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Fischer C, Knüsli J, Lhopitallier L, Tenisch E, Meuwly MG, Douek P, Meuwly JY, D’Acremont V, Kronenberg A, Locatelli I, Mueller Y, Senn N, Boillat-Blanco N. Pulse Oximetry as an Aid to Rule Out Pneumonia among Patients with a Lower Respiratory Tract Infection in Primary Care. Antibiotics (Basel) 2023; 12:496. [PMID: 36978363 PMCID: PMC10044291 DOI: 10.3390/antibiotics12030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Guidelines recommend chest X-rays (CXRs) to diagnose pneumonia and guide antibiotic treatment. This study aimed to identify clinical predictors of pneumonia that are visible on a chest X-ray (CXR+) which could support ruling out pneumonia and avoiding unnecessary CXRs, including oxygen saturation. A secondary analysis was performed in a clinical trial that included patients with suspected pneumonia in Swiss primary care. CXRs were reviewed by two radiologists. We evaluated the association between clinical signs (heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, abnormal auscultation, and oxygen saturation < 95%) and CXR+ using multivariate analysis. We also calculated the diagnostic performance of the associated clinical signs combined in a clinical decision rule (CDR), as well as a CDR derived from a large meta-analysis (at least one of the following: heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, or abnormal auscultation). Out of 469 patients from the initial trial, 107 had a CXR and were included in this study. Of these, 26 (24%) had a CXR+. We found that temperature and oxygen saturation were associated with CXR+. A CDR based on the presence of either temperature ≥ 37.8 °C and/or an oxygen saturation level < 95% had a sensitivity of 69% and a negative likelihood ratio (LR-) of 0.45. The CDR from the meta-analysis had a sensitivity of 92% and an LR- of 0.37. The addition of saturation < 95% to this CDR increased the sensitivity (96%) and decreased the LR- (0.21). In conclusion, this study suggests that pulse oximetry could be added to a simple CDR to decrease the probability of pneumonia to an acceptable level and avoid unnecessary CXRs.
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Affiliation(s)
- Chloé Fischer
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - José Knüsli
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | | | - Estelle Tenisch
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Marie-Garance Meuwly
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Pauline Douek
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Valérie D’Acremont
- Digital Global Health Department, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Andreas Kronenberg
- Medix General Practice, 3010 Bern, Switzerland
- Institute for Infectious Diseases, University Bern, 3010 Bern, Switzerland
| | - Isabella Locatelli
- Department of Education, Research, and Innovation, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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Tse CF, Chan YYF, Poon KM, Lui CT. Clinical prediction rule to predict pneumonia in adult presented with acute febrile respiratory illness. Am J Emerg Med 2018; 37:1433-1438. [PMID: 30355477 DOI: 10.1016/j.ajem.2018.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To derive a clinical prediction rule to predict pneumonia in patients with acute febrile respiratory illness to emergency departments. METHOD This was a prospective multicentre study. 537 adults were recruited. Those requiring resuscitation or were hypoxaemic on presentation were excluded. Pneumonia was defined as new onset infiltrates on chest X-ray (CXR), or re-attendance within 7 days and diagnosed clinically as having pneumonia. A predictive model, the Acute Febrile Respiratory Illness (AFRI) rule was derived by logistic regression analysis based on clinical parameters. The AFRI rule was internally validated with bootstrap resampling and was compared with the Diehr and Heckerling rule. RESULTS In the 363 patients who underwent CXR, 100 had CXR confirmed pneumonia. There were 7 weighted factors within the ARFI rule, which on summation, gave the AFRI score: age ≥ 65 (1 point), peak temperature within 24 h ≥ 40 °C (2 points), fever duration ≥3 days (2 points), sore throat (-2 points), abnormal breath sounds (1 point), history of pneumonia (1 point) and SpO2 ≤ 96% (1 point). With the bootstrap resampling, the AFRI rule was found to be more accurate than the Diehr and Heckerling rule (area under ROC curve 0.816, 0.721 and 0.566 respectively, p < 0.001). At a cut-off of AFRI≥0, the rule was found to have 95% sensitivity, with a negative predictive value of 97.2%. Using the AFRI score, we found CXR could be avoided for patients having a score of <0. CONCLUSION AFRI score could assist emergency physicians in identifying pneumonia patients among all adult patients presented to ED for acute febrile respiratory illness.
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Affiliation(s)
- Choi Fung Tse
- Accident & Emergency Department, Princess Margaret Hospital, Hospital Authority, Hong Kong.
| | - Yuet Yan Fiona Chan
- Accident & Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong.
| | - Kin Ming Poon
- Department of Accident & Emergency, Pok Oi Hospital, Hospital Authority, Hong Kong.
| | - Chun Tat Lui
- Accident & Emergency Department, Tuen Mun Hospital, Hospital Authority, Hong Kong.
