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Peters GA, Cash RE, Goldberg SA, Ordoobadi AJ, Camargo CA. Out-of-Hospital Presentation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbations in the United States: A Nationwide Retrospective Cohort Study. Ann Emerg Med 2023; 81:679-690. [PMID: 36669918 DOI: 10.1016/j.annemergmed.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE To describe the demographic, clinical, and emergency medical service (EMS) response characteristics associated with EMS activations for asthma and chronic obstructive pulmonary disease (COPD) exacerbations in the US. METHODS Using a nationwide set of out-of-hospital patient care report data from 2018 to 2019, we analyzed 9-1-1 EMS activations where asthma/COPD exacerbation was indicated by symptom, impression, or treatment provided. We excluded patients with ages less than 2 years or unknown, nonemergency transports, and encounters with any indication of anaphylaxis. Demographic, clinical, and EMS response characteristics were described for pediatric and adult patients with asthma/COPD exacerbations. RESULTS A total of 1,336,988 asthma/COPD exacerbations were included, comprising 5% of qualifying 9-1-1 scene activations from 2018 to 2019. Most patients were adults (96%). Most adult patients were female (55%), whereas most pediatric patients were male (58%). Most activations occurred in urban settings (82%), particularly in pediatric patients (90%). Most asthma/COPD exacerbations were managed by advanced life support units (94%). Inhaled bronchodilators and systemic corticosteroid therapy were administered to 75% and 14% of all patients, respectively. Adults more often had oxygen saturation <92% (43% vs 20% of pediatric patients) and were more often treated with assisted ventilation (9% vs 1%). CONCLUSION In this large nationwide sample of 9-1-1 activations treated and transported by EMS, 5% were for asthma/COPD exacerbation. Future work should focus on evidence-based standardization of EMS protocols and practice for asthma/COPD exacerbations to improve the quality of EMS care.
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Affiliation(s)
- Gregory A Peters
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rebecca E Cash
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Scott A Goldberg
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander J Ordoobadi
- Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Carlos A Camargo
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.
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Celiński M, Cybulski M, Fiłon J, Muszalik M, Goniewicz M, Krajewska-Kułak E, Ślifirczyk A. Analysis of Medical Management in Geriatric Patients in the Hospital Emergency Department by Example of Selected Cities with County Status in Poland: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:48. [PMID: 35010308 PMCID: PMC8744554 DOI: 10.3390/ijerph19010048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
The aim of this study was to analyse medical management in geriatric patients in the Hospital Emergency Departments in the Biała Podlaska County and Chełm County (Poland) between 2016 and 2018 in a group of patients ≥65 years of age. We analysed medical records of 829 patients transported to Hospital Emergency Departments by Medical Emergency Teams. The research was conducted in the period from June 2019 to March 2020. We analysed emergency medical procedure forms and medical records of patients transported to the hospitals. Cardiovascular diseases were diagnosed in 40% of patients. Mortality cases accounted for 3.1% of the 1200 interventions analysed. Ambulance dispatch resulted in the patient being transported to the Hospital Emergency Departments in more than 2/3 of cases. The concordance between the diagnoses made by the Medical Emergency Teams and those made at the Hospital Emergency Departments was confirmed for 78% patients admitted to the department (n = 647), whereas the concordance of classification at the group level was estimated at 71.7% (n = 594). Further in-patient treatment was initiated in some of the patients admitted to the department (n = 385). The mean time of hospital stay was 10.1 days. In conclusion, differences between the initial diagnosis made by the heads of the Medical Emergency Teams and the diagnosis made by the doctor on duty in the Hospital Emergency Departments depended on the chapter of diseases in the ICD-10 classification, but they were acceptable. The majority of the patients were transported to Hospital Emergency Departments. The most common groups of diseases that require Hospital Emergency Departments admission include cardiovascular diseases, injuries due to external causes, and respiratory diseases. A moderate percentage of patients were qualified for further specialist treatment in hospital departments.
