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1.
Br J Sports Med ; 54(2): 79-86, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30826805

RESUMO

OBJECTIVES: To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs). DESIGN: Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations. ELIGIBILITY CRITERIA: Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. DATA SOURCES: Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. RESULTS: 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work. CONCLUSION: These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.


Assuntos
Dor Musculoesquelética/terapia , Guias de Prática Clínica como Assunto , Medicina Baseada em Evidências , Humanos , Qualidade da Assistência à Saúde
2.
Br J Sports Med ; 52(5): 337-343, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29175827

RESUMO

OBJECTIVES: Undertake a systematic critical appraisal of contemporary clinical practice guidelines (CPGs) for common musculoskeletal (MSK) pain conditions: spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis) and shoulder. DESIGN: Systematic review of CPGs (PROSPERO number: CRD42016051653).Included CPGs were written in English, developed within the last 5 years, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. DATA SOURCES AND METHOD OF APPRAISAL: Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used for critical appraisal. RESULTS: 4664 records were identified, and 34 CPGs were included. Most were for osteoarthritis (n=12) or low back pain (n=11), most commonly from the USA (n=12). The mean overall AGREE II score was 45% (SD=19.7). Lowest mean domain scores were for applicability (26%, SD=19.5) and editorial independence (33%, SD=27.5). The highest score was for scope and purpose (72%, SD=14.3). Only 8 of 34 CPGS were high quality: for osteoarthritis (n=4), low back pain (n=2), neck (n=1) and shoulder pain (n=1).


Assuntos
Dor Musculoesquelética/terapia , Guias de Prática Clínica como Assunto , Humanos , Dor Lombar/terapia , Osteoartrite/terapia
4.
Wilderness Environ Med ; 26(1): 59-61, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25443755

RESUMO

Exercise-associated hyponatremia and its more serious form, known as exercise-associated hyponatremic encephalopathy, are recognized as some of the most important medical problems seen in a variety of different forms of endurance exercise. We describe a case of exercise-associated hyponatremic encephalopathy presenting as altered conscious state and seizures in a woman who had completed a 20-km open ocean swim. Her serum sodium measured approximately 1 hour after her seizure was 119 mmol/L on point-of-care testing. With ongoing critical care support and the use of hypertonic saline, she was able to be extubated the next day, neurologically intact, and ultimately was discharged from hospital without neurological sequelae. This case emphasizes both the importance of considering exercise-associated hyponatremic encephalopathy as a cause of neurological impairment in all athletes and the pivotal role of hypertonic saline in the treatment of this condition.


Assuntos
Encefalopatias/etiologia , Hiponatremia/complicações , Natação , Encefalopatias/diagnóstico , Encefalopatias/terapia , Transtornos da Consciência/diagnóstico , Transtornos da Consciência/etiologia , Transtornos da Consciência/terapia , Feminino , Humanos , Hiponatremia/diagnóstico , Hiponatremia/terapia , Pessoa de Meia-Idade , Convulsões/diagnóstico , Convulsões/etiologia , Convulsões/terapia , Austrália Ocidental
6.
Emerg Med J ; 31(4): 281-5, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23576231

RESUMO

AIM: The Thrombolysis in Myocardial Infarction (TIMI) risk score (range 0-7), used for emergency department (ED) risk stratification of patients with suspected acute coronary syndrome (ACS), underestimates risk associated with ECG changes or cardiac troponin elevation. A modified TIMI score (mTIMI, range 0-10), which gives increased weighting to these variables, has been proposed. We aimed to evaluate the performance of the mTIMI score in ED patients with suspected ACS. METHODS: A multicentre prospective observational study enrolled patients undergoing assessment for possible ACS. TIMI and mTIMI scores were calculated. The study outcome was a composite of all-cause death, myocardial infarction or coronary revascularisation within 30 days. RESULTS: Of the 1666 patients, 219 (13%) reached the study outcome. Area under the receiver operating characteristic curve for the composite outcome was 0.80 (0.76 to 0.83) for the mTIMI score compared with 0.71 (0.67 to 0.74) for the standard TIMI score, p<0.001, but there was no significant difference for death or revascularisation outcomes. Sensitivity and specificity for the composite outcome were 0.96 (0.92 to 0.98) and 0.23 (0.20 to 0.26), respectively, at score 0 for TIMI and mTIMI. At score <2, sensitivity and specificity were 0.82 (0.77 to 0.87) and 0.53 (0.51 to 0.56) for mTIMI, and 0.74 (0.68 to 0.79) and 0.54 (0.51 to 0.56) for standard TIMI, respectively. CONCLUSIONS: mTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.


