Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

INTRODUCTION

Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients.

METHODS

The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters.

RESULTS

Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways.

CONCLUSIONS

EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Endotracheal Intubation Strategy, Success, and Adverse Events Among Emergency Department Patients During the COVID-19 Pandemic

STUDY OBJECTIVE

To describe endotracheal intubation practices in emergency departments by staff intubating patients early in the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Multicenter prospective cohort study of endotracheal intubations conducted at 20 US academic emergency departments from May to December 2020, stratified by known or suspected COVID-19 status. We used multivariable regression to measure the association between intubation strategy, COVID-19 known or suspected status, first-pass success, and adverse events.

RESULTS

There were 3,435 unique emergency department endotracheal intubations by 586 participating physicians or advanced practice providers; 565 (18%) patients were known or suspected of having COVID-19 at the time of endotracheal intubation. Compared with patients not known or suspected of COVID-19, endotracheal intubations of patients with known or suspected COVID-19 were more often performed using video laryngoscopy (88% versus 82%, difference 6.3%; 95% confidence interval [CI], 3.0% to 9.6%) and passive nasal oxygenation (44% versus 39%, difference 5.1%; 95% CI, 0.9% to 9.3%). First-pass success was not different between those who were and were not known or suspected of COVID-19 (87% versus 86%, difference 0.6%; 95% CI, -2.4% to 3.6%). Adjusting for patient characteristics and procedure factors in those with low anticipated airway difficulty (n=2,374), adverse events (most commonly hypoxia) occurred more frequently in patients with known or suspected COVID-19 (35% versus 19%, adjusted odds ratio 2.4; 95% CI, 1.7 to 3.3).

CONCLUSION

Compared with patients not known or suspected of COVID-19, endotracheal intubation of those confirmed or suspected to have COVID-19 was associated with a similar first-pass intubation success rate but higher risk-adjusted adverse events.

Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema

OBJECTIVES

The objective of this study is to identify predictors of airway compromise among patients presenting to the emergency department with angioedema in order to develop and validate a risk score to augment clinician gestalt regarding need for intubation.

METHODS

Retrospective chart review of emergency department patients with a diagnosis of angioedema. After data extraction they were randomly divided into a training and test set. The training set was used to identify factors associated with intubation and to develop a model and risk score to predict intubation. The model and risk score were then applied to the test set.

RESULTS

A total of 594 patients were included. Past medical history of hypertension, presence of shortness of breath, drooling, and anterior tongue or pharyngeal swelling were independent predictors included in our final model and risk score. The Area Under the Curve for the Receiver Operator Characteristic curve was 87.55% (83.42%-91.69%) for the training set and 86.1% (77.62%-94.60%) for the test set.

CONCLUSIONS

A simple scoring algorithm may aid in predicting angioedema patients at high and low risk for intubation. External validation of this score is necessary before wide-spread adoption of this decision aid.

Novel Technique for Open Surgical Tracheostomy in Small Children

N/A

Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document

Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.

Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge

OBJECTIVES

Effective sepsis resuscitation depends on useful criteria for prompt identification of eligible patients. These criteria should reliably predict a discharge diagnosis of sepsis, ensuring that interventions are triggered for those who need it while avoiding potentially harmful interventions in those who do not. We sought to determine the proportion of patients meeting sepsis criteria in the emergency department (ED) that was ultimately diagnosed with sepsis and to quantify the subset of nonseptic patients with risk factors for harm from fluid resuscitation.

METHODS

This retrospective cohort study of adult ED patients at a tertiary academic medical center included vital signs and laboratory results from the first 6 hours, plus administration of intravenous antibiotics, to determine if patients met 2016 Sepsis-3 consensus criteria. If these patients also had hypotension and lactic acidosis, we categorized them as Sepsis-3 plus shock. We used discharge ICD-9 codes to determine if patients were ultimately diagnosed with sepsis.

RESULTS

Over 8 years, 3,121 ED patients met 2016 Sepsis-3 criteria in the first 6 hours. Of these, only 25% and 48% met explicit and implicit criteria for a discharge diagnosis of sepsis. Of 1,032 patients with Sepsis-3 plus shock, 48% and 62% met explicit and implicit criteria. Overall, 60% to 75% of ED patients meeting Sepsis-3 criteria with or without shock did not receive a sepsis discharge diagnosis. At least one plausible risk factor for harm from large-volume fluid resuscitation was identified among 19% to 36% of patients meeting sepsis criteria in the ED but not ultimately diagnosed with sepsis at discharge.

