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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.

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Presentation on theme: "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."— Presentation transcript:

1 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 †† * 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

2 B ACKGROUND haematology RESPIRATORY DISTRESS lungs trauma psychiatric cardiac renal


4 C PAP 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.

5 P RE-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

6 S TUDY AIM A prospective diagnostic audit to assess the accuracy of paramedic diagnosis of acute cardiogenic pulmonary oedema

7 D ATA 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

8 D ATA 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

9 D ATA COLLECTION – STAGE 2  Demographics matched to hospital records to obtain:  Emergency department (ED) diagnosis  (Hospital discharge diagnosis)  Investigator then unblinded  Diagnoses matched

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

11 R ESULTS No record (n=102)Complete data (n=1,155)Patients seen by ED doctor (n=1,162) Eligible patients (n=1,334) Transfer in (n=1)To primary care (n=19)GP referrals (n=34)Did not wait (n=16)ED diagnosis not recorded (n=7)

12 R ESULTS Complete data (n=1,155) ACPO (n=59)Not ACPO (n=1096) PRE-HOSPITAL DIAGNOSIS: ACPO (n=24) Not ACPO (n=35) ED DIAGNOSIS: ACPO (n=50) Not ACPO (n=1046)

13 R ESULTS 95% Confidence intervals  Prevalence6.41% 5.06-7.98%  Sensitivity32.43 % 22.00-44.32%  Specificity96.76% 95.53-97.73%  Positive predictive value40.68% 28.07-54.25%  Negative predictive value95.44% 94.03-96.60%  Likelihood ratio of +ve result10.02% 6.25-15.58%  Likelihood ratio of –ve result0.70% 0.58-0.80% ALL PATIENTSED diagnosis Pre-hospital diagnosisACPONot ACPOTotal: ACPO243559 Not ACPO5010461096 Total:7410811155

14 R ESULTS PARAMEDIC TECHNICIAN (n = 704)(n = 451)  Prevalence6.39%6.43% 4.70-8.46%4.35-9.1%  Sensitivity46.67 %10.34% 31.66-62.13%2.19-27.35%  Specificity95.30%99.05% 93.39-96.78%97.59-99.74%  +ve predictive value40.38%42.86% 27.01-54.90%9.90-81.59%  -ve predictive value96.32%94.14% 94.57-97.63%91.54-96.14%  LR +ve result9.92%10.91% 6.14-15.50%2.78-40.98%  LR –ve result0.56%0.91% 0.41-0.70%0.74-0.97%

15 R ESULTS ED diagnoses for patients with incorrect pre-hospital diagnosis of ACPO DiagnosisNo.% total (95% CI) RESPIRATORY2263% (45-79%) Infection823% (10-40%) Chronic obstructive pulmonary disease514% (5-30%) Other respiratory disease514% (5-30%) Respiratory failure39% (2-23%) Asthma13% (0-15%) CARDIOVASCULAR720% (8-13%) Chest pain ?cause39% (2-23%) Syncope and collapse13% (0-15%) Angina/unstable angina26% (0-19%) Ischaemic heart disease – other13% (0-15%) OTHER617% (6-35%) TOTAL35100%

16 C ONCLUSIONS  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

17 R EFERENCES 1.Cohen Solal A. et al (2004) Traitement médical de l’insufficance cardiaque aigüe décompensée. Annales de Cardiologie et d’Angéiologie 53: 200-208 2.British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax 57: 192-211 3.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 4.Durham B., Aguilera P., Dale K., Neimen H. (1999) Accuracy of pre-hospital diagnosis of primary respiratory distress. Acad Emerg Med 6(5): 474 5.Widger H.N., Johnson D.R., Cohan S., Felde R., Colella R. (1996) Assessment of lung auscultation by paramedics. Ann Emerg Med 28(3): 309-312

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