Assuntos
Dor no Peito/diagnóstico , Infarto do Miocárdio/diagnóstico , Terapia Trombolítica/métodos , Síndrome Coronariana Aguda/diagnóstico , Idoso , Área Sob a Curva , Causas de Morte , Dor no Peito/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco/métodos , Medição de Risco/normas , Sensibilidade e Especificidade
7.
J Allergy Clin Immunol ; 132(5): 1141-1149.e5, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23915715

RESUMO

BACKGROUND: Prospective human studies of anaphylaxis and its mechanisms have been limited, with few severe cases or examining only 1 or 2 mediators. OBJECTIVES: We wanted to define the clinical patterns of anaphylaxis and relationships between mediators and severity. METHODS: Data were collected during treatment and before discharge. Serial blood samples were taken for assays of mast cell tryptase, histamine, anaphylatoxins (C3a, C4a, C5a), cytokines (IL-2, IL-6, IL-10), soluble tumor necrosis factor receptor I, and platelet activating factor acetyl hydrolase. Principal component analysis defined mediator patterns, and logistic regression identified risk factors and mediator patterns associated with reaction severity and delayed reactions. RESULTS: Of 412 reactions in 402 people, 315 met the definition for anaphylaxis by the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network. Of 97 severe reactions 45 (46%) were hypotensive, 23 (24%) were hypoxemic, and 29 (30%) were mixed. One patient died. Severe reactions were associated with older age, pre-existing lung disease, and drug causation. Delayed deteriorations treated with epinephrine occurred in 29 of 315 anaphylaxis cases (9.2%) and were more common after hypotensive reactions and with pre-existing lung disease. Twenty-two of the 29 delayed deteriorations (76%) occurred within 4 hours of initial epinephrine treatment. Of the remaining 7 cases, 2 were severe and occurred after initially severe reactions, within 10 hours. All mediators were associated with severity, and 1 group (mast cell tryptase, histamine, IL-6, IL-10, and tumor necrosis factor receptor I) was also associated with delayed deteriorations. Low platelet activating factor acetyl hydrolase activity was associated with severe reactions. CONCLUSION: The results suggest that multiple inflammatory pathways drive reaction severity and support recommendations for safe observation periods after initial treatment.


Assuntos
Anafilaxia/diagnóstico , 1-Alquil-2-acetilglicerofosfocolina Esterase/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anafilaxia/sangue , Anafilaxia/complicações , Anafilaxia/tratamento farmacológico , Criança , Pré-Escolar , Testes de Química Clínica , Proteínas do Sistema Complemento/metabolismo , Citocinas/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Triptases/sangue , Adulto Jovem
8.
Med J Aust ; 198(11): 612-5, 2013 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-23919709

