Daniel Pilsgaard Henriksen

Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial

BACKGROUND When used with standard diagnostic testing, point-of-care ultrasonography might improve the proportion of patients admitted with respiratory symptoms who are correctly diagnosed 4 h after admission to the emergency department. We therefore assessed point-of-care ultrasonography of the heart, lungs, and deep veins in addition to the usual initial diagnostic testing in this patient population. METHODS In a prospective, parallel-group trial in the emergency department at Odense University Hospital, Odense, Denmark, patients (≥18 years) with a respiratory rate of more than 20 per min, oxygen saturation of less than 95%, oxygen therapy, dyspnoea, cough, or chest pain were randomly assigned in a 1:1 ratio with a computer-generated list to a standard diagnostic strategy (control group) or to standard diagnostic tests supplemented with point-of-care ultrasonography of the heart, lungs, and deep veins (point-of-care ultrasonography group). The primary endpoint was the percentage of patients with a correct presumptive diagnosis 4 h after admission to the emergency department. Only the physicians doing the primary clinical assessment and the auditors were masked. Analyses were by intention to treat. The study is registered with ClinicalTrials.gov, number NCT01486394. FINDINGS Between Dec 7, 2011, and March 15, 2013, 320 patients were randomly assigned to the control group (n=160) and point-of-care ultrasonography group (n=160). 158 patients in the point-of-care ultrasonography group and 157 in the control group were analysed. 4 h after admission to the emergency department, 139 patients (88·0%; 95% CI 82·8-93·1) in the point-of-care ultrasonography group versus 100 (63·7%; 56·1-71·3) in the control group had correct presumptive diagnoses (p<0·0001). The absolute and relative effects were 24·3% (95% CI 15·0-33·1) and 1·38 (1·01-1·31), respectively. No adverse events were reported. INTERPRETATION Point-of-care ultrasonography is a feasible, radiation free, diagnostic test, which alongside standard diagnostic tests is superior to standard diagnostic tests alone for establishing a correct diagnosis within 4 h. It should therefore be considered for routine use as part of the standard diagnostic tests in the emergency department for patients admitted with respiratory symptoms. FUNDING University of Southern Denmark, Odense University Hospital, and Højbjerg Fund.

Focused Sonography of the Heart, Lungs, and Deep Veins Identifies Missed Life-Threatening Conditions in Admitted Patients With Acute Respiratory Symptoms

BACKGROUND Patients with acute respiratory symptoms still remain a diagnostic challenge. The aim of the study was to evaluate whether focused sonography could potentially diagnose life-threatening conditions missed at the primary assessment in a patient population consisting of admitted patients with acute respiratory symptoms. METHODS A prospective blinded observational study was conducted in a medical ED. Inclusion criteria were the presence of one or more of the following: respiratory rate > 20/min, oxygen saturation < 95%, oxygen therapy initiated, dyspnea, cough, or chest pain. After the initial assessment, focused sonography of the heart, lungs, and deep veins was performed by a physician blinded to patient history and the results of the primary assessment. RESULTS One hundred thirty-nine patients were included. The focused sonographic examinations could be performed in 134 patients (96%). Focused sonography identified 19 patients (14%) with an acute life-threatening condition missed at the primary assessment. Diagnostic performance of focused sonography for the diagnosis of an acute life-threatening condition, when using audit as gold standard, was as follows: sensitivity, 100% (95% CI, 85.2%-100%); specificity, 93.3% (95% CI, 86.7%-97.3%); positive predictive value, 76.7% (95% CI, 57.7%-90.1%); and negative predictive value, 100% (95% CI, 96.3%-100%). CONCLUSIONS Focused sonography of the heart, lungs, and deep veins is fast, highly feasible, and able to diagnose life-threatening conditions missed at the primary assessment in admitted patients with acute respiratory symptoms. In an ED setting sonography can be used both for ruling in and ruling out acute life-threatening conditions in these patients.

