Can the ABCD Score be dichotomised to identify high−risk patients with trainsient ischaemic attack in the emergency department?

Background: Recent evidence shows a substantial short-term risk of ischaemic stroke after transient ischaemic attack (TIA). Identification of patients with TIA with a high short-term risk of stroke is now possible through the use of the “ABCD Score”, which considers age, blood pressure, clinical features and duration of symptoms predictive of stroke.

Aim: To evaluate the ability of dichotomising the ABCD Score to predict stroke at 7 and 90 days in a population with TIA presenting to an emergency department.

Methods: A retrospective audit was conducted on all probable or definite TIAs presenting to the emergency department of a metropolitan hospital from July to December 2004. The ABCD Score was applied to 98 consecutive patients with TIA who were reviewed for subsequent strokes within 90 days. Patients obtaining an ABCD Score ≥5 were considered to be at high risk for stroke.

Results: Dichotomising the ABCD Score categorised 48 (49%) patients with TIA at high risk for stroke (ABCD Score ≥5). This high-risk group contained all four strokes that occurred within 7 days (sensitivity 100% (95% confidence interval (CI) 40% to 100%), specificity 53% (95% CI 43% to 63%), positive predictive value 8% (95% CI 3% to 21%) and negative predictive value 100% (95% CI 91% to 100%)), and six of seven occurring within 90 days (sensitivity 86% (95% CI 42% to 99%), specificity 54% (95% CI 43% to 64%), positive predictive value 12.5% (95% CI 5% to 26%) and negative predictive value 98% (95% CI 88% to 100%)). Removal of the “age” item from the ABCD Score halved the number of false-positive cases without changing its predictive value for stroke.

Conclusion: In this retrospective analysis, dichotomising the ABCD Score was overinclusive but highly predictive in identifying patients with TIA at a high short-term risk of stroke. Use of the ABCD Score in the emergency care of patients with TIA is simple, efficient and provides a unique opportunity to prevent stroke in this population of patients.

Patient education and self-management programs in arthritis

♦ Arthritis self-management programs (ASMPs) are integrated into many clinical practice guidelines and policies, and are the core business of Arthritis Foundations.

♦ Australian Arthritis Foundations are embarking on a National Quality Assurance Program which should raise awareness and improve confidence in such programs.

♦ ASMPs aim to empower people, improve quality of life while living with chronic disease, increase healthy activities and improve self-monitoring — each of which can assist with clinical management, but can be difficult to evaluate.

♦ Although there is modest high-quality evidence of traditional “clinical outcomes” from ASMPs, these programs are strongly endorsed by consumers, are being used as a vehicle for healthcare reform, and have the potential to substantially improve public health.

♦ Coordinated national delivery of patient education programs has the potential to improve healthcare and outcomes for people with arthritis.

Radiation exposure and the justification of computed tomography scanning in an Australian hospital emergency department

In an emergency department (ED), computed tomography (CT) is particularly beneficial in the investigation of high-speed trauma patients. With the advent of multidetector CT (MDCT) scanners, it is becoming faster and easier to conduct scans. In recent years, this has become evident with an increasing number of CT requests. Patients who have multiple CT scans during their hospital stay can receive radiation doses that have an increased theoretical risk of induction of cancer. It is essential that the clinical justification for each CT scan be considered on an individual basis and that due consideration is given to the radiation risk and possible diagnostic benefit. The current lack of a central State or Commonwealth data repository for medical images is a contributing factor to excessive radiation dosage to the population. The principles of justification and radiation risks are discussed in this study.

Effect of clinician designation on emergency department fast track performance

Objective To examine the effect of clinician designation on emergency department (ED) fast track performance.
Design and Setting A retrospective audit of patients managed in the fast track area of an ED in metropolitan Melbourne, Australia.
Participants Patients triaged to ED fast track from 1 January 2008 to 31 December 2008 (n=8714).
Main Outcome Measures Waiting times in relation to Australasian triage scale (ATS) recommendations and ED length of stay (LOS) for non-admitted patients were examined for each clinician group.
Results Compliance with ATS waiting time recommendations was highest (82.5%) for emergency nurse practitioners/candidates and lowest (48.2%) for junior medical officers. Median ED LOS was less than 3 h for non-admitted patients, and 85.8% of non-admitted fast track patients (n=6278) left the ED within 4 h. Patients managed by emergency nurse practitioners/ candidates had the shortest ED LOS (median 1.7 h) and patients managed by junior medical officers and locum medical officers the longest ED LOS (median 2.7 h) (x²=498.539, df=6, p<0.001).
Conclusions Clinician designation does impact on waiting times and, to a lesser extent, ED LOS for patients managed in ED fast track systems. Future research should focus on obtaining a better understanding of the relationship between clinician expertise, time-based performance measures and quality of care indicators.

Small rural hospital emergency department database

This data includes activity and performance data from the emergency departments at the local hospitals (Rural Category Three Public Health Services) in the Southwest region of Victoria.

Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease

Background: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD.
Methods: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO2), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h.
Results: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P = 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P = 0.001). SpO2 > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO2 < 90% were not given oxygen (61.8%; 30%; 45.5%).
Conclusions: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence-based supporting
oxygen use and better understanding of clinicians’ oxygen decision-making in patients with COPD.

Assessing data quality issues in the Emergency Department through data and process mapping

Data and information quality is a well-established research topic and gradually appears on the decision-makers' top concern lists. Many studies have been conducted on how to investigate the generic data/information quality issues and factors by providing a high-level abstract framework or model. Based on these previous studies, this study tries to discuss the actual data quality issues with the operation-level and middle-level managers emerged during the emergency department data collection and reporting processes. By conduct data quality issues and business processes mapping, possible data quality issues are summarised under the well-known TOP model and the recommendations of data quality improvement are suggested.)