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Affiliation(s)
- Mariusz Celiński
- Department of Emergency Medicine, Faculty of Health Sciences, Pope John Paul II State School of Higher Education in Biała Podlaska, 21-500 Biała Podlaska, Poland; (M.C.); (A.Ś.)
| | - Mateusz Cybulski
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Białystok, 15-096 Białystok, Poland; (J.F.); (E.K.-K.)
| | - Joanna Fiłon
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Białystok, 15-096 Białystok, Poland; (J.F.); (E.K.-K.)
| | - Marta Muszalik
- Department of Geriatrics, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, University of Nicolaus Copernicus in Toruń, 85-094 Bydgoszcz, Poland;
| | - Mariusz Goniewicz
- Interfaculty Centre for Didactics, Department of Emergency Medicine, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Elżbieta Krajewska-Kułak
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Białystok, 15-096 Białystok, Poland; (J.F.); (E.K.-K.)
| | - Anna Ślifirczyk
- Department of Emergency Medicine, Faculty of Health Sciences, Pope John Paul II State School of Higher Education in Biała Podlaska, 21-500 Biała Podlaska, Poland; (M.C.); (A.Ś.)
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Doğan NÖ, Varol Y, Köktürk N, Aksay E, Alpaydın AÖ, Çorbacıoğlu ŞK, Aksel G, Baha A, Akoğlu H, Karahan S, Şen E, Ergan B, Bayram B, Yılmaz S, Gürgün A, Polatlı M. 2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force. Turk J Emerg Med 2021; 21:137-176. [PMID: 34849428 PMCID: PMC8593424 DOI: 10.4103/2452-2473.329630] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 01/18/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.
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Affiliation(s)
- Nurettin Özgür Doğan
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Yelda Varol
- Department of Pulmonology, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, University of Health Sciences, İzmir, Turkey
| | - Nurdan Köktürk
- Department of Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ersin Aksay
- Department of Emergency Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Aylin Özgen Alpaydın
- Department of Pulmonology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Şeref Kerem Çorbacıoğlu
- Department of Emergency Medicine, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Gökhan Aksel
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ayşe Baha
- Department of Pulmonology, Near East University, Nicosia, TRNC
| | - Haldun Akoğlu
- Department of Emergency Medicine, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Sevilay Karahan
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Elif Şen
- Department of Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Begüm Ergan
- Department of Pulmonology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Başak Bayram
- Department of Emergency Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Serkan Yılmaz
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Alev Gürgün
- Department of Pulmonology, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Mehmet Polatlı
- Department of Pulmonology, Faculty of Medicine, Aydın Adnan Menderes University, Aydın, Turkey
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Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain. Aust Crit Care 2021; 35:302-308. [PMID: 34419341 DOI: 10.1016/j.aucc.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) has become one of the most prevalent serious pathologies encountered in the emergency medical service (EMS). In hospital settings, noninvasive ventilation (NIV) therapy prevents complications from more aggressive treatments for that condition. However, the scarce evidence on the benefits of NIV in prehospital EMS (i.e., during transport to the hospital) is inconclusive. OBJECTIVES To determine whether the administration of NIV during prehospital EMS in cases of ARF reduces in-hospital mortality compared with starting NIV on arrival to in-patient EMS. METHODS This is a multicentre, observational, prospective cohort study. We recruited a total of 317 patients from the Madrid region (Spain) who were prescribed NIV for their ARF using a nonprobabilistic consecutive sampling method. Analyses of the main outcome (in-hospital mortality) and secondary outcomes (length of hospital stay, readmissions, percentage of intensive care unit admissions, and cost-effectiveness) will include descriptive analyses of patients' characteristics, as well as bivariate and multivariate analyses and cost-effectiveness analysis. DISCUSSION This study will provide data on NIV management in prehospital and in-patient EMS in patients with ARF. Results will contribute to the existing evidence on the benefits of NIV in the context of prehospital EMS while underlining the importance of a standardized formal training for physicians and nurses working in prehospital and in-patient EMSs. CONCLUSION The VentilaMadrid study will provide valuable data on the clinical factors of patients receiving NIV in prehospital EMS. Further, were our hypothesis to be confirmed, our results would strongly suggest that the administration of NIV in prehospital EMS by medical and nursing profesionals formally trained in the technique reduces mortality and improves prognoses.