Hypoalbuminemia Is a Strong Predictor of 30-Day All-Cause Mortality in Acutely Admitted Medical Patients: A Prospective, Observational, Cohort Study

Objective Emergency patients with hypoalbuminemia are known to have increased mortality. No previous studies have, however, assessed the predictive value of low albumin on mortality in unselected acutely admitted medical patients. We aimed at assessing the predictive power of hypoalbuminemia on 30-day all-cause mortality in a cohort of acutely admitted medical patients. Methods We included all acutely admitted adult medical patients from the medical admission unit at a regional teaching hospital in Denmark. Data on mortality was extracted from the Danish Civil Register to ensure complete follow-up. Patients were divided into three groups according to their plasma albumin levels (0–34, 35–44 and ≥45 g/L) and mortality was identified for each group using Kaplan-Meier survival plot. Discriminatory power (ability to discriminate patients at increased risk of mortality) and calibration (precision of predictions) for hypoalbuminemia was determined. Results We included 5,894 patients and albumin was available in 5,451 (92.5%). A total of 332 (5.6%) patients died within 30 days of admission. Median plasma albumin was 40 g/L (IQR 37–43). Crude 30-day mortality in patients with low albumin was 16.3% compared to 4.3% among patients with normal albumin (p<0.0001). Patients with low albumin were older and admitted for a longer period of time than patients with a normal albumin, while patients with high albumin had a lower 30-day mortality, were younger and were admitted for a shorter period. Multivariable logistic regression analyses confirmed the association of hypoalbuminemia with mortality (OR: 1.95 (95% CI: 1.31–2.90)). Discriminatory power was good (AUROC 0.73 (95% CI, 0.70–0.77)) and calibration acceptable. Conclusion We found hypoalbuminemia to be associated with 30-day all-cause mortality in acutely admitted medical patients. Used as predictive tool for mortality, plasma albumin had acceptable discriminatory power and good calibration.

Incidence rate of community-acquired sepsis among hospitalized acute medical patients-a population-based survey.

Objective:Sepsis is a frequent cause of admission, but incidence rates based on administrative data have previously produced large differences in estimates. The aim of the study was to estimate the incidence of community-acquired sepsis based on patients’ symptoms and clinical findings at arrival to the hospital. Design:Population-based survey. Setting:Medical emergency department from September 1, 2010, to August 31, 2011. Patients:All patients were manually reviewed using a structured protocol in order to identify the presence of infection. Vital signs and laboratory values were collected to define the presence of systemic inflammatory response syndrome and organ dysfunction. Measurements and Main Results:Incidence rate of sepsis of any severity. Among 8,358 admissions to the medical emergency department, 1,713 patients presented with an incident admission of sepsis of any severity, median age 72 years (5–95%; range, 26–91 yr), 793 (46.3%) were men, 728 (42.5%) presented with a Charlson comorbidity index greater than 2,621 (36.3%) were admitted with sepsis, 1,071 (62.5%) with severe sepsis, and 21 (1.2%) with septic shock. Incidence rate was 731/100,000 person-years at risk (95% CI, 697–767) in patients with sepsis of any severity, 265/100,000 person-years at risk (95% CI, 245–287) in patients with sepsis, 457/100,000 person-years at risk (95% CI, 430–485) in patients with severe sepsis, and 9/100,000 person-years at risk (95% CI, 6–14) in patients with septic shock. Conclusions:Based on symptoms and clinical findings at arrival, incidence rates of patients admitted to a medical emergency department with sepsis and severe sepsis are more frequent than previously reported based on discharge diagnoses.

Drug Dosing in Patients with Renal Insufficiency in a Hospital Setting using Electronic Prescribing and Automated Reporting of Estimated Glomerular Filtration Rate