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Luo G, Stone BL, Johnson MD, Tarczy-Hornoch P, Wilcox AB, Mooney SD, Sheng X, Haug PJ, Nkoy FL. Automating Construction of Machine Learning Models With Clinical Big Data: Proposal Rationale and Methods. JMIR Res Protoc 2017; 6:e175. [PMID: 28851678 PMCID: PMC5596298 DOI: 10.2196/resprot.7757] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 12/14/2022] Open
Abstract
Background To improve health outcomes and cut health care costs, we often need to conduct prediction/classification using large clinical datasets (aka, clinical big data), for example, to identify high-risk patients for preventive interventions. Machine learning has been proposed as a key technology for doing this. Machine learning has won most data science competitions and could support many clinical activities, yet only 15% of hospitals use it for even limited purposes. Despite familiarity with data, health care researchers often lack machine learning expertise to directly use clinical big data, creating a hurdle in realizing value from their data. Health care researchers can work with data scientists with deep machine learning knowledge, but it takes time and effort for both parties to communicate effectively. Facing a shortage in the United States of data scientists and hiring competition from companies with deep pockets, health care systems have difficulty recruiting data scientists. Building and generalizing a machine learning model often requires hundreds to thousands of manual iterations by data scientists to select the following: (1) hyper-parameter values and complex algorithms that greatly affect model accuracy and (2) operators and periods for temporally aggregating clinical attributes (eg, whether a patient’s weight kept rising in the past year). This process becomes infeasible with limited budgets. Objective This study’s goal is to enable health care researchers to directly use clinical big data, make machine learning feasible with limited budgets and data scientist resources, and realize value from data. Methods This study will allow us to achieve the following: (1) finish developing the new software, Automated Machine Learning (Auto-ML), to automate model selection for machine learning with clinical big data and validate Auto-ML on seven benchmark modeling problems of clinical importance; (2) apply Auto-ML and novel methodology to two new modeling problems crucial for care management allocation and pilot one model with care managers; and (3) perform simulations to estimate the impact of adopting Auto-ML on US patient outcomes. Results We are currently writing Auto-ML’s design document. We intend to finish our study by around the year 2022. Conclusions Auto-ML will generalize to various clinical prediction/classification problems. With minimal help from data scientists, health care researchers can use Auto-ML to quickly build high-quality models. This will boost wider use of machine learning in health care and improve patient outcomes.
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Michael D Johnson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Peter Tarczy-Hornoch
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States.,Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States.,Department of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Adam B Wilcox
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Peter J Haug
- Homer Warner Research Center, Intermountain Healthcare, Murray, UT, United States.,Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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Marconi GP, Chang T, Pham PK, Grajower DN, Nager AL. Traditional nurse triage vs physician telepresence in a pediatric ED. Am J Emerg Med 2013; 32:325-9. [PMID: 24445223 DOI: 10.1016/j.ajem.2013.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/13/2013] [Accepted: 12/15/2013] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES The objective of the study is to compare traditional nurse triage (TNT) in a pediatric emergency department (PED) with physician telepresence (PTP). METHODS This is a prospective 2 × 2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children's hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. RESULTS Paired samples t tests showed a statistically significant difference in triage time between TNT and PTP (P = .03) but no significant difference in documentation errors (P = .10). Triage scores of TNT were 71% accurate, compared with PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP, and most indicated that they would prefer PTP again at their next PED visit. Physician telepresence diagnostic ordering was comparable with the actual PED physician ordering, showing no statistical differences. CONCLUSIONS Using PTP technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors, and patient and parent satisfaction.
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Affiliation(s)
- Greg P Marconi
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA.
| | - Todd Chang
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Phung K Pham
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Daniel N Grajower
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
| | - Alan L Nager
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90027, USA
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Sucov A, Valente J, Reinert SE. Time to first antibiotics for pneumonia is not associated with in-hospital mortality. J Emerg Med 2013; 45:1-7. [PMID: 23485266 DOI: 10.1016/j.jemermed.2012.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 06/27/2012] [Accepted: 11/05/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Time to first antibiotic (TTFA) is postulated to impact pneumonia mortality. The Joint Commission/Centers for Medicare and Medicaid Services national quality standards previously indicated that TTFA should be <6 h (modified from <4 h when the study was initiated, now eliminated as a time measure entirely). OBJECTIVE The purpose of this article was to determine whether TTFA is associated with inpatient mortality. METHODS The records of 444 consecutive patients admitted with pneumonia at a single institution were retrospectively reviewed for a correlation between TTFA and inpatient complications, including death. Statistical significance was set at p < 0.01 due to multiple comparisons. RESULTS Patients whose TTFA was <4 h had more complications (27% vs. 3%; p < 0.01) including death, intensive care unit admission, and intubation. These patients were judged sicker on arrival (median Emergency Severity Index 2 vs. 3; p < 0.001) and were more likely to be triaged to a critical care bed (36% vs. 5%; p < 0.001). Shortness of breath was the only presenting factor that was more frequent in the TTFA <4-h group (61% vs. 16%; p < 0.01). CONCLUSIONS Shorter TTFA is not associated with improved inpatient mortality. TTFA should not be considered to be a marker of quality of care but rather a reflection of patient disease severity.
