Showing papers by "Steve Goodacre published in 2009"

A multicentre randomised controlled trial of the use of continuous positive airway pressure and non-invasive positive pressure ventilation in the early treatment of patients presenting to the emergency department with severe acute cardiogenic pulmonary oedema: the 3CPO trial.

Abstract: OBJECTIVES To determine whether non-invasive ventilation reduces mortality and whether there are important differences in outcome by treatment modality. DESIGN Multicentre open prospective randomised controlled trial. SETTING Patients presenting with severe acute cardiogenic pulmonary oedema in 26 emergency departments in the UK. PARTICIPANTS Inclusion criteria were age > 16 years, clinical diagnosis of acute cardiogenic pulmonary oedema, pulmonary oedema on chest radiograph, respiratory rate > 20 breaths per minute, and arterial hydrogen ion concentration > 45 nmol/l (pH < 7.35). INTERVENTIONS Patients were randomised to standard oxygen therapy, continuous positive airway pressure (CPAP) (5-15 cmH2O) or non-invasive positive pressure ventilation (NIPPV) (inspiratory pressure 8-20 cmH2O, expiratory pressure 4-10 cmH2O) on a 1:1:1 basis for a minimum of 2 hours. MAIN OUTCOME MEASURES The primary end point for the comparison between NIPPV or CPAP and standard therapy was 7-day mortality. The composite primary end point for the comparison of NIPPV and CPAP was 7-day mortality and tracheal intubation rate. Secondary end points were breathlessness, physiological variables, intubation rate, length of hospital stay and critical care admission rate. Economic evaluation took the form of a cost-utility analysis, taken from an NHS (and personal social services) perspective. RESULTS In total, 1069 patients [mean age 78 (SD 10) years; 43% male] were recruited to standard therapy (n = 367), CPAP [n = 346; mean 10 (SD 4) cmH2O] or NIPPV [n = 356; mean 14 (SD 5)/7 (SD 2) cmH2O]. There was no difference in 7-day mortality for standard oxygen therapy (9.8%) and non-invasive ventilation (9.5%; p = 0.87). The combined end point of 7-day death and intubation rate was similar, irrespective of non-invasive ventilation modality (CPAP 11.7% versus NIPPV 11.1%; p = 0.81). Compared with standard therapy, non-invasive ventilation was associated with greater reductions (treatment difference, 95% confidence intervals) in breathlessness (visual analogue scale score 0.7, 0.2-1.3; p = 0.008) and heart rate (4/min, 1-6; p = 0.004) and improvement in acidosis (pH 0.03, 0.02-0.04; p < 0.001) and hypercapnia (0.7 kPa, 0.4-0.9; p < 0.001) at 1 hour. There were no treatment-related adverse events or differences in other secondary outcomes such as myocardial infarction rate, length of hospital stay, critical care admission rate and requirement for endotracheal intubation. Economic evaluation showed that mean costs and QALYs up to 6 months were 3023 pounds and 0.202 for standard therapy, 3224 pounds and 0.213 for CPAP, and 3208 pounds and 0.210 for NIPPV. Modelling of lifetime costs and QALYs produced values of 15,764 pounds and 1.597 for standard therapy, 17,525 pounds and 1.841 for CPAP, and 17,021 pounds and 1.707 for NIPPV. These results suggest that both CPAP and NIPPV accrue more QALYs but at higher cost than standard therapy. However, these estimates are subject to substantial uncertainty. CONCLUSIONS Non-invasive ventilatory support delivered by either CPAP or NIPPV safely provides earlier improvement and resolution of breathlessness, respiratory distress and metabolic abnormality. However, this does not translate into improved short- or longer-term survival. We recommend that CPAP or NIPPV should be considered as adjunctive therapy in patients with severe acute cardiogenic pulmonary oedema in the presence of severe respiratory distress or when there is a failure to improve with pharmacological therapy. TRIAL REGISTRATION Current Controlled Trials ISRCTN07448447.

