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A CCURACY OF P ARAMEDIC D IAGNOSIS OF A CUTE C ARDIOGENIC P ULMONARY O EDEMA A prospective diagnostic audit of 1, PowerPoint Presentation
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A CCURACY OF P ARAMEDIC D IAGNOSIS OF A CUTE C ARDIOGENIC P ULMONARY O EDEMA A prospective diagnostic audit of 1,334 patients Emma Jenkinson * , Malcolm Woollard ** , Robert Newcombe † , Iain Robertson-Steel ††

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ACCURACY OF PARAMEDIC DIAGNOSIS OF ACUTE CARDIOGENIC PULMONARY OEDEMAA prospective diagnostic audit of 1,334 patients

Emma Jenkinson*, Malcolm Woollard**,

Robert Newcombe†, Iain Robertson-Steel††

*Heartlands Hospital/West Midlands Ambulance Service, **Faculty of Pre-hospital Care Research Unit,

†Medical Statistics Department, University of Cardiff, ††West Midlands Ambulance Service NHS Trust

United Kingdom

slide2

psychiatric

haematology

lungs

cardiac

trauma

renal

BACKGROUND

RESPIRATORY DISTRESS

slide4

CPAP IN LVF

“…single greatest advance in the management of these [LVF] patients in the past decade…”

Cohen Solal et al 1, 2004

CPAP is effective in patients with pulmonary oedema who remain hypoxic despite maximal medical treatment

BTS Guidelines 2, 2002

Some UK ambulance services are looking to introduce CPAP for paramedic use, one service already has.

slide5

PRE-HOSPITAL DIAGNOSIS OF ACPO

  • Seven main studies 3
    • Overall error rates 9-23%
  • Additional study found 92% accuracy 4
  • Paramedic identification of common lung sounds found to be unreliable in 40% of cases 5
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STUDY AIM

A prospective diagnostic audit to assess the accuracy of paramedic diagnosis of acute cardiogenic pulmonary oedema

slide7

DATA COLLECTION

  • Prospective audit
  • Population: patients brought to Heartlands (BHH) by West Midlands Ambulance Service (WMAS)
  • Publicised beforehand
  • 2 stages, 2 teams to allow for blinding
  • An estimated 1,300 patients required
  • Data collected between 4 Dec 05 until 31 Mar 06
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DATA COLLECTION – STAGE 1

  • WMAS PRFs searched to identify patients taken to BHH with:
    • Diagnosis of ACPO OR
    • Furosemide given OR
    • Presenting complaint of respiratory distress OR
    • Any of the following diagnoses:
      • Acute asthma  Croup
      • SOB ?cause  Exacerbation COPD
      • Chest infection  Pulmonary oedema
      • Haemoptysis
  • Excluded if seen by Dr
slide9

DATA COLLECTION – STAGE 2

  • Demographics matched to hospital records to obtain:
    • Emergency department (ED) diagnosis
    • (Hospital discharge diagnosis)
  • Investigator then unblinded
    • Diagnoses matched
slide10

DATA ANALYSIS

  • Two-by-two tables produced in SPSS:
    • Positive or negative pre-hospital diagnosis of ACPO
    • Positive or negative ED diagnosis of ACPO
  • Results then entered into StatsDirect to calculate:
    • Sensitivity
    • Specificity
    • PPV
    • NPV
    • PLR
    • NLR

Proportion of patients with ACPO correctly identified by ambulance staff as having ACPO

Proportion of patients without ACPO correctly identified by ambulance staff as not having ACPO

By how much does the probability of having ACPO increase with a positive pre-hospital diagnosis?

How much the probability of ACPO decreases with a negative pre-hospital diagnosis of ACPO

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Eligible patients (n=1,334)

No record (n=102)

GP referrals (n=34)

Transfer in (n=1)

Did not wait (n=16)

To primary care (n=19)

Patients seen by ED doctor (n=1,162)

ED diagnosis not recorded (n=7)

Complete data (n=1,155)

RESULTS

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PRE-HOSPITAL DIAGNOSIS:

ACPO (n=59)

Not ACPO (n=1096)

ED DIAGNOSIS:

ED DIAGNOSIS:

ACPO

(n=24)

Not ACPO

(n=35)

ACPO

(n=50)

Not ACPO

(n=1046)

Complete data (n=1,155)

RESULTS

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RESULTS

95% Confidence intervals

  • Prevalence 6.41% 5.06-7.98%
  • Sensitivity 32.43 % 22.00-44.32%
  • Specificity 96.76% 95.53-97.73%
  • Positive predictive value 40.68% 28.07-54.25%
  • Negative predictive value 95.44% 94.03-96.60%
  • Likelihood ratio of +ve result 10.02% 6.25-15.58%
  • Likelihood ratio of –ve result 0.70% 0.58-0.80%
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RESULTS

PARAMEDIC TECHNICIAN

(n = 704) (n = 451)

  • Prevalence 6.39% 6.43%

4.70-8.46% 4.35-9.1%

  • Sensitivity 46.67 % 10.34%

31.66-62.13% 2.19-27.35%

  • Specificity 95.30% 99.05%

93.39-96.78% 97.59-99.74%

  • +ve predictive value 40.38% 42.86%

27.01-54.90% 9.90-81.59%

  • -ve predictive value 96.32% 94.14%

94.57-97.63% 91.54-96.14%

  • LR +ve result 9.92% 10.91%

6.14-15.50% 2.78-40.98%

  • LR –ve result 0.56% 0.91%

0.41-0.70% 0.74-0.97%

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CONCLUSIONS

  • Sensitivity low, specificity high
  • A positive diagnosis carried some predictive value
  • If patients are treated for ACPO by pre-hospital staff this is likely to be appropriate
  • A large proportion of patients with ACPO are likely to be missed
  • Further training is required to improve diagnosis
slide17

REFERENCES

Cohen Solal A. et al (2004) Traitement médical de l’insufficance cardiaque aigüe décompensée. Annales de Cardiologie et d’Angéiologie 53: 200-208

British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax57: 192-211

Shapiro S.E. (2005) Evidence review: Emergency medical services treatment of patients with congestive heart failure/acute pulmonary edema: do risks outweight the benefits? J Emerg Nursing 31(1): 51-57

Durham B., Aguilera P., Dale K., Neimen H. (1999) Accuracy of pre-hospital diagnosis of primary respiratory distress. Acad Emerg Med6(5): 474

Widger H.N., Johnson D.R., Cohan S., Felde R., Colella R. (1996) Assessment of lung auscultation by paramedics. Ann Emerg Med28(3): 309-312