RESUMO

OBJECTIVE: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice. DESIGN: Using data sourced from the Emergency Department Information Systems for the calendar 2013s 2009 to 2011 at three major tertiary hospitals in Perth, Western Australia, we compared four methods for calculating general practice-type patients. These were the validated Sprivulis method, the widely used Australasian College for Emergency Medicine method, a discharge diagnosis method developed by the Tasmanian Department of Human and Health Services, and the Australian Institute of Health and Welfare (AIHW) method. MAIN OUTCOME MEASURE: General practice-type patient attendances to EDs, estimated using the four methods. RESULTS: All methods except the AIHW method showed that 10%-12% of patients attending tertiary EDs in Perth may have been suitable for general practice. These attendances comprised 3%-5% of total ED length of stay. The AIHW method produced different results (general practice-type patients accounted for about 25% of attendances, comprising 10%-11% of total ED length of stay). General practice-type patient attendances were not evenly distributed across the week, with proportionally more patients presenting during weekday daytime (08:00-17:00) and proportionally fewer overnight (00:00-08:00). This suggests that it is not a lack of general practitioners that drives patients to the ED, as weekday working hours are the time of greatest GP availability. CONCLUSION: The estimated proportion of general practice-type patients attending the EDs of Perth's major hospitals is 10%-12%, and this accounts for < 5% of the total ED length of stay. The AIHW methodology overestimates the actual proportion of general practice-type patient attendances.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Medicina Geral/estatística & dados numéricos , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Aglomeração , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Austrália Ocidental/epidemiologia
9.
Emerg Med J ; 30(2): 149-54, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22436507

RESUMO

OBJECTIVE: To evaluate the accuracy of a 2-h serial multiple biomarker (SMB) protocol for exclusion of myocardial infarction (MI) in the Emergency Department. METHODS: A prospective, multicentre, observational study enrolled patients undergoing evaluation for possible MI. Blood samples at presentation and 2 h later were analysed for myoglobin, creatinine kinase-MB, troponin-I and B-natriuretic peptide. Thrombolysis in Myocardial Infarction (TIMI) score and National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline for acute coronary syndrome were used to determine clinical risk. Primary outcome was MI diagnosed at index presentation. Secondary outcome was composite of all-cause mortality, MI and previously unplanned coronary revascularisation within 30 days. RESULTS: 1758 patients were recruited. 168 (11%) of 1501 with data sufficient for analysis had MI, and 223 (14%) of 1620 had a secondary outcome. SMB sensitivity and specificity were 0.90 (95% CI 0.84 to 0.94) and 0.41 (95% CI 0.39 to 0.44) for MI. For 30-day outcome, SMB sensitivity and specificity were 0.84 (95% CI 0.78 to 0.88) and 0.41 (95% CI 0.39 to 0.44), compared with standard 8-12 h troponin sensitivity and specificity of 0.79 (95% CI 0.73 to 0.84) and 0.96 (95% CI 0.95 to 0.97). Combined with risk scores, SMB had sensitivity and specificity for MI of 0.99 (0.96 to 1.00) and 0.11 (95% CI 0.09 to 0.12) for TIMI score 0, compared with 0.98 (95% CI 0.94 to 0.99) and 0.31 (95% CI 0.29 to 0.34) for NHF/CSANZ low/intermediate risk groups. CONCLUSIONS: SMB alone is not sufficiently sensitive to exclude MI. Combined with risk scoring, SMB appears to identify patients at lower risk. This requires prospective validation.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Biomarcadores/sangue , Dor no Peito/diagnóstico , Infarto do Miocárdio/diagnóstico , Idoso , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mioglobina/sangue , Peptídeos Natriuréticos/sangue , Estudos Prospectivos , Sensibilidade e Especificidade , Troponina I/sangue
10.
BMC Cardiovasc Disord ; 12: 8, 2012 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-22340728

