), the prevalence of myocardial infarction was 15.3%. Lower high-sensitivity troponin concentrations at presentation and smaller absolute changes during serial sampling were associated with a lower likelihood of myocardial infarction and a lower short-term risk of cardiovascular events. For example, high-sensitivity troponin I concentrations of less than 6 ng per liter and an absolute change of less than 4 ng per liter after 45 to 120 minutes (early serial sampling) resulted in a negative predictive value of 99.5% for myocardial infarction, with an associated 30-day risk of subsequent myocardial infarction or death of 0.2%; a total of 56.5% of the patients would be classified as being at low risk. These findings were confirmed in an external validation data set. CONCLUSIONS: A risk-assessment tool, which we developed to integrate the high-sensitivity troponin I or troponin T concentration at emergency department presentation, its dynamic change during serial sampling, and the time between the obtaining of samples, was used to estimate the probability of myocardial infarction on emergency department presentation and 30-day outcomes. (Funded by the German Center for Cardiovascular Research [DZHK]; ClinicalTrials.gov numbers, NCT00470587, NCT02355457, NCT01852123, NCT01994577, and NCT03227159; and Australian New Zealand Clinical Trials Registry numbers, ACTRN12611001069943, ACTRN12610000766011, ACTRN12613000745741, and ACTRN12611000206921.).


Assuntos
Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Medição de Risco/métodos , Troponina/sangue , Adulto , Idoso , Biomarcadores/sangue , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Troponina I/sangue
5.
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.

6.
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.

7.
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.

8.
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.

9.
Artigo em Inglês | MEDLINE | ID: mdl-30772842

RESUMO

CONTEXT: A rapid method of methadone conversion known as the Perth Protocol is commonly used in Australian palliative care units. There has been no follow-up or validation of this method and no comparison between different methods of conversion. OBJECTIVES: The primary objective of this study was to test the hypothesis that the achieved doses of methadone are independent of the conversion method (rapid vs slower). The secondary objectives included examining the relationship between calculated target doses, actual achieved doses and duration of conversions. METHODS: This is a retrospective chart audit conducted at two hospital sites in the Brisbane metropolitan area of Australia which used different methadone conversion methods. RESULTS: Methadone conversion ratios depended on previous opioid exposure and on the method of conversion used. The method most commonly used in Australia for calculating target doses for methadone when converting from strong opioids is a poor predictor of actual dose achieved. More appropriate conversion ratios are suggested. CONCLUSION: Further research is needed to refine the ratios used in practice when converting patients from strong opioids to methadone. Caution and clinical expertise are required. A palliative methadone registry may provide useful insights.

10.
Int J Cardiol ; 269: 114-121, 2018 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-30224031

RESUMO

BACKGROUND: Various scores have been derived for the assessment of syncope patients in the emergency department (ED) but stay inconsistently validated. We aim to compare their performance to the one of a common, easy-to-use CHADS2 score. METHODS: We prospectively enrolled patients ≥ 40 years old presenting with syncope to the ED in a multicenter study. Early clinical judgment (ECJ) of the treating ED-physician regarding the probability of cardiac syncope was quantified. Two independent physicians adjudicated the final diagnosis after 1-year follow-up. Major cardiovascular events (MACE) and death were recorded during 2 years of follow-up. Nine scores were compared by their area under the receiver-operator characteristics curve (AUC) for death, MACE or the diagnosis of cardiac syncope. RESULTS: 1490 patients were available for score validation. The CHADS2-score presented a higher or equally high accuracy for death in the long- and short-term follow-up than other syncope-specific risk scores. This score also performed well for the prediction of MACE in the long- and short-term evaluation and stratified patients with accuracy comparative to OESIL, one of the best performing syncope-specific risk score. All scores performed poorly for diagnosing cardiac syncope when compared to the ECJ. CONCLUSIONS: The CHADS2-score performed comparably to more complicated syncope-specific risk scores in the prediction of death and MACE in ED syncope patients. While better tools incorporating biochemical and electrocardiographic markers are needed, this study suggests that the CHADS2-score is currently a good option to stratify risk in syncope patients in the ED. TRIAL REGISTRATION: NCT01548352.

11.
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.

12.
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.

