Marcus Kennedy

A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia

Background: Several severity scores have been proposed to predict patient outcome and to guide initial management of patients with community acquired pneumonia (CAP). Most have been derived as predictors of mortality. A study was undertaken to compare the predictive value of these tools using different clinically meaningful outcomes as constructs for “severe pneumonia”. Methods: A prospective cohort study was performed of all patients presenting to the emergency department with an admission diagnosis of CAP from March 2003 to March 2004. Clinical and laboratory features at presentation were used to calculate severity scores using the pneumonia severity index (PSI), the revised American Thoracic Society score (rATS), and the British Thoracic Society (BTS) severity scores CURB, modified BTS severity score, and CURB-65. The sensitivity, specificity, positive and negative predictive values were compared for four different outcomes (death, need for ICU admission, and combined outcomes of death and/or need for ventilatory or inotropic support). Results: 392 patients were included in the analysis; 37 (9.4%) died and 26 (6.6%) required ventilatory and/or inotropic support. The modified BTS severity score performed best for all four outcomes. The PSI (classes IV+V) and CURB had a very similar performance as predictive tools for each outcome. The rATS identified the need for ICU admission well but not mortality. The CURB-65 score predicted mortality well but performed less well when requirement for ICU was included in the outcome of interest. When the combined outcome was evaluated (excluding patients aged >90 years and those from nursing homes), the best predictors were the modified BTS severity score (sensitivity 94.3%) and the PSI and CURB score (sensitivity 83.3% for both). Conclusions: Different severity scores have different strengths and weaknesses as prediction tools. Validation should be done in the most relevant clinical setting, using more appropriate constructs of “severe pneumonia” to ensure that these potentially useful tools truly deliver what clinicians expect of them.

Review article: Leaving the emergency department without being seen

Patients who leave the ED without being seen (LWBS) are unlikely to be satisfied with the quality of the service provided and might be at risk from conditions that have not been assessed or treated. We therefore examined the available research literature to inform the following questions: (i) In patients who attend for ED care, what factors are associated with the decision to LWBS? (ii) In patients who attend for ED care, are there adverse health outcomes associated with the decision to LWBS? (iii) Which interventions have been used to try to reduce the number of patients who attend for ED care and LWBS? From the available literature, there was insufficient evidence to draw firm conclusions; however, the literature does suggest that patients who LWBS have conditions of lower urgency and lower acuity, are more likely to be male and younger, and are likely to identify prolonged waiting times as a central concern. LWBS patients generally have very low rates of subsequent admission, and reports of serious adverse events are rare. Many LWBS patients go on to seek alternative medical attention, and they might have higher rates of ongoing symptoms at follow‐up. Further research is recommended to include comprehensive cohort or well‐designed case–control studies. These studies should assess a wide range of related factors, including patient, hospital and other relevant factors. They should compare outcomes for groups of LWBS patients with those who wait and should include cross‐sectoral data mapping to truly detect re‐attendance and admission rates.

Identifying severe community‐acquired pneumonia in the emergency department: A simple clinical prediction tool

Objective:  To identify independent predictors of severe pneumonia in a local population, and create a simple severity score that would be useful in the ED.

Patients Who Leave Without Being Seen in Emergency Departments: An Analysis of Predictive Factors and Outcomes

OBJECTIVES The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia. METHODS This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re-presentations to ED; 48-hour hospital admissions; and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented. RESULTS There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non-English-speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self-referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62); however, ED re-presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67). CONCLUSIONS Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.

Prehospital noninvasive ventilation: a viable treatment option in the urban setting.