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Finn JC, Brink D, Mckenzie N, Garcia A, Tohira H, Perkins GD, Arendts G, Fatovich DM, Hendrie D, McQuillan B, Summers Q, Celenza A, Mukherjee A, Smedley B, Pereira G, Ball S, Williams T, Bailey P. Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial. Emerg Med J 2021; 39:37-44. [PMID: 33771819 DOI: 10.1136/emermed-2020-210256] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/27/2021] [Accepted: 02/27/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress. METHODS We conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay. RESULTS 708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care -1.0, IQR -3.0 to 0.0 vs CPAP -3.5, IQR -5.2 to -2.0), median difference -2.0 (95% CI -2.5 to -1.6); and RR (usual care -4.0, IQR -9.0 to 0.0 min-1 vs CPAP -8.0, IQR -14.0 to -4.0 min-1), median difference -4.0 (95% CI -5.0 to -4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI -0.17 to 0.90). CONCLUSIONS The use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay. TRIAL REGISTRATION NUMBER ACTRN12615001180505.
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Affiliation(s)
- Judith C Finn
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia .,St John Western Australia, Perth, Western Australia, Australia
| | - Deon Brink
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia.,St John Western Australia, Perth, Western Australia, Australia
| | - Nicole Mckenzie
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia.,Critical Care Division, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Antony Garcia
- St John Western Australia, Perth, Western Australia, Australia
| | - Hideo Tohira
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia.,School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Daniel M Fatovich
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Royal Perth Hospital, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Delia Hendrie
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Brendan McQuillan
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Quentin Summers
- Respiratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Antonio Celenza
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Ashes Mukherjee
- Emergency Department, Armadale Kelmscott District Memorial Hospital, Armadale, Western Australia, Australia
| | - Ben Smedley
- Emergency Department, Rockingham General Hospital, Cooloongup, Western Australia, Australia
| | - Gavin Pereira
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Stephen Ball
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia.,St John Western Australia, Perth, Western Australia, Australia
| | - Teresa Williams
- Critical Care Division, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Paul Bailey
- Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia.,St John Western Australia, Perth, Western Australia, Australia
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6
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Fuller GW, Keating S, Goodacre S, Herbert E, Perkins GD, Rosser A, Gunson I, Miller J, Ward M, Bradburn M, Thokala P, Harris T, Marsh MM, Scott AJ, Cooper C. Prehospital continuous positive airway pressure for acute respiratory failure: the ACUTE feasibility RCT. Health Technol Assess 2021; 25:1-92. [PMID: 33538686 DOI: 10.3310/hta25070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute respiratory failure is a life-threatening emergency. Standard prehospital management involves controlled oxygen therapy. Continuous positive airway pressure is a potentially beneficial alternative treatment; however, it is uncertain whether or not this treatment could improve outcomes in NHS ambulance services. OBJECTIVES To assess the feasibility of a large-scale pragmatic trial and to update an existing economic model to determine cost-effectiveness and the value of further research. DESIGN (1) An open-label, individual patient randomised controlled external pilot trial. (2) Cost-effectiveness and value-of-information analyses, updating an existing economic model. (3) Ancillary substudies, comprising an acute respiratory failure incidence study, an acute respiratory failure diagnostic agreement study, clinicians perceptions of a continuous positive airway pressure mixed-methods study and an investigation of allocation concealment. SETTING Four West Midlands Ambulance Service hubs, recruiting between August 2017 and July 2018. PARTICIPANTS Adults with respiratory distress and peripheral oxygen saturations below the British Thoracic Society's target levels were included. Patients with limited potential to benefit from, or with contraindications to, continuous positive airway pressure were excluded. INTERVENTIONS Prehospital continuous positive airway pressure (O-Two system, O-Two Medical Technologies Inc., Brampton, ON, Canada) was compared with standard oxygen therapy, titrated to the British Thoracic Society's peripheral oxygen saturation targets. Interventions were provided in identical sealed boxes. MAIN OUTCOME MEASURES Feasibility objectives estimated the incidence of eligible patients, the proportion recruited and allocated to treatment appropriately, adherence to allocated treatment, and retention and data completeness. The primary clinical end point was 30-day mortality. RESULTS Seventy-seven patients were enrolled (target 120 patients), including seven patients with a diagnosis for which continuous positive airway pressure could be ineffective or harmful. Continuous positive