13.
Circulation ; 138(10): 989-999, 2018 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-29691270

RESUMO

BACKGROUND: Combining 2 signals of cardiomyocyte injury, cardiac troponin I (cTnI) and T (cTnT), might overcome some individual pathophysiological and analytical limitations and thereby increase diagnostic accuracy for acute myocardial infarction with a single blood draw. We aimed to evaluate the diagnostic performance of combinations of high-sensitivity (hs) cTnI and hs-cTnT for the early diagnosis of acute myocardial infarction. METHODS: The diagnostic performance of combining hs-cTnI (Architect, Abbott) and hs-cTnT (Elecsys, Roche) concentrations (sum, product, ratio, and a combination algorithm) obtained at the time of presentation was evaluated in a large multicenter diagnostic study of patients with suspected acute myocardial infarction. The optimal rule-out and rule-in thresholds were externally validated in a second large multicenter diagnostic study. The proportion of patients eligible for early rule-out was compared with the European Society of Cardiology 0/1 and 0/3 hour algorithms. RESULTS: Combining hs-cTnI and hs-cTnT concentrations did not consistently increase overall diagnostic accuracy as compared with the individual isoforms. However, the combination improved the proportion of patients meeting criteria for very early rule-out. With the European Society of Cardiology 2015 guideline recommended algorithms and cut-offs, the proportion meeting rule-out criteria after the baseline blood sampling was limited (6% to 24%) and assay dependent. Application of optimized cut-off values using the sum (9 ng/L) and product (18 ng2/L2) of hs-cTnI and hs-cTnT concentrations led to an increase in the proportion ruled-out after a single blood draw to 34% to 41% in the original (sum: negative predictive value [NPV] 100% [95% confidence interval (CI), 99.5% to 100%]; product: NPV 100% [95% CI, 99.5% to 100%]) and in the validation cohort (sum: NPV 99.6% [95% CI, 99.0-99.9%]; product: NPV 99.4% [95% CI, 98.8-99.8%]). The use of a combination algorithm (hs-cTnI <4 ng/L and hs-cTnT <9 ng/L) showed comparable results for rule-out (40% to 43% ruled out; NPV original cohort 99.9% [95% CI, 99.2-100%]; NPV validation cohort 99.5% [95% CI, 98.9-99.8%]) and rule-in (positive predictive value [PPV] original cohort 74.4% [95% Cl, 69.6-78.8%]; PPV validation cohort 84.0% [95% Cl, 79.7-87.6%]). CONCLUSIONS: New strategies combining hs-cTnI and hs-cTnT concentrations may significantly increase the number of patients eligible for very early and safe rule-out, but do not seem helpful for the rule-in of acute myocardial infarction. CLINICAL TRIAL REGISTRATION: URL (APACE): https://www.clinicaltrial.gov . Unique identifier: NCT00470587. URL (ADAPT): www.anzctr.org.au . Unique identifier: ACTRN12611001069943.

14.
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.

15.
Clin Chem ; 64(5): 820-829, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29419380

RESUMO

BACKGROUND: Low concentrations of cardiac troponin (cTn) have been recommended for rapid rule-out of acute myocardial infarction (AMI). We examined the Beckman Coulter Access high-sensitivity cardiac troponin I (hs-cTnI) assay to identify a single test threshold that can safely rule out AMI. METHODS: This analysis used stored samples collected in 2 prospective observational studies. In all, 1871 patients presenting to a tertiary emergency department with symptoms of acute coronary syndrome had blood taken for measurement of cTnI on presentation. The endpoint was type 1 myocardial infarction (T1MI). Sensitivity and negative predictive value (NPV) were calculated for hs-cTnI values below the 99th percentile. RESULTS: Ninety-eight patients had T1MI (5.2%), and 638 (34.1%) patients had an hs-cTnI <2 ng/L (limit of detection), with sensitivity of 99.0% (95% CI, 94.4%-100%) and NPV of 99.8% (95% CI, 99.1%-100%). No hs-cTnI value above a concentration of 2 ng/L achieved sensitivity of 99%. However, an NPV of 99.5% was achieved at values <6 ng/L. A cutoff <6 ng/L enabled 1475 (78.8%) patients to be ruled out on presentation with sensitivity of 93.9% (95% CI, 87.1%-97.7%). CONCLUSIONS: A single baseline cTn <2 ng/L measured with the Access hs-cTnI assay performed well for rule-out of AMI. This cutoff concentration identified 99% of patients with AMI and could reduce the number of patients requiring lengthy assessment. A cutoff of <6 ng/L yielded a high NPV but missed more cases of AMI than would be acceptable to clinicians.

16.
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
17.
Acad Emerg Med ; 25(4): 434-443, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29131477

RESUMO

OBJECTIVES: Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome (ACS) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms (ECGs) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score (EDACS) combined with a single measurement of high-sensitivity cardiac troponin (hs-cTn) could allow early discharge of a clinically meaningful proportion of patients. METHODS: We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS. The primary outcome was major adverse cardiac events (MACE) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high-sensitivity cardiac troponin T (hs-cTnT) concentration and high-sensitivity cardiac troponin I (hs-cTnI) concentration with EDACS. We used a standard smoothing technique on the probability density function for hs-cTn and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE. RESULTS: From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs-cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs-cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low risk). CONCLUSION: Single measurements of both hs-cTnI and hs-cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.

18.
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
19.
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
20.
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
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