Objective. To determine the viability of prehospital noninvasive ventilation (NIV) as a prelude to a definitive clinical trial. Methods. This was a retrospective observational study of patients (aged > 55 years, severe shortness of breath) transported to a tertiary emergency department (10/5/03–12/28/04). Data were extracted from paramedic andhospital medical records. The primary outcome measure was the number of patients who could potentially benefit from prehospital NIV. They were defined as “conscious upon paramedic arrival andwho required ventilatory support (bag/valve/mask ventilation [BVM], NIV or endotracheal intubation) during transport or within 30 minutes of arrival at the emergency department (ED).” The secondary outcome measures were the effectiveness of existing paramedic treatment regimens andparamedic management times. Results. Two hundred sixty-four patients were enrolled (mean age 75.5 ± 8.7 years, 59.1% male). Sixty-seven patients (25.4%, 95% CI: 20.3–31.2) met the primary outcome measure: 31 (11.7%, 95% CI: 8.2–16.4) received prehospital BVM, an additional 35 (13.3%, 95% CI: 9.5–18.1) received NIV in the ED andone (0.4%, 95% CI: 0.0–2.4) was intubated in the ED. Prehospital treatment resulted in significant (p < 0.001) improvements in systolic blood pressure (151.2 dropping to 144.2 mmHg), respiratory rate (29.4 dropping to 26.3 breaths/minute), andoxygen saturation (92.3% rising to 96.2%). Median paramedic management time was 33 minutes (IQR 29–40). Conclusion. Prehospital treatment significantly improved patient vital signs. However, a considerable proportion of patients still required ventilatory support either prehospital or early in their ED course. Further research is indicated to determine if these patients would benefit from prehospital NIV.

Identifying the opportunities for health promoting emergency departments.

STUDY OBJECTIVE To describe the opportunities for health promotion in emergency departments (EDs). METHODS A comprehensive literature review and consultation with ED staff (seven focus groups) and other health professionals (workshop). RESULTS Opportunities for patient health information and education within EDs are described in the literature. In contrast, the health promoting hospitals literature showcases integrated approaches for health promotion, emphasizing organisational structures, and culture changes to support effective health promotion. This type of integration has not developed in EDs, where individual issues based health promotion projects have emerged. ED staff readily described the:existing health promotion interventions and possible improvements and opportunities for potential health promotion interventions related to the needs of their patients, the community or their organisation. Other health professionals supported EDs taking a greater role in health promotion and suggested organisational partnerships that would assist in developing this. CONCLUSION There are numerous opportunities to enhance health promotion in EDs. With support, EDs could deliver comprehensive health promotion programs for patients, staff, and communities.

Empiric antibiotic prescribing for patients with community-acquired pneumonia: where can we improve?

Background:  Community acquired pneumonia is one of the most common infections for which antibiotics are prescribed in Australia.

Equitable emergency access: rhetoric or reality?

The present paper is based on an address given at the Australian Financial Review Health Congress in February, 2005. Lets start with the underlying premise that patients have a valid right to fair and just access to emergency care. Fairness and justice are concepts more comfortably placed within legal and sociological settings than within health. They refer to our ability to deliver care without bias or favour. Our college has published a statement asserting patients’ right to appropriate access (Patients’ Right to Access Emergency Department Care. ACEM Policy Statement P31, March 2004). The other underlying premise in this discussion is that this issue of equity of access actually matters. It may be of significance at a moral level, at a relative resource consumption level, at the level of occupation of system capacity, or at the level of clinical outcomes for individual patients.

Prehospital transfusion of red cell concentrates in a paramedic-staffed helicopter emergency medical service

The optimal volume and type of intravenous fluid for the treatment of blood loss in the prehospital setting is controversial. The use of red cell concentrates (RCCs) may be associated with improved outcomes; however, the administration of blood products is limited to physicians in many jurisdictions. We sought to describe the characteristics of RCC transfusions in a paramedic‐staffed helicopter emergency medical system in Victoria, Australia.

Extracorporeal membrane oxygenation retrieval factors and survival to intensive care unit discharge

Audit of extracorporeal membrane oxygenation (ECMO) retrieval service operating in Victoria, Australia, regarding retrieval factors and patient survival to intensive care unit (ICU) discharge.