Information sheets for patients with acute chest pain: randomised controlled trial

Abstract: Objectives To determine whether providing an information sheet to patients with acute chest pain reduces anxiety, improves health related quality of life, improves satisfaction with care, or alters subsequent symptoms or actions. Design Single centre, non-blinded, randomised controlled trial. Setting Chest pain unit of an emergency department. Participants 700 consecutive patients with acute chest pain and no clear diagnosis at initial presentation. Interventions After a diagnostic assessment patients were randomised to receive either standard verbal advice or verbal advice followed by an information sheet. Main outcome measures The primary outcome was anxiety (hospital anxiety and depression scale). Secondary outcomes were depression (hospital anxiety and depression scale), health related quality of life (SF-36), patient satisfaction, presentation with further chest pain within one month, lifestyle change (smoking cessation, diet, exercise), further information sought from other sources, and planned healthcare seeeking behaviour in response to further pain. Results 494 of 700 (70.6%) patients responded. Compared with those receiving standard verbal advice those receiving advice and an information sheet had lower mean hospital anxiety and depression scale scores for anxiety (7.61 v 8.63, difference 1.02, 95% confidence interval 0.20 to 1.84) and depression (4.14 v 5.28, difference 1.14, 0.41 to 1.86) and higher scores for mental health and perception of general health on the SF-36. The information sheet had no significant effect on satisfaction with care, subsequent symptoms, lifestyle change, information seeking, or planned actions in the event of further pain. Conclusions Provision of an information sheet to patients with acute chest pain can reduce anxiety and depression and improve mental health and perception of general health but does not alter satisfaction with care or other outcomes. Trial registration Current Controlled Trials ISRCTN85248020.

Paper-based versus computer-based records in the emergency department: Staff preferences, expectations, and concerns

Abstract: Although the potential benefits of computer-based records have been identified in different areas of the healthcare environment, in many settings paper-based records and computer-based records are still used in parallel. In this article, emergency department (ED) staff perspectives about the use of paper- or computer-based records are presented. This was a qualitative study in which data were collected using in-depth semi-structured interviews with the ED staff. The interviews were transcribed verbatim and data were analysed using framework analysis. In total, 34 interviews were undertaken. The study identified a number of factors which might encourage or discourage the use of paper-based and computer-based records in the ED. Users also expressed their concerns and expectations. Although there is a tendency towards computerizing healthcare settings, user acceptance of technology should not be underestimated. To improve user acceptance, users’ concerns should be investigated and addressed appropriately.

Accessibility versus confidentiality of information in the emergency department.

Abstract: Introduction: In the emergency department (ED), clinicians can benefit greatly from having access to information at the point of care. It has been suggested that using computerised information systems could improve the accessibility of information. However, making information accessible, while maintaining confidentiality, is one of the main challenges of implementing information systems. This article presents the ED staff perspectives about the accessibility and confidentiality of information in the ED. Method: The authors undertook a qualitative study in March–April 2007. Data were collected using in-depth semi-structured interviews with the ED staff of an ED located in Northern England. In total, 34 interviews were conducted and transcribed verbatim. Data were analysed using framework analysis. Results: The results showed that the ED staff had role-based access to the current information systems, and these systems met only a small part of their information needs. As a result, different sources were used to get access to the needed information. Although the ED staff believed that improving the accessibility of information could be helpful in emergency care services, there were concerns about the confidentiality of information. The confidentiality of information could be threatened—for example, by sharing passwords, misusing patient information or by unauthorised staff having access to patient information. Conclusion: To design a system, the accessibility and confidentiality of information should be addressed in parallel. A balance between these two is needed, as the failure of each of these may negatively influence the use of the system.

Feeling fixed and its contribution to patient satisfaction with primary angioplasty: a qualitative study.