airway pressure was fully delivered to 74% of participants (target 75%). There were no major protocol violations/non-compliances. Full data were available for all key outcomes (target ≥ 90%). Thirty-day mortality was 27.3%. Of the 21 deceased participants, 14 (68%) either did not have a respiratory condition or had ceiling-of-treatment decision implemented that excluded hospital non-invasive ventilation and critical care. The base-case economic evaluation indicated that standard oxygen therapy was probably cost-effective (incremental cost-effectiveness ratio £5685 per quality-adjusted life-year), but there was considerable uncertainty (population expected value of perfect information of £16.5M). Expected value of partial perfect information analyses indicated that effectiveness of prehospital continuous positive airway pressure was the only important variable. The incidence rate of acute respiratory failure was 17.4 (95% confidence interval 16.3 to 18.5) per 100,000 persons per year. There was moderate agreement between the primary prehospital and final hospital diagnoses (Gwet's AC1 coefficient 0.56, 95% confidence interval 0.43 to 0.69). Lack of hospital awareness of the Ambulance continuous positive airway pressure (CPAP): Use, Treatment Effect and economics (ACUTE) trial, limited time to complete trial training and a desire to provide continuous positive airway pressure treatment were highlighted as key challenges by participating clinicians. LIMITATIONS During week 10 of recruitment, the continuous positive airway pressure arm equipment boxes developed a 'rattle'. After repackaging and redistribution, no further concerns were noted. A total of 41.4% of ambulance service clinicians not participating in the ACUTE trial indicated a difference between the control and the intervention arm trial boxes (115/278); of these clinician 70.4% correctly identified box contents. CONCLUSIONS Recruitment rate was below target and feasibility was not demonstrated. The economic evaluation results suggested that a definitive trial could represent value for money. However, limited compliance with continuous positive airway pressure and difficulty in identifying patients who could benefit from continuous positive airway pressure indicate that prehospital continuous positive airway pressure is unlikely to materially reduce mortality. FUTURE WORK A definitive clinical effectiveness trial of continuous positive airway pressure in the NHS is not recommended. TRIAL REGISTRATION Current Controlled Trials ISRCTN12048261. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gordon W Fuller
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Samuel Keating
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Esther Herbert
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andy Rosser
- West Midlands Ambulance Service, Brierley Hill, UK
| | | | | | - Matthew Ward
- West Midlands Ambulance Service, Brierley Hill, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Praveen Thokala
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tim Harris
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Margaret M Marsh
- Sheffield Emergency Care Forum, Royal Hallamshire Hospital, Sheffield, UK
| | - Alexander J Scott
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Fuller GW, Goodacre S, Keating S, Herbert E, Perkins G, Ward M, Rosser A, Gunson I, Miller J, Bradburn M, Harris T, Cooper C. The diagnostic accuracy of pre-hospital assessment of acute respiratory failure. Br Paramed J 2020; 5:15-22. [PMID: 33456393 PMCID: PMC7783963 DOI: 10.29045/14784726.2020.12.5.3.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Acute respiratory failure (ARF) is a common medical emergency. Pre-hospital management includes controlled oxygen therapy, supplemented by specific management options directed at the underlying disease. The aim of the current study was to characterise the accuracy of paramedic diagnostic assessment in acute respiratory failure. Methods: A nested diagnostic accuracy and agreement study comparing pre-hospital clinical impression to the final hospital discharge diagnosis was conducted as part of the ACUTE (Ambulance CPAP: Use, Treatment effect and Economics) trial. Adults with suspected ARF were recruited from the UK West Midlands Ambulance Service. The pre-hospital clinical impression of the recruiting ambulance service clinician was prospectively recorded and compared to the final hospital diagnosis at 30 days. Agreement between pre-hospital and hospital diagnostic assessments was evaluated using raw agreement and Gwets AC1 coefficient. Results: 77 participants were included. Chronic obstructive pulmonary disease (32.9%) and lower respiratory tract infection (32.9%) were the most frequently suspected primary pre-hospital diagnoses for ARF, with secondary contributory conditions recorded in 36 patients (46.8%). There was moderate agreement between the primary pre-hospital and hospital diagnoses, with raw agreement of 58.5% and a Gwets AC1 coefficient of 0.56 (95% CI 0.43 to 0.69). In five cases, a non-respiratory final diagnosis was present, including: myocardial infarction, ruptured abdominal aortic aneurysm, liver failure and sepsis. Conclusions: Pre-hospital assessment of ARF is challenging, with limited accuracy compared to the final hospital diagnosis. A syndromic approach, providing general supportive care, rather than a specifically disease-orientated treatment strategy, is likely to be most appropriate for the pre-hospital environment.
