ASEM Best Paper Prizes 2010

ACEM 2010

Best Paper Prize

SMARTACOP: Pneumonia Risk Stratification in the Top End

Karen Robins-Browne, Allen C Cheng, Kathleen Thomas, Didier Palmer, Bart J Currie, Dianne Stephens, Joshua S Davis

Royal Darwin Hospital; Menzies School of Health Research

Introduction: SMART-COP is a simple pneumonia security scoring system, used to predict the need for intensive respiratory and/or vasopressor support (IRVS) which was developed and validated in non-tropical Australia. A previous retrospective study on a hospitalised sepsis cohort at Royal Darwin Hospital (RDH) found that SMART-COP underestimates pneumonia severity, and that a modification including locally relevant additions (SMARTACOP) demonstrated improved sensitivity. We aimed to prospectively compare this modified score with SMART-COP and PSI scores in pneumonia patients attending the RDH emergency department (ED).

Methods: We conducted a prospective observational study of adult patients presenting to RDH with pneumonia between November 2008 and November 2009. Chest x-rays were reviewed to confirm pneumonia, and each patients SMART-COP, SMARTACOP and PSI scores were against the need for IRVS.

Result: There were 367 ED attendances for pneumonia of whom 283 (77.1%) were admitted to hospital, 37 (10%) required IVRS and 10 (2.8%) died. Mean age was 50.0 years, 52% were male and 59% were indigenous. The sensitivity of a SMART-COP score < = 3, SMARTACOP score > = 3 and a PSI class > = 3 fore predicting IVRS were 97%, 97% and 78% respectively. The AUROC for SMART-COP, SMARTACOP and PSI for predicting IVRS was 89.4%, 88.3% and 76.4% respectively (9=0.003).

Conclusions: In contrast to an earlier study, we found no significant advantage of the SMARTACOP over the SMART-COP score for the prediction of IRVS, but both scores significantly outperformed PSI. As in the rest of Australia, the SMART-COP score should replace the PSI in Tropical Australia for pneumonia risk satisfaction in the emergency department.

SSEM Conference 2010

Best Trainee Paper

"Pilot study of high sensitivity TroponinT compared to current 4th generation TroponinT: Patient outcomes and the implication for clinicians"

S.Jairam 1 ,P.Jones1 , L.Samaraie 2 , A.Chateline 2 , R.Stewart 2, J.Davidson3, M.Lee 2 , T.Wang1
1Adult Emergency department, 2Greenlane Cardiovascular Service, 3 Laboratory Services, Auckland Public Hospital, Auckland.


Background: High sensitivity troponin T (hsTnT) detects low levels of cardiac troponin T with high precision compared to the 4th generation (cTnT) test. Whether this is will lead to improved diagnosis of acute myocardial infarction (AMI) is debated.

Objectives: The primary aims were to determine how many more positive tests we would find using the new test in our setting, and to describe the clinical outcomes for these patients compared to those who tested negative or positive with both assays. The primary outcome was the proportion of new positive tests. The secondary outcome was the 90day combined end point of revascularization, AMI, readmission or death.

Method: Convenience cohort of 225 blood samples from 181 patients were tested with both assays. A retrospective review of the electronic patient records using a standard data extraction form was conducted. Data extractors were blind to the hsTnT results. Two senior clinicians independently reviewed the ‘new positive’ group to confirm the clinical diagnosis and assign an adjudicated diagnosis.

Results: With hsTnT the number of positives more than doubled compared to cTnT; 49.7% versus 22.4%, McNemar’s Chi2 = 42.02, p=<0.0001. Of 181 patients tested, 161 charts were reviewed (89%). 81 patients tested negative with both assays, 44 were cTnT negative/hsTnT positive and 36 were positive for both assays. 29.6%, 54.5% and 50% in each group respectively reached the combined 90 day endpoint, however in only 4 cases (all positive with both assays) was this due to AMI or cardiovascular death. The primary diagnosis in the ‘new positives’ was myocardial infarction (9%), other cardiac (30%) and other medical (61%).

Conclusion: Most ‘new positive’ hsTnT were not due to AMI and it is therefore less useful as a ‘rule in’ test for AMI than the previous assay. A positive hsTnT is associated with worse 90day outcome, regardless of underlying diagnosis, but whether this adds anything to the clinical impression is unknown. As a result of this study we have developed an education intervention to reduce the number of inappropriate troponin test requests.

SSEM Conference 2010

Best Free Paper

"Inhaled or ingested foreign bodies referred to NETS* NSW - A 10 year review"

*Newborn and paediatric Emergency Transport Service (New South Wales)

A Kee, NETS Registrar
S Dalton, Paediatric Emergency Consultant and NETS Consultant
Newborn and paediatric Emergency Transport Service (New South Wales), Australia

Background: Inhaled or ingested foreign bodies in children are a common presentation to NSW emergency departments. Removal of the foreign body may require paediatric anaesthesia and airway management skills, often requiring transfer to a paediatric tertiary referral hospital. Given the theoretical risk of foreign body displacement and potential airway complications during transit, children with suspected respiratory tract or oesophageal foreign bodies have traditionally been moved with a medical escort despite limited published data to support this practice.

Methods: All cases referred to NETS between 2000 and 2010 were reviewed retrospectively utilising the NETS database and medical records. Children with an uncertain history or clinical picture of foreign body ingestion or inhalation were excluded.