Abstract: Background: Primary angioplasty is being used increasingly as an alternative to intravenous thrombolysis for patients with acute ST-elevation myocardial infarction. Aims: To explore positive and negative views of patient and carer experiences of undergoing primary angioplasty. Methods: We undertook semi-structured qualitative interviews (n=16). We identified a thematic framework from transcripts then coded data according to themes identified. Results: Participants were extremely positive about their experiences of primary angioplasty. They were impressed by the speed and efficiency of the process and their quick recovery from feeling extremely ill. Participants expressed a high degree of confidence in the procedure and many spoke of being ‘fixed’ following resolution of their symptoms. This may have been engendered by witnessing the procedure take place as well as successful treatment of a potentially fatal heart attack. The speed of resolution and feeling of being fixed led some participants to question whether they had actually had a heart attack. Conclusions: The ‘high-tech’ efficient procedure of primary angioplasty and fast recovery contributes to high levels of patient satisfaction. The feeling of being fixed and lack of belief at having had a heart attack may have implications for uptake of rehabilitation and lifestyle changes following hospital discharge.

Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram.

Abstract: Background: Clinical features may be used to determine which patients with suspected acute coronary syndrome (ACS), but a normal or non-diagnostic ECG, should be selected for further investigation or inpatient care. We aimed to measure the diagnostic value of clinical features for ACS. Methods: Standardised data relating to presenting characteristics, associated features and risk factors were collected at seven chest pain units established for the ESCAPE trial. All patients received troponin measurement at least 6 h after last significant symptoms, creatine kinase MB(mass) gradient over 2 h and, if appropriate, treadmill exercise testing. The reference standard of ACS was defined as troponin >0.03 ng/ml, creatine kinase MB(mass) gradient >3.0 ng/ml or early positive treadmill exercise test. Results: 1576 patients were analysed, including 132 (8.4%) with ACS. Patients with ACS were older, had longer symptom duration, were more likely to be a man, hypertensive and an ex-smoker or have pain radiating to their right arm. On multivariate analysis, only age, duration, sex and radiation of pain to the right arm were independently associated with ACS. Likelihood ratios (95% CI) were radiation of pain to the right arm, 2.9 (95% CI 1.4 to 6.3), male sex 1.2 (95% CI 1.0 to 1.3) and female sex 0.79 (95% CI 0.62 to 1.0). The area under the receiver operator characteristic curve for age was 0.629 (95% CI 0.573 to 0.686) and for duration was 0.546 (95% CI 0.481 to 0.610). Conclusion: Clinical features have very limited value for diagnosing ACS in patients with a normal or non-diagnostic ECG. Radiation of pain to the right arm increases the likelihood of ACS.

Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units

Abstract: This paper is a report of a study to explore the experiences of individuals receiving Chest Pain Unit care and routine Emergency Department care for acute chest pain. Chest Pain Units were established in the United States of America with the aim of reducing admissions and costs, whilst improving quality of life and care satisfaction. Trials showed these units to be safe and practical; however, there was a need to establish whether Chest Pain Units could be cost-effective in the United Kingdom, and whether use of a nurse-led protocol could be acceptable to patients. We carried out 26 semi-structured interviews in 2005-2006 with patients across seven trial Chest Pain Units in the United Kingdom (14 in intervention sites and 12 in control sites) to explore issues that patients considered were important in their care experiences, and to develop possible explanations for the main trial outcomes. We analysed transcripts using the Framework approach to identify themes relating to care experiences. Differences in care experiences were more distinct between individual sites than between control and intervention sites. Satisfaction with care was high overall. Interactions with healthcare professionals, in particular specialist nurses, were valued in terms of reassurance, calming effect and competence. Indications for care improvement concerned information-giving about investigations, diagnosis, and self-care advice. Patients with non-cardiac causes needed to feel more supported after discharge. Differences between modes of care may not coincide with identified trial outcomes. Qualitative methods can identify aspects of care that improve patient acceptability. The specialist nurse role appears particularly important in providing satisfactory individualized chest pain care.

Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments

Abstract: Background: A recent meta-analysis showed that intravenous and nebulised magnesium sulphate have similar levels of evidence to support their use in the treatment of acute asthma in adults. This consisted of weak evidence of effect on respiratory function and hospital admissions, with wide confidence intervals ranging from no effect to significant positive effects. Current BTS/SIGN guidelines suggest an equivocal role for intravenous magnesium sulphate and no role for nebulised magnesium sulphate. A study was performed to assess what emergency physicians currently do in their management of acute asthma. Method: A postal survey was undertaken of all adult emergency departments within the UK. A structured questionnaire was sent to all clinical leads in emergency medicine about their current usage of both intravenous and nebulised magnesium sulphate in the treatment of acute asthma. Results: 180 of the 251 emergency departments in the UK responded (72%). Magnesium sulphate was used in 93%, mostly because it was expected to relieve breathlessness (70%) or reduce HDU/ITU admissions (51%). It was predominantly given to those patients with acute severe asthma (84%) and life-threatening exacerbations (87%), with most stating they would give the drug if there was no response to repeated nebulisers (68%). In comparison, nebulised magnesium sulphate was only used in two emergency departments (1%). The main reason for not administering the drug via a nebuliser was insufficient evidence (51%). Conclusions: Intravenous magnesium sulphate is widely used for acute asthma, usually for patients with severe or life-threatening asthma who have not responded to initial treatment. Nebulised magnesium sulphate, by contrast, is hardly used at all. The use of intravenous magnesium sulphate is more extensive than current guidelines or available evidence would appear to support.

Effect of 24-h alcohol licensing on emergency departments: the South Yorkshire experience

Abstract: Background The alcohol Licensing Act (2003) was introduced to England and Wales on 23 November 2005. A single-centre study in 2007 from St Thomas9s Hospital concluded that their alcohol-related attendances had significantly increased after the implementation of this new Act. This study aimed to assess whether this finding was reproduced in other hospitals. Method A retrospective cohort study, reviewing anonymised routine data from four emergency departments (ED) in South Yorkshire, was undertaken. The study population was adults (over the age of 18 years) attending the ED with injuries or illnesses directly related to alcohol in the 12 months before and after the implementation of the Licensing Act (2003). The primary outcome was the number of these alcohol-related attendances. Secondary outcomes assessed whether there was any change in the timing of these presentations. Results Alcohol-related attendances, as detected by clinical coding, increased from 0.6% to 0.7% as a proportion of all attendances (95% CI 0.1 to 0.2, p Conclusion Trends in alcohol-related attendances after the implementation of the Licensing Act (2003) varied across South Yorkshire hospitals and probably reflect local factors rather than any consistent impact from the Act.

IT IN THE EMERGENCY DEPARTMENT - What is the Impact of Technology?

Abstract: Emergency Department Information Systems (EDIS) are commonly used to improve access to patient information at the point of care. While such systems hold great promise, there has been little research evaluating the impact of these systems. To investigate the Emergency Department (ED) staff perceptions of the impact of computerised information systems in this department, a qualitative study was conducted. In this study, data were collected using in-depth semi-structured interviews with the ED staff. In total, 34 interviews were conducted and data were analysed using framework analysis. . The results showed that the impact of information systems could be categorised as individual impact, organisational impact, and impact on patient care. The impact of technology could be positive (e.g., improving the accessibility of information) or negative (e.g., interrupting staff workflow due to system downtime). The results suggest that although clinical information systems are designed to influence clinical practice positively, the likelihood of the negative impacts should not be underestimated. Evaluation studies are needed to investigate the impact of technology as a measure for system success or failure.

Consent in emergency and resuscitation research.