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Affiliation(s)
- Andrew Sucov
- Department of Emergency Medicine, Saint Anne's Hospital, Fall River, Massachusetts 02721, USA
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Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, Samaria JK, Gaur SN, Jindal SK. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29:S27-62. [PMID: 23019384 PMCID: PMC3458782 DOI: 10.4103/0970-2113.99248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - S. K. Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - for the Pneumonia Guidelines Working Group
- Pneumonia Guidelines Working Group Collaborators (43) A. K. Janmeja, Chandigarh; Abhishek Goyal, Chandigarh; Aditya Jindal, Chandigarh; Ajay Handa, Bangalore; Aloke G. Ghoshal, Kolkata; Ashish Bhalla, Chandigarh; Bharat Gopal, Delhi; D. Behera, Delhi; D. Dadhwal, Chandigarh; D. J. Christopher, Vellore; Deepak Talwar, Noida; Dhruva Chaudhry, Rohtak; Dipesh Maskey, Chandigarh; George D’Souza, Bangalore; Honey Sawhney, Chandigarh; Inderpal Singh, Chandigarh; Jai Kishan, Chandigarh; K. B. Gupta, Rohtak; Mandeep Garg, Chandigarh; Navneet Sharma, Chandigarh; Nirmal K. Jain, Jaipur; Nusrat Shafiq, Chandigarh; P. Sarat, Chandigarh; Pranab Baruwa, Guwahati; R. S. Bedi, Patiala; Rajendra Prasad, Etawa; Randeep Guleria, Delhi; S. K. Chhabra, Delhi; S. K. Sharma, Delhi; Sabir Mohammed, Bikaner; Sahajal Dhooria, Chandigarh; Samir Malhotra, Chandigarh; Sanjay Jain, Chandigarh; Subhash Varma, Chandigarh; Sunil Sharma, Shimla; Surender Kashyap, Karnal; Surya Kant, Lucknow; U. P. S. Sidhu, Ludhiana; V. Nagarjun Mataru, Chandigarh; Vikas Gautam, Chandigarh; Vikram K. Jain, Jaipur; Vishal Chopra, Patiala; Vishwanath Gella, Chandigarh
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Weiner SG, Brown SF, Goetz JD, Webber CA. Weekly E-mail reminders influence emergency physician behavior: a case study using the Joint Commission and Centers for Medicare and Medicaid Services Pneumonia Guidelines. Acad Emerg Med 2009; 16:626-31. [PMID: 19538501 DOI: 10.1111/j.1553-2712.2009.00442.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Improving physician compliance with evidence-based guidelines is challenging. The authors wanted to determine if weekly e-mail reminders to emergency department (ED) staff increase compliance with Joint Commission and the Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia quality measures. METHODS One nurse administrator reviewed records on a weekly basis for all adult patients admitted to the hospital from the ED with a working diagnosis of pneumonia. An e-mail was then sent to all ED staff indicating the percentage of patients with antibiotic timing less than 4 hours from arrival. The names of individuals who administered antibiotics in less than 1 hour were highlighted. This study compared the time to antibiotics for 11 months before and 11 months after commencing this intervention. RESULTS There were 281 patients in the control cohort, and 37 met exclusion criteria, leaving 244 for analysis. There were 342 patients in the intervention cohort, and 40 met exclusion criteria, leaving 302 for analysis. The median time from arrival to chest radiograph order decreased significantly from 61 to 47 minutes (p < 0.001). The median time interval from chest radiograph order to antibiotic administration did not change significantly (92 to 88 minutes, p = 0.294). The overall median time from arrival to antibiotic administration decreased significantly from 162 to 146 minutes (p = 0.018). The percentage of patients with antibiotic administration within 4 hours increased from 77.5% to 86.1% (p = 0.009). CONCLUSIONS Weekly e-mail reminders listing performance on antibiotic administration recommendations are associated with increased compliance with a clinical guideline.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
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