CONCLUSIONS

Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge. Urgent treatment bundles triggered by consensus criteria in the early phase of ED care may be administered to several patients without sepsis, potentially exposing some to interventions of uncertain benefit and possible harm.

BOugie or stylet in patients UnderGoing Intubation Emergently (BOUGIE): protocol and statistical analysis plan for a randomised clinical trial

INTRODUCTION

Intubation-related complications are less frequent when intubation is successful on the first attempt. The rate of first attempt success in the emergency department (ED) and intensive care unit (ICU) is typically less than 90%. The bougie, a semirigid introducer that can be placed into the trachea to facilitate a Seldinger-like technique of tracheal intubation and is typically reserved for difficult or failed intubations, might improve first attempt success. Evidence supporting its use, however, is from a single academic ED with frequent bougie use. Validation of these findings is needed before widespread implementation.

METHODS AND ANALYSIS

The BOugie or stylet in patients Undergoing Intubation Emergently trial is a prospective, multicentre, non-blinded randomised trial being conducted in six EDs and six ICUs in the USA. The trial plans to enrol 1106 critically ill adults undergoing orotracheal intubation. Eligible patients are randomised 1:1 for the use of a bougie or use of an endotracheal tube with stylet for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is severe hypoxaemia, defined as an oxygen saturation less than 80% between induction until 2 min after completion of intubation. Enrolment began on 29 April 2019 and is expected to be completed in 2021.

ETHICS AND DISSEMINATION

The trial protocol was approved with waiver of informed consent by the Central Institutional Review Board at Vanderbilt University Medical Center or the local institutional review board at an enrolling site. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03928925).

Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers

INTRODUCTION

Bag mask ventilation (BMV) and extraglottic devices (EGDs) are two common methods of providing rescue ventilation. BMV can be difficult to perform effectively, especially for inexperienced providers and in patients with difficult airway characteristics. There is some evidence that the laryngeal tube (LT) can be successfully placed by inexperienced providers to provide effective ventilation. However, it is unclear whether ventilation provided by LT is superior to that of BMV, especially in the hands of inexperienced airway providers. Therefore, we aimed to compare ventilation efficacy of inexperienced airway providers with BMV versus LT by primarily measuring tidal volumes and secondarily measuring peak pressures on a simulated model.

METHODS

We performed a crossover study first year emergency medicine residents and third and fourth year medical students. After a brief instructional video followed by hands on practice, participants performed both techniques in random order on a simulated model for two minutes each. Returned tidal volumes and peak pressures were measured.

RESULTS

Twenty participants were enrolled and 1200 breaths were measured, 600 per technique. The median ventilation volumes were 194 milliliters (mL) for BMV, and 387 mL for the laryngeal tube, with a median absolute difference of 170 mL (95% confidence interval [CI] 157-182 mL) (mean difference 148 mL [95% CI, 138-158 mL], p<0.001). The median ventilation peak pressures were 23 centimeters of water (cm H₂O) for BMV, and 30 cm H₂O for the laryngeal tube, with a median absolute difference of 7 cm H₂O (95% CI, 6-8 cm H2O) (mean difference 8 cm H₂O [95% CI, 7-9 cm H₂O], p<0.001).

CONCLUSION

Inexperienced airway providers were able to provide higher ventilation volumes and peak pressures with the LT when compared to BMV in a manikin model. Inexperienced providers should consider using an LT when providing rescue ventilations in obtunded or hypoventilating patients without intact airway reflexes. Further study is required to understand whether these findings are generalizable to live patients.

Randomized Clinical Trial Comparing Procedural Amnesia and Respiratory Depression Between Moderate and Deep Sedation With Propofol in the Emergency Department

OBJECTIVES

The objective was to determine if there is a difference in procedural amnesia and adverse respiratory events (AREs) between the target sedation levels of moderate (MS) and deep (DS) procedural sedation.