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Affiliation(s)
- Gordon W Fuller
- University of Sheffield: ORCID iD: https://orcid.org/0000-0001-8532-3500
| | | | | | | | | | | | | | | | | | | | - Tim Harris
- Barts and The London School of Medicine and Dentistry
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Sneath E, Bunting D, Hazell W, Tippett V, Yang IA. Pre-hospital and emergency department pathways of care for exacerbations of chronic obstructive pulmonary disease (COPD). J Thorac Dis 2019; 11:S2221-S2229. [PMID: 31737349 PMCID: PMC6831923 DOI: 10.21037/jtd.2019.10.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/17/2019] [Indexed: 11/06/2022]
Abstract
Exacerbations are serious complications of chronic obstructive pulmonary disease (COPD) that often require acute care from pre-hospital and emergency department (ED) services. Despite being a frequent cause of emergency presentations, gaps remain in both literature and practice for emergency care pathways of COPD exacerbations. This review seeks to address these gaps and focuses on the literature of pre-hospital and ED systems of care and how these intersect with patients experiencing an exacerbation of COPD. The literature in this area is expanding rapidly; however, more research is required to further understand exacerbations and how they are addressed by emergency medical services worldwide. For the purpose of this review, the pre-hospital domain includes ambulance and other emergency transport services, and encompasses medical interventions delivered prior to arrival at an ED or hospital. The ED domain is defined as the area of a hospital or free-standing centre where patients arrive to receive emergent medical care prior to admission. In many studies there is a significant overlap between these two domains and frequent intersection and collaboration between services. In both of these domains, for the management of COPD exacerbations, several overarching themes have been identified in the literature. These include: the appropriate delivery of oxygen in the emergency setting; strategies to improve the provision of care in accordance with diagnostic and treatment guidelines; strategies to reduce the requirement for emergency presentations; and, technological advances including machine learning which are helping to improve emergency healthcare systems.
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Affiliation(s)
- Emily Sneath
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Denise Bunting
- Research & Evaluation Unit, Queensland Ambulance Service, Brisbane, Australia
| | - Wayne Hazell
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Emergency Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Vivienne Tippett
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Ian A. Yang
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Thoracic Medicine, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
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9
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Ambient Particulate Matter and Paramedic Assessments of Acute Diabetic, Cardiovascular, and Respiratory Conditions. Epidemiology 2019; 30:11-19. [PMID: 30334919 PMCID: PMC6276863 DOI: 10.1097/ede.0000000000000929] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Ambulance data provide a useful source of population-based and spatiotemporally resolved information for assessing health impacts of air pollution in nonhospital settings. We used the clinical records of paramedics to quantify associations between particulate matter (PM2.5) and diabetic, cardiovascular, and respiratory conditions commonly managed by those responding to calls for emergency ambulance services. Methods: We evaluated 394,217 paramedic assessments from three states in Southeastern Australia (population 13.2 million) and daily PM2.5 concentrations modeled at 5 km resolution from 2009 to 2014. We used a time-stratified, case-crossover analysis adjusted for daily meteorology to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for each clinical outcome per 10 µg/m3 increase in daily PM2.5 at lags from 0 to 2 days. Results: Increased PM2.5 was associated with increased odds of paramedic assessments of hypoglycemia (OR = 1.07; 95% CI = 1.02, 1.12, lag 0), arrhythmia (OR = 1.05; 95% CI = 1.02, 1.09, lag 0), heart failure (OR = 1.07; 95% CI = 1.02, 1.12, lag 1), faint (OR = 1.09; 95% CI = 1.04–1.13, lag 0), asthma (OR = 1.06; 95% CI = 1.01, 1.11, lag 1), chronic obstructive pulmonary disease (OR = 1.07; 95% CI = 1.01, 1.13, lag 1), and croup (OR = 1.09; 95% CI = 1.02, 1.17). We did not identify associations with cerebrovascular outcomes. Conclusions: Ambulance data enable the evaluation of important clinical syndromes that are often initially managed in nonhospital settings. Daily PM2.5 was associated with hypoglycemia, faint, and croup in addition to the respiratory and cardiovascular outcomes that are better established.
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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