In patients with impaired renal function, drug dose adjustment is often required. Non‐adherence to clinical prescribing recommendations may result in severe adverse events. In previous studies, the prevalence rate of non‐adherence to recommended dosing has been reported to be 19–67%. Using the clinical support system Renbase® as reference, we investigated the use and dosing of drugs in patients with impaired renal function in a university hospital setting using electronic prescription and automatic reporting of estimated glomerular filtration rate (eGFR). In all, 232 patients with an eGFR in the range of 10–49 ml/min./1.73 m2 were included. We identified 436 episodes with administration of renal risk drugs (prescribed to 183 patients): 410 drugs required dose adjustment according to the eGFR and 26 should be avoided. In total, the use or dosing of 66 (15%) of the 436 renal risk drugs was not in agreement with recommendations in Renbase®. This reflects less disagreement with expert guidelines than reported previously, indicating a possible beneficial effect of electronic prescribing and reporting of eGFR. However, we also found that disagreement to some extent reflected inappropriate drug use. We conclude that despite implementation of electronic prescribing and automated reporting of eGFR, patients with renal insufficiency may still be exposed to inappropriate drug use, with potential increased risk of adverse effects. Initiatives to reduce medication errors such as the use of electronic decision support systems should be explored.

How Well Do Discharge Diagnoses Identify Hospitalised Patients with Community-Acquired Infections? – A Validation Study

Background Credible measures of disease incidence, trends and mortality can be obtained through surveillance using manual chart review, but this is both time-consuming and expensive. ICD-10 discharge diagnoses are used as surrogate markers of infection, but knowledge on the validity of infections in general is sparse. The aim of the study was to determine how well ICD-10 discharge diagnoses identify patients with community-acquired infections in a medical emergency department (ED), overall and related to sites of infection and patient characteristics. Methods We manually reviewed 5977 patients admitted to a medical ED in a one-year period (September 2010-August 2011), to establish if they were hospitalised with community-acquired infection. Using the manual review as gold standard, we calculated the sensitivity, specificity, predictive values, and likelihood ratios of discharge diagnoses indicating infection. Results Two thousand five hundred eleven patients were identified with community-acquired infection according to chart review (42.0%, 95% confidence interval [95%CI]: 40.8–43.3%) compared to 2550 patients identified by ICD-10 diagnoses (42.8%, 95%CI: 41.6–44.1%). Sensitivity of the ICD-10 diagnoses was 79.9% (95%CI: 78.1–81.3%), specificity 83.9% (95%CI: 82.6–85.1%), positive likelihood ratio 4.95 (95%CI: 4.58–5.36) and negative likelihood ratio 0.24 (95%CI: 0.22–0.26). The two most common sites of infection, the lower respiratory tract and urinary tract, had positive likelihood ratios of 8.3 (95%CI: 7.5–9.2) and 11.3 (95%CI: 10.2–12.9) respectively. We identified significant variation in diagnostic validity related to age, comorbidity and disease severity. Conclusion ICD-10 discharge diagnoses identify specific sites of infection with a high degree of validity, but only a moderate degree when identifying infections in general.

Risk Factors for Hospitalization Due to Community-Acquired Sepsis – A Population-Based Case-Control Study

Background The aim of the study was to estimate risk factors for hospitalization due to sepsis and to determine whether these risk factors vary by age and gender. Methods We performed a population-based case-control study of all adult patients admitted to a medical ED from September 2010 to August 2011. Controls were sampled within the hospital catchment-area. All potential cases were manually validated using a structured protocol. Vital signs and laboratory values measured at arrival were registered to define systemic inflammatory response syndrome and organ dysfunction. Multivariable logistic regression was used to elucidate which predefined risk factors were associated with an increased or decreased risk hospitalization due to sepsis. Results A total of 1713 patients were admitted with sepsis of any severity. The median age was 72 years (interquartile range: 57–81 years) and 793 (46.3%) were male. 621 (36.3%) patients were admitted with sepsis, 1071 (62.5%) with severe sepsis and 21 (1.2%) with septic shock. Episodes with sepsis of any severity were associated with older age (85+ years adjusted OR 6.02 [95%CI: 5.09–7.12]), immunosuppression (4.41 [3.83–5.09]), alcoholism-related conditions (2.90 [2.41–3.50]), and certain comorbidities: psychotic disorder (1.90 [1.58–2.27]), neurological (1.98 [1.73–2.26]), respiratory (3.58 [3.16–4.06]), cardiovascular (1.62 [1.41–1.85]), diabetes (1.82 [1.57–2.12]), cancer (1.44 [1.22–1.68]), gastrointestinal (1.71 [1.44–2.05]) and renal (1.46 [1.13–1.89]). The strength of the observed associations for comorbid factors was strongest among younger individuals. Conclusions Hospitalization due to sepsis of any severity was associated with several independent risk factors, including age and comorbid factors.