METHODS

This was a prospective, randomized clinical trial of consenting adult patients planning to undergo DS with propofol between March 5, 2015, and May 24, 2017. Patients were randomized to a target sedation level of MS or DS using the American Society of Anesthesiologist's definitions. Drug doses, vital signs, observer's assessment of alertness/sedation (OAAS) score, end-tidal CO₂ (ETCO₂ ), and the need for supportive airway maneuvers (SAMs; bag-valve mask use, repositioning, and stimulation to induce respirations) were monitored continuously. A standardized image was shown every 30 seconds starting 3 minutes before the procedure continuing until the patient had returned to baseline after the procedure. Recall and recognition of images were assessed 10 minutes after the sedation. Subclinical respiratory depression (RD) was defined as SaO₂ ≤ 91%, change in ETCO₂ ≥ 10 mm Hg, or absent ETCO₂ at any time. The occurrence of RD with a SAM was defined as an ARE. Patient satisfaction, pain, and perceived recollection and physician assessment of procedure difficulty were collected using visual analog scales (VASs). Data were analyzed with descriptive statistics and Wilcoxon rank-sum test.

RESULTS

A total of 107 patients were enrolled: 54 randomized to target MS and 53 to DS. Of the patients randomized to target MS, 50% achieved MS and 50% achieved DS. In the target DS group, 77% achieved DS and 23% achieved MS. The median total propofol dose (mg/kg) was lower in the MS group: MS 1.4 (95% confidence interval [CI] = 1.3-1.6, IQR = 1) versus DS 1.8 (95% CI = 1.6-2.0, IQR = 0.9). There were no differences in median OAAS during the procedure (MS 2.4 and DS 2.8), lowest OAAS (MS 2 and DS 2), percentage of images recalled (MS 4.7% vs. DS 3.8%, p = 0.73), or percentage of images recognized (MS 61.1% vs. DS 55%, p = 0.52). In the MS group, 41% patients had any AREs compared to 42% in the DS group (p = 0.77, 95% CI difference = -0.12 to 0.24). The total number of AREs was 23% lower in the MS group (p = 0.01, 95% CI = -0.41 to -0.04). There was no difference in patient-reported pain, satisfaction, or recollection VAS scores. Provider's rating of procedural difficulty and procedural success were similar in both groups.

CONCLUSIONS

Targeting MS or DS did not reliably result in the intended sedation level. Targeting MS, however, resulted in a lower rate of total AREs and fewer patients had multiple AREs with no difference in procedural recall. As seen in previous reports, patients who achieved MS had less AREs than those who achieved DS. Our study suggests that a target of MS provides adequate amnesia with less need for supportive airway interventions than a target level of DS, despite the fact that it often does not result in intended sedation level.

The Bougie and First-Pass Success in the Emergency Department

STUDY OBJECTIVE

The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success.

METHODS

We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation.

RESULTS

Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]).

CONCLUSION

Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.

The neurocognitive effects of a conducted electrical weapon compared to high intensity interval training and alcohol intoxication - implications for Miranda and consent

While the physiologic effects of conducted electrical weapons (CEW) have been the subjects of numerous studies over nearly two decades, their effects on neurocognitive functioning, both short-term and long-term, have only recently been studied. In a 2014 study involving use-of-force scenarios, including a CEW scenario, we found that there was a decline in neurocognitive performance immediately post-scenario in all groups; however this effect was transient, of questionable clinical/legal significance, not statistically different between the groups, and, returned to baseline by one hour post-scenario. Two subsequent studies by other authors have also found transient neurocognitive effects in the immediate post-exposure period; however, in one study, the effect was greater in one measure (of 5) for the CEW compared to exertion, and the authors suggested that this effect could have implications for the Miranda waiver obtained before custodial interrogation as well as consent. In our current study, we compared the neurocognitive effects of an exposure to a CEW to another exertion regimen, as well as to alcohol intoxication given the latter has significant established case law with regard to the Miranda waiver and consent. Such a comparison may offer more insight into the clinical/legal significance of any measured changes. As with the prior studies, the neurocognitive performance decrements of the CEW and exertion regimens, found only in one measure in this study (of three), were transient, and here, non-significant. Only alcohol intoxication resulted in statistically significant performance declines across all measures and these were persistent over the study period. Given that the neurocognitive changes associated with the CEW were non-significant, but were significant for alcohol intoxication, and given that current case law does not use intoxication as a per se or bright line barrier to Miranda and consent, our results do not suggest that a CEW exposure should preclude waiving of Miranda rights or obtaining consent.

Discordance between ICD-Coded Myocardial Infarction and Diagnosis according to the Universal Definition of Myocardial Infarction

BACKGROUND

International Classification of Diseases (ICD) coding is the standard diagnostic tool for healthcare management. At present, type 2 myocardial infarction (T2MI) classification by the Universal Definition of Myocardial Infarction (MI) remains ignored in the ICD system. We determined the concordance for the diagnosis of MI using ICD-9 coding vs the Universal Definition.