Abstract: The article by Lewis et al. in this edition of the journal (pp. 234–241) gives a fascinating insight into the knowledge of emergency physicians about the current national and international status of consent for emergency care research. The lack of awareness demonstrated must be tackled through training and educational programs. To fully establish ourselves as an independent speciality, we must have a firm academic foundation, and we need to create the evidence base from which to determine our treatments. This certainly needs university academics to lead research; however, the pragmatic clinically based research that we need cannot be carried out in the ‘ivory towers’ – it must be carried out in the real world to ensure that it is generalizable to everyday practice. Emergency medicine research will have to take place in nonacademic centres, usually with many emergency departments cooperating in large multicentre studies. This means that every emergency physician must play their part – and to do this all must know the Good Clinical Practice guidelines for research specified by the International Conference on Harmonisation of Technical Requirements for the Registration of Pharmaceuticals for Human Use (http://www.ich.org), an important part of which is an awareness of the regulations around consent. Training in this area should be regarded as a core competency for all emergency physicians and should be emphasized in our CME programs.

Critical appraisal for emergency medicine: 5 Evaluation of a diagnostic test

Abstract: Studies of diagnostic tests commonly inform practice in emergency medicine. They aim to determine whether the test under investigation accurately identifies patients with and without the disease, as defined by a reference standard test. Several key issues need to be considered in appraising whether a study is likely to yield a reliable estimate of the diagnostic parameters. It is also important to be able to interpret what the diagnostic parameters actually mean. The reference standard is the criterion by which it is decided that the patient has, or does not have, the disease. Typical reference standards might be: a single diagnostic test that is known to be accurate, eg, contrast venography for deep vein thrombosis; a combination of diagnostic tests that will reliably rule in and rule out disease, eg, lung perfusion scanning for pulmonary embolus combined with pulmonary angiography in equivocal cases; diagnostic testing with follow-up for negative cases to identify cases of disease that may have initially been misclassified as no disease. An ideal reference standard should correctly classify patients with and without disease. However, it should also be safe and simple to apply, because it would be unethical to ask patients to undergo dangerous or complex testing purely for research purposes. If an ideal reference standard does exist, then there is little need to evaluate new diagnostic tests! So we have something of a catch 22 situation. This is why judging whether a reference standard is acceptable involves weighing its potential accuracy against the feasibility of any alternative approaches. The choice of reference standard will often involve a trade-off between validity and generalisability. A study that uses a highly accurate reference standard in all patients is likely to …

Critical appraisal for emergency medicine: 6 systematic reviews.

Abstract: Systematic reviews are increasingly being seen as the optimal source of knowledge for evidence-based practice. A good systematic review will provide an unbiased summary of existing evidence and, provided it is applicable to local patients, should guide clinical practice. Being able to appraise systematic reviews is therefore a crucial skill for emergency physicians. The use of complex statistical techniques in meta-analysis often distracts the clinician attempting to appraise a systematic review. As previously suggested in this series, complex statistical issues are best left to a statistician. Instead, we should focus upon the many important insights that clinical experience can bring to appraisal. A systematic review is a scientific study. It follows the introduction, methods, results and discussion approach. The conclusion should represent an unbiased synthesis of available data relating to a specific question. It may not be very entertaining to read but, if undertaken properly, will provide an objective answer based upon the best scientific evidence. A narrative review is not a scientific study. The authors present their opinions of a particular topic with reference to primary studies they have selected. A good narrative review should be interesting, entertaining or provocative, but it should not be considered to provide scientific evidence. The differences between a systematic and a narrative review are summarised in table 1. View this table: Table 1 Differences between systematic and narrative reviews The process of identifying, selecting and assessing studies for inclusion in a systematic review should be open, explicit and objective. Data collection for a systematic review typically involves three stages: (1) literature searching and retrieval; (2) the selection of appropriate papers; (3) quality assessment of selected papers. These three steps should be based upon explicit criteria and should ideally be carried out by two independent assessors who are blind to each other’s decisions. The review should report the total number of articles identified by …