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.