RESUMO

BACKGROUND: Acute Decompensated Cardiac Failure (ADCF) is frequently associated with deterioration in renal function. Neutrophil gelatinase-associated lipocalin (NGAL) is an early marker of kidney injury. We aimed to determine if NGAL measured at admission predicts in-hospital acute kidney injury (AKI) in ADCF. METHODS: A prospective observational study measured NGAL and B-natriuretic peptide (BNP) from patients with ADCF presenting to two tertiary hospitals. Patients received standard care and were followed up daily as inpatients. ADCF was defined by PRIDE score ≥ 6 and AKI by RIFLE criteria. RESULTS: One hundred and two patients (median age 80, IQR 69-84 years, 52% male) were enrolled. AKI developed in 22 (25%) of 90 for whom outcome data was available. Seven patients died. NGAL was significantly elevated in those who developed AKI versus those who did not (median 130 ng/ml vs 69 ng/ml, p = 0.002). NGAL was also higher in those who died (median 136 ng/ml vs 68 ng/ml, p = 0.005). AKI was significantly associated with risk of death (5/22 (23%) vs 1/68 (1.5%), p = 0.001), but not length of hospital stay. NGAL significantly correlated with admission eGFR but not BNP. For prediction of AKI, NGAL > 89 ng/ml had sensitivity of 68% and specificity of 70% with area under the receiver operator characteristic (ROC) curve of 0.71 (0.58-0.84). After adjustment for baseline renal function, the odds ratio (OR) for AKI was 3.73 (1.26-11.01) if admission NGAL > 89 ng/ml. CONCLUSIONS: Elevated NGAL at admission is associated with in-hospital AKI and mortality in patients with ADCF. However, it has only moderate diagnostic accuracy in this setting.


Assuntos
Injúria Renal Aguda/diagnóstico , Insuficiência Cardíaca/mortalidade , Lipocalinas/sangue , Proteínas Proto-Oncogênicas/sangue , Injúria Renal Aguda/etiologia , Proteínas de Fase Aguda , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Creatinina/sangue , Feminino , Insuficiência Cardíaca/complicações , Humanos , Lipocalina-2 , Masculino , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade
11.
BMC Geriatr ; 12: 8, 2012 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-22429561

RESUMO

BACKGROUND: This study sought to determine whether early allied health intervention by a dedicated Emergency Department (ED) based team, occurring before or in parallel with medical assessment, reduces hospital admission rates amongst older patients presenting with one of ten index problems. METHODS: A prospective non-randomized trial in patients aged sixty five and over, conducted in two Australian hospital EDs. Intervention group patients, receiving early comprehensive allied health input, were compared to patients that received no allied health assessment. Propensity score matching was used to compare the two groups due to the non-randomized nature of the study. The primary outcome was admission to an inpatient hospital bed from the ED. RESULTS: Of five thousand two hundred and sixty five patients in the trial, 3165 were in the intervention group. The admission rate in the intervention group was 72.0% compared to 74.4% in the control group. Using propensity score probabilities of being assigned to either group in a conditional logistic regression model, this difference was of borderline statistical significance (p = 0.046, OR 0.88 (0.76-1.00)). On subgroup analysis the admission rate in patients with musculoskeletal symptoms and angina pectoris was less for those who received allied health intervention versus those who did not. This difference was significant. CONCLUSIONS: Early allied health intervention in the ED has a significant but modest impact on admission rates in older patients. The effect appears to be limited to a small number of common presenting problems.


Assuntos
Pessoal Técnico de Saúde/tendências , Serviço Hospitalar de Emergência/tendências , Admissão do Paciente/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Prospectivos , Fatores de Tempo
12.
BMC Geriatr ; 11: 6, 2011 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-21281473

RESUMO

BACKGROUND: Guidelines recommend that older people should receive multi-factorial interventions following an injurious fall however there is limited evidence that this is routine practice. We aimed to improve the delivery of evidence based care to patients presenting to the Emergency Department (ED) following a fall. METHODS: A prospective before and after study was undertaken in the ED of a medium-sized hospital in Perth, Western Australia. Participants comprised 313 community-dwelling patients, aged 65 years and older, presenting to ED as a result of a fall. A multi-faceted strategy to change practice was implemented and included a referral pathway, audit and feedback and additional falls specialist staff. Key measures to show improvements comprised the proportion of patients reviewed by allied health, proportion of patients referred for guideline care, quality of care index, all determined by record extraction. RESULTS: Allied health staff increased the proportion of patients being reviewed from 62.7% in the before period to 89% after the intervention (P < 0.001). Before the intervention a referral for comprehensive guideline care occurred for only 6/177 (3.4%) of patients, afterwards for 28/136 (20.6%) (difference = 17.2%, 95% CI 11-23%). Average quality of care index (max score 100) increased from 18.6 (95% CI: 16.7-20.4) to 32.6 (28.6-36.6). CONCLUSIONS: A multi-faceted change strategy was associated with an improvement in allied health in ED prioritizing the review of ED fallers as well as subsequent referral for comprehensive geriatric care. The processes of multi-disciplinary care also improved, indicating improved care received by the patient.


