ASEM Best Paper Prizes 2007
ACEM Annual Scientific Meeting November 2007
"BNP Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department"
Author: Dr A Maali Lockage et al the Alfred Hospital Melbourne, Victoria
Background: Dyspnoea is the most common presenting symptom of acute decompensated heart failure (HF) to the ED. The aim of this study is to determine whether B-type Natiuretic Peptide (BNP) testing in patients presenting with dyspnoea to the emergency department improves the accuracy of diagnosis of HF.
Method: Patients presenting to the Alfred Emergency and Trauma Centre with a chief complaint of dyspnoea were enrolled prospectively between August 2005 and March 2007. Patients were randomly allocated to have BNP levels tested or not. Two reviewers independently determined the presence of HF based on all available information including case notes, investigations and clinical course while being blinded to the BNP result (gold standard). The accuracy of the emergency department disposition diagnosis of HF was compared to the gold standard in the non-BNP and BNP groups.
Results: Of a cohort 406 patients, the expert panel diagnosed HF in 42%. The sensitivity of the disposition diagnosis for HF without the BNP test was 68% (95%CI:58-78%) and improved to 78% (95%CI: 69-87%) with the availability of the BNP test. However, the specificity decreased from 93% (95%CI: 89-97%) without the BNP result to 88% (95%CI: 82-94%) with the BNP result. The accuracy of the disposition diagnosis was 83% (95CI: 78-88&) without the BNP result and 84% (95%CI: 79-89%) with the BNP result. On comparison of the BNP and the non-BNP groups there was no significant difference in any of the measures accuracy.
Conclusion: In an Australian ED, testing BNP levels did not significantly improve the accuracy of a diagnosis of acute decompensated heart failure.
International Conference of Emergency Nursing, October 2007 Melbourne, Victoria
"Improving the Accuracy of Triage"
Author: Margaret Fry
Background: There has been an increasing focus on systems to improve patient flow in EDs. Many of these systems rely on the tirage nurse 'streaming' patients to separate teams and fast track areas, based on prediction of likely admission or discharge.
Aim: To explore the accuracy with which triage nurses predict patient disposition, including comparison between hospitals, diagnostic groups and admitted and discharged patients.
Methods: Over two separate one week periods, triage nurses at two urban tertiary hospitals were asked, at the time of performing the patient's triage assessment, to electronically record whether they thought a patient would be admitted or discharged. The patient's ultimate disposition (admission or discharge), age, sex, diagnostic group, triage category and time of arrival were also recorded.
Results: The triage nurses recorded a predicted disposition in 1342 patients over the study period, of whom 36.0% were subsequently admitted. There was no difference in the distribution of diagnosis, admission rates, age, sex or time of arrival between 1342 patients who had a predicted disposition recorded and the 769 patients who did not.
Overall, the triage nurse correctly predicted the disposition in 75.7% of patients (95%CI: 73.2-78.0). Nurses were more accurate at predicting discharge than admission (83.3% v 65.1%, P=0.04). Triage nurses were most accurate at predicting admission in patients with higher triage categories, and most accurate at predicting discharge in patients with injuries and other musculoskeletal problems (89.6%, 95%CI: 85.6-92.6). Predicted discharge was least accurate for patients with cardiovascular disease, with 41.1% (95%CI: 26.4 - 57.8) of predicted discharges in this category subsequently requiring admission.
Conclusion: Triage nurses can accurately predict likely discharge in patients with acute injury and musculoskeletal conditions. This supports the role of triage nurses in appropriately identifying patients for 'fast track' streaming. Predicting disposition in other patient groups, especially those with cardiovascular complaints, is less accurate.
5th Annual Autumn Seminar in Emergency Medicine, QLD
"Oxygenation of Spontaneously Breathing Children in Resuscitation: Flow Study through a Manual Paediatric Resuscitator"
Author: Dr Sarah Whitelaw, Gold Coast ED Registrar
Abstract: Manual resuscitators are often used without bag compression to passively supply oxygen to spontaneously breathing patients in resuscitation. Their safety and effectiveness in this setting have been previously questioned, with oxygen outflow measured as significantly lower than inflow, however the negative inspiratory pressures associated with spontaneous inspiration were not applied.
Objective: To investigate the effect of distance of the mask from the face on gas outflow from the device and on gas inflow through the mouth when a paediatric manual resuscitator is used to passively deliver oxygen in the setting of simulated spontaneous respiration.