Comparison of the Five Danish Regions Regarding Demographic Characteristics, Healthcare Utilization, and Medication Use—A Descriptive Cross-Sectional Study

Background While Denmark is well known for its plethora of registers. Many studies are conducted on research databases that only cover parts of Denmark, and regional differences could potentially threaten these studies’ external validity. The aim of this study was to assess sociodemographic and health related homogeneity of the five Danish regions. Methods We obtained descriptive data for the five Danish regions, using publicly available data sources: Statbank Denmark, the Danish Ministry of Economic Affairs, and Medstat.dk. These data sources comprise aggregate data from four different nationwide registers: The Danish National Patient Register, The Danish Civil Registration System, The Danish Register of Medicinal Product Statistics, and The Danish National Health Service Register for Primary Care. We compared the Danish regions regarding demographic and socioeconomic characteristics, health care utilization, and use of medication. For each characteristic, one-year prevalence was obtained and analyses were performed for 2013 and 2008 to account for possible change over time. Results In 2013, 5,602,628 persons were living in Denmark. The mean age was 40.7 years in the entire Danish population and ranged between 39.6 to 42.4 years in the five regions (coefficient of variation between regions [CV] = 0.028). The proportion of women in Denmark was 50.4% (CV = 0.009). The proportion of residents with low education level was 28.7% (CV = 0.051). The annual number of GP contacts was 7.1 (range: 6.7–7.4, CV = 0.040), and 114 per 1,000 residents were admitted to the hospital (range: 101–131, CV = 0.107). The annual number of persons redeeming a prescription of any medication was 723 per 1,000 residents (range: 718–743, CV = 0.016). Analyses for 2008 showed comparable levels of homogeneity as for 2013. Conclusions We found substantial homogeneity between all of the five Danish regions with regard to sociodemographic and health related characteristics. Epidemiologic studies conducted on regional subsets of Danish citizens have a high degree of generalizability.

Readmissions of medical patients: an external validation of two existing prediction scores

BACKGROUND Hospital readmissions are increasingly used as a quality indicator with a belief that they are a marker of poor care and have led to financial penalties in UK and USA. Risk scoring systems, such as LACE and HOSPITAL, have been proposed as tools for identifying patients at high risk of readmission but have not been validated in international populations. AIM To perform an external independent validation of the HOSPITAL and LACE scores. DESIGN An unplanned secondary cohort study. METHODS Patients admitted to the medical admission unit at the Hospital of South West Jutland (10/2008-2/2009; 2/2010-5/2010) and the Odense University Hospital (6/2009-8/2011) were analysed. Validation of the scores using 30 day readmissions as the endpoint was performed. RESULTS A total of 19 277 patients fulfilled the inclusion criteria. Median age was 67 (range 18-107) years and 8977 (46.6%) were female. The LACE score had a discriminatory power of 0.648 with poor calibration and the HOSPITAL score had a discriminatory power of 0.661 with poor calibration. The HOSPITAL score was significantly better than the LACE score for identifying patients at risk of 30 day readmission (P < 0.001). The discriminatory power of both scores decreased with increasing age. CONCLUSION Readmissions are a complex phenomenon with not only medical conditions contributing but also system, cultural and environmental factors exerting a significant influence. It is possible that the heterogeneity of the population and health care systems may prohibit the creation of a simple prediction tool that can be used internationally.

Nontraumatic Hypotension and Shock in the Emergency Department and the Prehospital setting, Prevalence, Etiology, and Mortality: A Systematic Review

Background Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ≤ 90 mmHg) with or without the presence of shock in the prehospital and ED setting. Methods We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality. Results Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies. Conclusion There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.