METHODS

Cardiac troponin I (cTnI) was measured by both contemporary (cTnI) and high-sensitivity (hs-cTnI) assays in 1927 consecutive emergency department (ED) patients [Use of TROPonin In Acute coronary syndromes (UTROPIA) cohort] who had cTnI ordered on clinical indication. All patients were adjudicated using both contemporary and hs-cTnI assays. The Kappa index and McNemar test were used to assess concordance between ICD-9 code 410 and type 1 MI (T1MI) and type 2 MI (T2MI).

RESULTS

Among the 249 adjudicated MIs using the contemporary cTnI, only 69 (28%) were ICD-coded MIs. Of 180 patients not ICD coded as MI, 34 (19%) were T1MI and 146 (81%) were T2MI. For the ICD-coded MIs, 79% were T1MI and 21% were T2MI. A fair Kappa index, 0.386, and a McNemar difference of 0.0892 (P &lt; 0.001) were found. Among the 207 adjudicated MIs using the hs-cTnI assay, 67 (32%) were ICD coded as MI. Of the 140 patients not ICD coded as MI, 27 (19%) were T1MI and 113 (81%) were T2MI. For the ICD-coded MIs, 85% were T1MI and 15% T2MI. A moderate Kappa index, 0.439, and a McNemar difference of 0.0674 (P &lt; 0.001) were found.

CONCLUSIONS

ICD-9–coded MIs captured only a small proportion of adjudicated MIs, primarily from not coding T2MI. Our findings emphasize the need for an ICD code for T2MI.

Ovarian vein ablation: coils or surgery?

Objective: The aim of this study is to compare the results, namely improvement in pelvic pain and overall satisfaction with treatment by surgery, or by coils and sclerotherapy, for pelvic congestion syndrome (PCS) when caused by ovarian vein incompetence based on ultrasound assessment. To do so requires a brief description of the diagnosis of PCS and ovarian vein incompetence, and a discussion of the indications for treatment.

Methods: The same questionnaire as used for a previous surgical series in 1989–95 was used for the present study. Independent assessment of responses to the questionnaire using visual analogue scales, together with review of the clinical notes, enabled statistical evaluation of two treatment groups. Treatment was by surgery from 1989 to 1998, and by coils and sclerotherapy from January 1999 to June 2002. Obtaining demographic and presenting symptom data has enabled us to compare the two groups, as well as the results of the two treatments.

Results: There was no significant difference between the demographics and presenting symptoms of surgical and coil treatment groups. Surgical and coil groups combined show a statistically significant reduction in perceived pelvic pain, and overall satisfaction with treatment. There is no difference in reduction of perceived pelvic pain or in overall satisfaction between surgical and coil treatment groups.

Conclusion: Treatment based on ultrasound diagnosis is justified. Surgical ovarian vein ablation should not be considered as having been superseded by coils. The latter has some advantages but also cost implications. Long-term success of coil treatment has not yet been proven. Recanalization of the ovarian vein, if it occurs, can be treated by further coils or surgery.

Using Near Infrared Spectroscopy for Tissue Oxygenation Monitoring During Procedural Sedation: The Occurrence of Peripheral Tissue Oxygenation Changes With Respiratory Depression and Supportive Airway Measures

OBJECTIVES

The objective was to assess whether respiratory depression and supportive airway measures occurring during procedural sedation are associated with changes in peripheral tissue oxygen saturation (StO2 ).

METHODS

This was a prospective observational study of adult patients undergoing procedural sedation in the emergency department (ED). Patients undergoing sedation with propofol, 1:1 propofol and ketamine, and 4:1 propofol and ketamine were included. Clinical interventions, sedative medication doses, vital signs, end-tidal capnography (ETCO2 ), pulse oximetry (SpO2 ), and peripheral tissue oxygen saturation (StO2 ) were recorded. Respiratory depression was defined as the occurrence of a recorded SpO2  < 92%, an increase in ETCO2  > 10 mm Hg from baseline, or loss of capnography waveform. Supportive airway measures documented during the procedure included bag-valve mask ventilation, airway repositioning maneuvers, increase in supplemental oxygen, and stimulation to induce respiration. Relative changes in StO2 between baseline and nadir were compared among patients who met respiratory depression criteria or required a supportive airway measure and those who did not.