Results: There were 204 referrals for suspected respiratory or gastrointestinal foreign body over a 10 year period. Half of all cases (n=106, 52%) resulted in the dispatch of a NETS retrieval team. Most of these children (n=92) were subsequently transferred by NETS to a tertiary hospital. We analysed the rate of adverse events and medical interventions required during transport in this group. A small number of children (n=16/92) were intubated at the referral hospital for signs of airway obstruction or secondary respiratory failure at the time of presentation, and required intensive care interventions during transport. The majority of children were not intubated for transport (n=76/92), and there were no recorded airway emergencies in transit. In one case a child coughed up a plastic foreign body which was removed uneventfully from the oropharynx.

Conclusions: Based on this review, concerns regarding dislodgement of foreign bodies and airway obstruction during transport of non-intubated patients are not supported. Most children requiring retrieval to a higher level of care for foreign body removal could be safely transported without medical escort or intensive care retrieval teams. However the decision regarding transport of these patients should be made on a case by case basis in consultation with accepting hospitals and medical retrieval experts.

CENA Conference 2010

"Assessing the inaccuracy of automatic devices in taking postural measurements in the Emergency Department"

Dind, A.1
Short, A. PhD RMT MT-BC RGIMT AMI Fellow 2
Ekholm, J. RN, Dipp AppSc Nurs, BHS, MClN (Emergency), Grad Cert Adult Ed and Training, Cert IV 3
Holdgate, A. FACEM MMed 4

1. The University of New South Wales, Sydney, NSW 2052,
2. Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, The University of New South Wales and Centre for Health Stewardship, The Australian National University
3. Centre for Education and Workforce Development, SSWAHS, CEWD, Eastern Campus, Liverpool Hospital, Locked bag 7103, Liverpool BC, NSW, 1871
4. Emergency Medicine Research Unit, Liverpool Hospital, Sydney, NSW 2170

Background: Triage nurses rely on postural blood pressure (BP) measurements to assess patient haematological stability. Automatic devices are most commonly used because of time and resource constraints. However, research illustrates that they are inaccurate in taking single measurements when compared to the manual gold standard device. This study aimed to determine whether automatic devices are also inaccurate in taking postural measurements. The clinically acceptable differences were predetermined to be <20mmHg for sBP and <10mmHg for dBP as these thresholds define orthostatic hypotension (OH) and have triage implications.

Method: Postural BPs were taken sequentially with a automatic device (Dinamap Procare) and a manual device (WelchAllyn 767). The order of the devices was randomised with a two-minute interval between measurements. Postural drops were calculated from the supine and standing readings for each device.
Results: The manual device found that 10 of the 150 adult patients had OH (6.7%). The automatic device detected OH with a sensitivity of only 30% and a specificity of 91%. The positive predictive value was 20% and the negative predictive value was 95%. Furthermore, 12.67% of automatic-manual sBP differences and 36.67% of dBP differences fell outside the clinically acceptable ranges. The inaccuracy of the automatic device was not influenced by the magnitude of the BP.

Conclusion: The inaccuracy of the automatic device was often clinically significant, which has serious implications for patient care. The device cannot reliably detect or rule out OH, even when the BP is in the normal range. Therefore, triage nurses need to use manual devices whenever they take postural BPs. Further studies are required to provide a better evidence base to inform best clinical practice.

Terrigal EM Conference, New South Wales 2010

"Fatigue in Emergency Registrars"

Authors: Julia Haire, Sally Ferguson, James Tilleard, Matthew Thomas, Paul Negus, Adrian Weissenfeld and Jillian Dorian;
Department of Emergency Medicine, Nambour General Hospital, Sunshine Coast District, Queensland, Australia Centre for Sleep Research, Division of Education, Arts and Social Sciences, University of South Australia, Adelaide, South Australia

Objective: To evaluate the effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and performance on a psychometric test in a group of emergency registrars working an Australian emergency department.

Methods: A prospective observational study with a repeated within-subjects component was conducted. The amount of time slept during consecutive day and night shifts was determined using sleep diaries and actigraphs. Subjective fatigue levels before and after both day and night shifts was measured. Reciprocal Reaction Times (RRT), using the Psychomotor Vigilance Test (PVT), was evaluated before and after both day and night shifts.

Results: A total of 11 registrars participated in the study with n=80 night shifts and n=40 day shifts and n=107 night shift PVT trials and n=48 day shift PVT trials available for analysis. Sleep time during the run of night shifts was found to be similar to sleep time during the run of day shifts. Time spent awake prior to the start of a night shift was significantly greater than time spent awake prior to the start of a day shift. The mean number of hours spent awake prior to the end of a night shift was 14.33 (13.56-15.10) hours. Subjective fatigue scores became significantly worse over any shift and were worst at the end of a night shift. The RRT was significantly worse at the end of the night shift compared to the beginning of a night shift but was significantly better at the start of a night shift compared with the start of the day shift. There was no difference in RRT between the end of a night shift and the beginning of a day shift.

Conclusion: Registrars sleep a similar amount of time on night shifts as they do on day shifts. Despite reporting the highest levels of fatigue at the end of a night shift there is no significant difference in RRT at the end of a night shift compared to the beginning of a day shift. This correlates with the finding that at the end of a night shift the registrars have, on average, not been awake for greater than 16 hours which is the critical point at which decline in psychomotor performance is expected to commence.

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