Assuntos
Acidentes por Quedas , Serviço Hospitalar de Emergência/normas , Fidelidade a Diretrizes/normas , Qualidade da Assistência à Saúde/normas , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Feminino , Humanos , Masculino , Seleção de Pacientes , Estudos Prospectivos
14.
Aust Health Rev ; 44(4): 637-641, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32553086

RESUMO

Objective The aim of this study was to investigate the frequency and type of emergency department (ED) presentations involving drugs and/or alcohol (DA) among young people. Methods A retrospective chart review was conducted of patients aged 14-25 years who presented to the ED at a tertiary hospital between 7 October and 25 November 2013. Data were collected on standardised data sheets, including whether DA was a factor in the patient's presentation. Results In all, 713 ED presentations of patients aged 14-25 years were included in this review (mean age 20 years). Of these, 94 (13%) presentations involved DA (median blood alcohol level 0.12%; range 0.01-0.39%); among patients aged 14-17 years, 13 (8%) presentations involved DA. Patient presentations involving DA were more likely to occur overnight and at weekends, had higher Australasian Triage Scale scores and had longer ED lengths of stay. These patients were also more likely to present with aggression, because of an assault, or with mental health disorders. Conclusion DA are involved in a substantial number of presentations of young people to the ED and are associated with an increased risk of assault and aggression. Public health strategies should target the links between DA use and mental health in young people. What is known about the topic already? It is known that the use of alcohol and drugs in young people is an ongoing public health concern. Research suggests this cohort of the population is more likely to present to an ED with an injury than the comparative age group not intoxicated by drugs or alcohol, and is more likely to be reviewed after hours. Alcohol is the predominant drug that had been used by young people at the time of the present study. What does this paper add? This paper reviews the number and types of presentations to a tertiary ED. In so doing, many more areas were researched (rather than simply link to injury) and, as a result, it was found that young people present to the ED with an increased risk of mental health issues and an increased risk of aggression. The study also found that young people intoxicated with DA most commonly presented for different reasons than the same sober cohort. What are the implications for practitioners? We know that young people intoxicated with DA represent a different public health issue than the sample group, and, as a result, public health initiatives must concentrate on the confounding factors of the presenting complaint, notably education surrounding the risk of mental health disturbance and increased aggression rates. Furthermore, the study should benefit practitioners, showing that more mental health services should be available after hours for this cohort presenting with issues related to DA.


Assuntos
Preparações Farmacêuticas , Transtornos Relacionados ao Uso de Substâncias , Adolescente , Adulto , Serviço Hospitalar de Emergência , Humanos , Estudos Retrospectivos , Triagem , Adulto Jovem
15.
Emerg Med Australas ; 31(3): 393-398, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30198199

RESUMO

OBJECTIVE: To determine if an ultrasound-guided femoral nerve block (FNB) is superior to an ultrasound-guided fascia iliaca compartment block (FICB) in providing pain relief to patients with a neck of femur or proximal femoral fracture. METHODS: A double-blind randomised controlled trial was conducted. All participants received two blocks, one active and one placebo. An active FICB was administered to 52 participants and 48 participants received an active FNB. RESULTS: Analysis was completed on data collected from 100 participants. Most patients were elderly and the majority were female. Both FICB and FNB achieved clinically significant mean reductions in pain scores (2.62 for FICB and 2.3 for FNB). There was no significant difference in reduction in pain scores between the two cohorts, P = 0.408. CONCLUSIONS: Ultrasound-guided FNB is not superior to ultrasound-guided FICB, with both facilitating an equivalent analgesia effect in patients with a neck of femur or proximal femur fracture.