RESULTS

Ninety-three patients were enrolled. Thirty-two patients (34.4%) met criteria for respiratory depression, and 31 (33.3%) required intervention in the form of a supportive airway measure. The median percent change in StO2 from procedure baseline to nadir in patients meeting criteria for respiratory depression was 13.6%, compared to 4.2% in those who did not. The change in StO2 in patients who required a supportive airway measure was 12.5% versus 5.4% in those who did not.

CONCLUSIONS

Patients with respiratory depression and the use of supportive airway measures had greater changes in StO2 during procedural sedation than in patients who did not. Peripheral tissue oxygen saturation monitoring may be a useful tool for assessing respiratory adverse events in patients undergoing procedural sedation in the ED.

A comparison of routine, opt-out HIV screening with the expected yield from physician-directed HIV testing in the ED

OBJECTIVES

The Centers for Disease Control and Prevention recommends routine opt-out HIV screening in health care settings. Our goal was to evaluate the feasibility and yield of this strategy in the emergency department (ED) and to compare it to the expected yield of physician-directed testing.

METHODS

This is a cross-sectional study in an urban ED during random shifts over 1 year. Patients were ineligible for screening if they were younger than 18 years or older than 64, a prisoner, a victim of sexual assault, in an ED resuscitation room, or had altered mental status. Research associates administered rapid HIV tests and conducted standardized interviews. The patients' ED physician, blinded to the HIV result, was asked if they would have ordered a rapid HIV test if it had been available.

RESULTS

Of 7756 ED patients, 3957 (51%) were eligible for HIV screening, and 2811 (71%) of those did not opt out. Routine testing yielded 9 new HIV cases (0.32% of those tested; 95% confidence interval, 0.16%-0.63%). Physician-directed testing would have missed most of these infections: 2 of the 785 patients identified by physicians for testing would have been newly diagnosed with HIV (0.25%; 95% confidence interval, 0.04%-1.0%). Of the 9 new HIV cases, 5 established HIV care, and their median CD4 count was 201 cells/μL (range, 71-429 cells/μL).

CONCLUSIONS

Routine opt-out HIV screening was feasible and accepted by a majority of ED patients. The yield of this strategy only modestly exceeded what may have been observed with physician-directed testing.

The incidence and notification of measles in Australia

The incidence of measles in Australia in 1986 was estimated as 43 per 100,000 population, high by the standards of countries where immunization levels are high, low by the standards of countries where immunization levels are low. It is estimated that only 5 per cent of cases are notified in New South Wales, one of only 2 States which require notification. The reasons for this, its significance and a possible remedy are discussed.

Detecting depression in the aged: Is there concordance between screening tools and the perceptions of nursing home staff and residents? A pilot study in a rural aged care facility

OBJECTIVE

Recognition of depression in the elderly is exacerbated in rural and remote regions by a lack of mental health specialists. In nursing homes, screening tools have been advocated to circumvent the variable reliability of both nursing staff and residents in recognising depression. Debate concerning the utility of screening tools abounds. Previous research has neglected concordance between screening tools, nursing staff and residents in recognising depression. The present study aimed to determine if there was a significant difference in the proportion of depressed residents identified by recognition sources, and assessed the level of chance corrected agreement between sources.

PARTICIPANTS

One hundred and two residents of aged care facilities in Wagga Wagga, Australia, mean age of 85.19 +/- 7.09 years.

SETTING

Residents were interviewed within their residential aged care facility.

DESIGN

Cross-sectional, between-subjects design.

MAIN OUTCOME MEASURES

Residents, nursing staff, Geriatric Depression Scale (GDS-12R) and Hamilton Depression Rating Scale.

RESULTS

Hamilton Depression Rating Scale and nursing staff professional opinion were not significantly different; however, both measures were significantly different to the resident measures (GDS-12R and resident opinion). Kappa statistic analysis of outcome measures revealed, at best, no more than a moderate level of chance corrected agreement between said sources.

CONCLUSION

It is tentatively argued that the different sources might correspond to qualitatively different 'depression' constructs, and that health professionals who are concerned with depression in the elderly be aware of the disparity between, and subsequently consider, a variety of recognition sources.