Methods: This prospective bench test used hot-wire anemometry to quantify the velocity flow field in the mask of a Marshall Classic Paediatric Manual Resuscitator and through the mouth of a Little Junior CPR training mannequin, at varying distances of 0mm, 5mm and 10mm between the mask and the mannequin face, and compared it to a gas inflow of 15 litres per minute. Spontaneous respiration was simulated by using a pump to create a constant negative pressure equivalent to that required to generate the normal minute volume of a 5 year old (2.828 litres per minute). Flow visualisation was used to corroborate the hot-wire data.
Results: With a perfect seal between facemask and mannequin face, we measured a passive gas outflow of 7.9 +/- 0.8 litres per minute; 52.66% of inflow. As the distance between facemask and face increased, measured outflow decreased to 4.4 +/- 0.4 litres per minute at 10mm; 29.33% of inflow. The flow rate through the mouth remained constant at 10.6 +/- 1.1 litres per minute regardless of the position of the facemask. The shape of the velocity field within the mask was characterised by the geometry of the fish mouth valve, and at the boundary of the mask inlet, a region of reversed flow was confirmed with flow visualisation.
Conclusion: Manual resuscitators passively deliver higher than previously measured outflows when applied in the real life setting of negative inspiratory pressures, however measured outflow remains significantly less than inflow, and decreases with loosening of the seal between facemask and the face. As outflow decreases, entrainment of air increases and the resuscitator acts as a variable performance oxygen delivery device. We recommend a close seal when using manual resuscitators to passively deliver oxygen to spontaneously breathing patients, and propose a future study comparing delivered flow and oxygen concentration between manual resuscitators and non re-breather masks in the setting of spontaneous respiration.
Spring Seminar 2007
"Laryngoscope Illumination Grade Helps Tracheal Intubation Time’ Study The “LITE– IT”
Author: Simone Moore, Donovan Dwyer, Glenn Arendts St George Hospital NSW
Background: Endotracheal intubation is an important, time critical, life-saving Emergency Medicine procedure. Laryngoscope characteristics may influence time to successful intubation. The aim of this study was to determine whether laryngoscope light of variable intensity would influence the length of time required to achieve successful endotracheal intubation.
Methods: An in vivo single blind prospective randomised crossover trial was conducted using a variable light source laryngoscope and three clinically plausible intensities of light - High (600 Lux), Medium (200Lux), and Low (50Lux). 36 volunteer senior emergency medical staff repeatedly intubated two manikins 3 times each, based on one of six randomly assigned permutations of light intensity. The primary endpoint was time to successful intubation.
Results: There was no statistically significant difference in time to intubation versus light intensity for either manikin.
Conclusion: The intensity of laryngoscope light across a clinically plausible range does not affect time to intubation.
Spring Seminar 2007
"Burn Disaster Preparedness and Response Plans in North-Western Australia (NWA)"
Author: Chris Heyes, Medical Student, UWA Medical School
Introduction: With the mining industry booming in NWA, the threat of a burns disaster from an industrial fire or explosion, natural disaster, or a myriad of other causes is an increasing reality. An explosion at BHP’s Port Hedland iron ore plant in may 2004, which killed one worker and caused serious burns injuries to three others, underlines this risk. With the population in NWA increasing exponentially in recent times, the health infrastructure is sometimes struggling to keep pace.
Methods: In order to qualify the disaster risk preparedness & best response in the region, numerous interviews were conducted with key figures from variety of relevant agencies. Consultations were held with senior physicians, nurses, and hospitals in the region as well as officials from the: Fire and Emergency Services (FESA); St John's Ambulance; Royal Flying Doctor Service; Royal Perth Hospital Burns Unit (RPHBU); Disaster Preparedness and Management Unit; Australian Defence Force; occupational physicians and representatives from industry is in the region Major towns and hospitals in the region were visited and assessed on site. A review of internal government documents from the Health Department, FESA and the Australian Transport Safety Bureau, detailing recent disasters and disaster exercises was conducted. An extensive literature review was performed and patient notes from severe burns cases transferred to the RPHBU from NWA were also examined.
Conclusion: The combination of a health infrastructure under stress, limited resources, the extreme remoteness of NWA, and a booming mine industry, which is susceptible to burns disasters, underlines the value of developing the preparedness and response plans of this region has such a disaster.
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