Assuntos
Fáscia/efeitos dos fármacos , Artéria Femoral/efeitos dos fármacos , Fraturas do Colo Femoral/tratamento farmacológico , Bloqueio Nervoso/normas , Ultrassonografia de Intervenção/normas , Idoso , Idoso de 80 Anos ou mais , Analgesia/métodos , Analgesia/normas , Analgesia/estatística & dados numéricos , Método Duplo-Cego , Feminino , Fraturas do Colo Femoral/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Bloqueio Nervoso/estatística & dados numéricos , Medição da Dor/métodos , Ultrassonografia de Intervenção/métodos , Ultrassonografia de Intervenção/estatística & dados numéricos
16.
Emerg Med Australas ; 31(5): 780-786, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30806016

RESUMO

OBJECTIVE: To compare methods of assessment of the burden of primary care-type ED (PCTED) presentations against clinical assessment by general practitioners (GPs) in ED. METHODS: A cross-sectional study involving clinical assessment of patients presenting to four EDs in Western Australia. The GPs assessed patients who were likely to be discharged home from ED, and considered whether they could be managed in general practice. Patient presentations were defined by the GPs as: PCTED; PCTED if additional primary care resources were available; or not PCTED. RESULTS: GP researchers determined that 80% of patients assessed were PCTED presentations, with one-third of these considered PCTED presentations if additional resources were available. A high proportion of identified PCTED presentations included categories excluded by previous methods. Analysis of linked data found the cohort assessed to be of lower urgency, younger, and with a shorter length of stay than the average patient being discharged from ED. After accounting for potential bias, it is suggested that 20-40% of all ED presentations could be PCTED presentations. CONCLUSIONS: Previous methods determining the burden of PCTED presentations have not been validated. Many presentations excluded by previous methods were identified as manageable in general practice by GPs clinically assessing patients in ED. Improved validation of criteria used to identify PCTED presentations will enable appropriately designed interventions to reduce such events.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Clínicos Gerais/psicologia , Necessidades e Demandas de Serviços de Saúde/classificação , Atenção Primária à Saúde , Adolescente , Adulto , Criança , Estudos de Coortes , Estudos Transversais , Serviço Hospitalar de Emergência/organização & administração , Feminino , Clínicos Gerais/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Austrália Ocidental
17.
Eur J Emerg Med ; 25(4): 237-241, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28027074

RESUMO

BACKGROUND: The risk of early reattendance after discharge has been proposed as a performance indicator for emergency departments (EDs), but is not uniform in all patients. Those individuals at the highest risk of reattendance may benefit from an intense intervention to reduce this risk, and our objective was to test this hypothesis in a clinical trial. METHODS: A randomized-controlled trial was conducted in the EDs of two hospitals. Very high-risk adults aged 65 years and older, identified using a validated risk-prediction nomogram and being discharged from ED, were randomized to receive a postdischarge patient-centred intervention or standard care. The intervention focused on identifying and supporting patients to address risk factors for future hospital presentation. The primary outcome measure was any unplanned ED reattendance within 28 days. Secondary outcomes included 28-day and 1-year hospital usage, institutionalization and death. RESULTS: We enrolled 164 patients, 82 in each study arm. There was an 8% absolute (95% confidence interval: -7%-20%) and a 20% relative risk reduction for an intervention patient making an unplanned ED reattendance within 28 days. This difference was not statistically significant (P=0.26). CONCLUSION: This postdischarge intervention was associated with only small and nonsignificant reductions in ED reattendance.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Estado Terminal/terapia , Serviço Hospitalar de Emergência/organização & administração , Alta do Paciente/tendências , Readmissão do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/organização & administração , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/organização & administração , Estado Terminal/mortalidade , Feminino , Seguimentos , Avaliação Geriátrica/métodos , Pesquisas sobre Atenção à Saúde , Humanos , Tempo de Internação , Masculino , Alta do Paciente/estatística & dados numéricos , Análise de Sobrevida , Austrália Ocidental
18.
Emerg Med Australas ; 30(3): 366-374, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29094472