Diversity of ethnic and racial VNTR RFLP fixed-bin frequency distributions

To examine the impact that intra- and interracial genetic diversities have on VNTR RFLP-fragment-size distributions, a multiracial (East Asian, African American, U.S. Southwest Hispanic, and European Caucasian) and multiethnic (Chinese, Japanese, Korean, and Vietnamese) database has been constructed for the following loci: D1S7, D2S44, D4S139, and D10S28. Homogeneity between samples was examined using the Komologorov-Smirnov two-sample test for RFLP fragment sizes and a log-likelihood test for fixed-bin frequencies with theoretical and Monte Carlo empirical significance levels. Small but significant differences between theoretical and empirical significance-level distributions were observed with both procedures, particularly with the latter. The significance levels of the two types of tests were poorly correlated. Statistically significant differences in fragment-size and fixed-bin distributions were found within and between races, with greater differences occurring between races. Cluster analysis and principal components analysis, using different similarity measures, did not support the hypothesis of greater intra- than interracial diversity, which suggests that ethnic variation can be conservatively estimated by racial variation.

Reasons for encounter and diagnosed health problems: convergence between doctors and patients

This study of 521 encounters in 25 urban general practices in Australia, compares both patient and doctor reported reasons for encounter (RFE) and diagnoses. Although doctors and their patients generally agreed on the overall distribution of RFE and diagnoses that arose, there was disagreement in at least 30% of paired comparisons within individual encounters. There was better agreement for RFE than for diagnoses. This may have been partly due to differences in the classification systems used. However, it suggests that diagnoses recalled by patients at later household interview are at best only a rough approximation of the diagnoses recorded by the doctor. These findings are important both for patient care and for the conduct of general practice morbidity research.

Using general practitioners to measure community morbidity

Randomly-selected patients drawn from randomly-selected General Practitioners (GPs) (two-stage cluster sample) were compared with a sample of the general population, who had visited a GP, selected using close approximations to standard household survey methods (area probability) of the Australian Bureau of Statistics. If GP patients drawn in this way resemble a random sample of the Australian community who have recently used GP services, then confidence should increase in this much cheaper method as a source of morbidity statistics. Interviews focused upon each person's last visit to the GP, with questions about reasons for attending, diagnoses and treatments, and various demographic items. In univariate analyses of 22 demographic items, 17 consultation items and 27 diagnoses and treatments, only five items were differently distributed between the GP patients and the area sample. Pairs of data items were also similar in the two groups. Items were examined using multidiscriminant analysis, to determine those that discriminated between the two groups and to calculate predicted group membership on the basis of these items. This analysis correctly classified only 56.7% of study subjects into their true group (GP patient or area sample) when based on items that were differently distributed between the groups, and 53.3% when all items were used, indicating that discrimination was only slightly better than chance. This result increases the confidence with which GP patients can be used to estimate levels of morbidity in the community if random selection is used to select GPs and if their patients are also randomly selected.

How representative are patients in general practice morbidity surveys?

This study examined differences arising from the sampling of patients from general practice and household surveys. When 25 general practitioners, who agreed to participate in one week morbidity survey in inner western Sydney, were compared with all general practitioners (192) identified in the area, they were not significantly different in terms of socio-demographic variables and practice details. When the demographic characteristics of a sample of patients at 539 encounters with the 25 participating general practitioners were compared with those of a sample of 500 patients identified from a household survey who had consulted with any general practitioner within 2 weeks of the interview, few differences were found. Few significant differences were found in the reasons for encounter and diagnoses treated as recalled by the patients of the two groups. No differences were found in management--specifically prescription, investigations and referral--or with respect to health status. This study suggests that sampling of patients from randomly selected general practitioners can produce useful representative samples for studies of morbidity even when doctor participation rates are as low as 29%.

Language skills of general practitioners in Sydney

Nearly 50% of the general practitioners in nine representative local-government areas of Sydney spoke one of 27 languages other than English. The most common languages were Chinese dialects, Indian dialects, Italian, German and French. Bilingual and multilingual doctors tended to practise in local government areas with relatively large non-English-speaking populations. Nevertheless, some language groups would not have easy access to a general practitioner, particularly to a female doctor, who speaks their language.

Relationship between perceived workload and manpower in general practice

A survey of general practitioners in nine local government areas representative of metropolitan Sydney allowed comparison of self-perceived workload and manpower as measured by population per general practitioner. Thirty-one per cent of general practitioners felt themselves to be too busy, 54% just right and 15% not busy enough. The overall manpower level was a population of 1108 people per general practitioner. There was no direct relationship between workload perception and general practice manpower. The implications of this for manpower planning are discussed.