Estimation of the severity of breathlessness in the emergency department: a dyspnea score

From the BMC:

Background

Dyspnea is a frequent complaint in emergency departments (ED). It has a significant amount of subjective and affective components, therefore the dyspnea scores, based on the patients’ rating, can be ambiguous. Our purpose was to develop and validate a simple scoring system to evaluate the severity of dyspnea in emergency care, based on objectively measured parameters.

Methods

We performed a double center, prospective, observational study including 350 patients who were admitted in EDs with dyspnea. We evaluated the patients’ subjective feeling about dyspnea and applied our Dyspnea Severity Score (DSS), rating the dyspnea in 7 Dimensions from 0 to 3 points. The DSS was validated using the deterioration of pH, base-excess and lactate levels in the blood gas samples (Objective Classification Scale (OCS) 9 points and 13 points groups).

Results

All of the Dimensions correlated closely with the OCS values and with the subjective feeling of the dyspnea. Using multiple linear regression analysis we were able to decrease the numbers of Dimensions from seven to four without causing a significant change in the determination coefficient in any OCS groups. This reduced DSS values (exercise tolerance, cooperation, cyanosis, SpO2 value) showed high sensitivity and specificity to predict the values of OCS groups (the ranges: AUC 0.77–0.99, sensitivity 65–100%, specificity 64–99%). There was a close correlation between the subjective dyspnea scores and the OCS point values (p < 0.001), though the scatter was very large.

Conclusions

A new DSS was validated which score is suitable to compare the severity of dyspnea among different patients and different illnesses. The simplified version of the score (its value ≥7 points without correction factors) can be useful at the triage or in pre-hospital care.

The HEART Score Is Safe to Use in the Emergency Department

From the NEJM:

The HEART score — based on History, Electrocardiogram, Age, Risk factors, and Troponin level — provides risk stratification and disposition recommendations (inpatient admission, observation, or discharge) for emergency department (ED) patients presenting with chest pain. It has been externally validated and is used by some hospitals as part of their risk-stratification algorithms. However, its effect on use of healthcare resources is not known.

In a Dutch study, nine EDs switched from usual care to use of the HEART score in random order. Discharged patients were followed up with troponin testing the same or next day. The primary outcome was incidence of major adverse cardiac events (MACE) within 6 weeks. Adherence with the score’s recommendations and resource use were also evaluated.

Roughly 3650 patients were included in the analysis. The incidence of MACE was 1.3% lower with HEART care than with usual care. The incidence of MACE among the 715 patients classified as low-risk by HEART was 2.0%, including one death from unknown causes. There were no significant differences in the use of healthcare resources between HEART care and usual care, likely because 41% of patients classified as low-risk (and thus appropriate for discharge) received additional observation, second troponin measurement, and stress testing instead.

Call an Ambulance — for Care

From H&HN:

Meeting in Chicago under the aegis of the American College of Emergency Physicians a little over four years ago, a consortium of 10 EMS-affiliated physicians and health care strategists from around the country, including Beck, proposed a new model for delivery of appropriate, around-the-clock, comprehensive, planned or unplanned care outside the hospital, using interprofessional medical teams.

They called it mobile integrated health care practice, or MIHP. The P has since been dropped as confusing. But as MIH, it’s an idea that is already recording encouraging results.

“It makes a big difference for the patients to have an advanced practice provider go to their home after they’ve been discharged and look around,” he says. “In almost all cases, something’s not right. Patients are given a number to call if they have problems, and we have a multi-triage system to decide whether they can wait or need an ambulance immediately. Their discharge summary lists the physician who’s responsible and, if appropriate, that’s where we take them.”

Says Beck: “Some hospitals are trying to manage the present. They’re caught up in working their way through the challenges of the near term. Others have a strategy that’s more outward looking. They’re pursuing value-focused care. For them, mobile integrated health is coming into focus pretty quickly. It’s a new iteration of a familiar set of players … and a pretty exciting new set of menu choices for hospitals and health systems that are thinking holistically.”

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department

From the Annals of Internal Medicine:

Background:The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.

Objective:

To measure the effect of use of the HEART score on patient outcomes and use of health care resources.

Design:

Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846)

Setting:

Emergency departments in 9 Dutch hospitals.

Patients:

Unselected patients with chest pain presenting at emergency departments in 2013 and 2014.

Intervention:

All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to “HEART care,” during which physicians calculated the HEART score to guide patient management.

Measurements:

For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness.

Results:

A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed.

Limitation:

Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.

Conclusion:

Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.

Telehealth can aid population health growth in rural areas

From Medical Economics:

Telehealth has brought significant savings to rural hospitals, a new report from NTCA-The Rural Broadband Association concludes. The technology is also proving to be pivotal to the growth of population health initiatives aimed at providing care to chronically ill rural residents in need of specialty care.

The report, Anticipating Economic Returns of Rural Telehealth, notes that the national average estimates for cost-related savings annually per medical facility from telehealth include travel expense savings of $5,718, lost wages savings of $3,431 and hospital cost savings of $20,841.

‘Doctor’ robot could help solve sports-concussion dilemma in rural America

From MedicalXPress:

From bustling cities to tiny farming communities, the bright lights of the local stadium are common beacons to the Friday night ritual of high school football.

But across the sprawling stretches of rural America, these stadiums are commonly far from doctors who could quickly diagnose and treat head injuries that have brought so much scrutiny to the sport.

A first-of-its-kind study from the Peter O’Donnell Jr. Brain Institute and Mayo Clinic shows the technology exists to ease this dilemma: By using a remote-controlled robot, a neurologist sitting hundreds of miles from the field can evaluate athletes for concussion with the same accuracy as on-site physicians.

Patients in team-based practices less likely to visit ED after hospital discharge

Press Release:

Older patients enrolled in team-based primary care practices in Quebec had similar rates of hospital readmission, and lower rates of emergency department visits and death after hospital discharge, compared with those in traditional fee-for-service practices, found a study published in CMAJ (Canadian Medical Association Journal).

“Our study showed that the newer team-based primary care delivery model in Quebec was associated with some better post-discharge outcomes among older or chronically ill patients, notably lower rates of emergency department visits and death,” writes Dr. Bruno Riverin, Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, Quebec, with coauthors.

Hospital readmissions cost the Canadian health care system $1.8 billion each year (excluding physician costs) and many older or chronically ill patients are at increased risk of complications in the weeks after discharge.

The large study looked at data on 312 377 older or chronically ill patients in Quebec who were admitted to hospital between November 2002 and January 2009 (620 656 admissions). The researchers found that about 1 in 4 older or chronically ill patients who had been in hospital for any cause returned within 30 days (for either readmission or an emergency department visit).

“Patients enrolled in team-based primary care practices had a 5% lower 30-day risk of emergency department visits not associated with readmission, and significantly fewer patients died in the early period after hospital discharge compared with patients enrolled in traditional primary care practices,” write the authors.

They hypothesize that health care professionals in these team-based practices are better able to coordinate care for the sickest patients, which helps reduce hospital readmission and death.

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The study was conducted by researchers at McGill University; Montreal Children’s Hospital; McGill University Health Centre, Direction de la santé publique du CIUSS du Centre-Sud-de-l’Île-de-Montréal, Montréal, Quebec; and University of Pittsburgh, Pittsburgh, Pennsylvania.