RESUMO

OBJECTIVE: Clinical diagnosis of anaphylaxis is principally based on symptoms and signs. However, particularly for patients with atypical symptoms, laboratory confirmation of anaphylaxis would be useful. This study investigated the utility of mast cell tryptase, an available clinical biomarker, for differentiating anaphylaxis from other causes of critical illness, which can also involve mast cell activation. METHODS: Tryptase was measured (ImmunoCAP) in serum from patients with anaphylaxis and non-anaphylactic critical illness (controls) at ED arrival, and after 1-2, 3-4 and 12-24 h. Differences in both peak and delta (difference between highest and lowest) tryptase concentrations between groups were investigated using linear regression models, and diagnostic ability was analysed using Receiver Operating Characteristic curve analysis. RESULTS: Peak tryptase was fourfold (95% CI: 2.9, 5.5) higher in anaphylaxis patients (n = 67) than controls (n = 120) (P < 0.001). Delta-tryptase was 5.1-fold (95% CI: 2.9, 8.9) higher in anaphylaxis than controls (P < 0.001). Optimal test characteristics (sensitivity: 72% [95% CI: 59, 82] and specificity: 72% [95%CI: 63, 80]) were observed when peak tryptase concentrations were >11.4 ng/mL and/or delta-tryptase ≥2.0 ng/mL. For hypotensive patients, peak tryptase >11.4 ng/mL had improved test characteristics (sensitivity: 85% [95% CI: 65, 96] and specificity: 92% [95% CI: 85, 97]); the use of delta-tryptase reduced test specificity. CONCLUSION: While peak and delta tryptase concentrations were higher in anaphylaxis than other forms of critical illness, the test lacks sufficient sensitivity and specificity. Therefore, mast cell tryptase values alone cannot be used to establish the diagnosis of anaphylaxis in the ED. In particular, tryptase has limited utility for differentiating anaphylactic from non-anaphylactic shock.


Assuntos
Anafilaxia/diagnóstico , Mastócitos/microbiologia , Triptases/análise , Adulto , Anafilaxia/sangue , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Hipóxia/sangue , Hipóxia/diagnóstico , Modelos Lineares , Masculino , Mastócitos/classificação , Pessoa de Meia-Idade , Curva ROC , Sensibilidade e Especificidade , Choque/sangue , Choque/diagnóstico , Triptases/sangue
20.
Emerg Med Australas ; 29(1): 77-82, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27681837

RESUMO

OBJECTIVE: The aim of this study was to compare methods for quantifying general practice-type (GP-type) patients in a paediatric ED to determine the robustness of current identification methods. METHODS: Data was sourced from the ED Information System for 5 years (2010-2014) from the tertiary paediatric hospital in Perth, Western Australia, Australia. A further detailed analysis of 2014 presentations established an independent sample for valid statistical comparison of the three methods used to identify GP-type patients: Australian Institute of Health and Welfare, ACEM and the Diagnosis. RESULTS: A total of 348 020 patients presented in 2010-2014, with the percentage of GP-type patients identified varying from 38% to 68% by the three methods. Fewer GP-type presentations occurred over each consecutive year and had significantly lower median medical consultation times and ED length of stay when compared with the total presentation sample. GP-type presentations were evenly spread across the days and times of the week, with ACEM demonstrating only fewer presentations during office hours (P = 0.02). In 2014 there was only overlap in 36.6% cases for all three methods - 6.9% exclusively flagged by ACEM, 22.7% by Australian Institute of Health and Welfare and 0.2% by the Diagnosis method. CONCLUSIONS: We demonstrated that current models to quantify perceived GP-type presentations were inconsistent in paediatric patients. All methods flagged a high proportion of GP-type presentations, and although the reasons for these presentations are multifactorial and not easily explained by access to GP services alone, they do represent a significant workload in the paediatric ED.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Avaliação como Assunto , Medicina Geral/estatística & dados numéricos , Pacientes/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Aglomeração , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Lactente , Masculino , Pediatria/métodos , Estudos Retrospectivos , Austrália Ocidental
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