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Flaws DF, Barnett A, Fraser J, Latu J, Ramanan M, Tabah A, Tippett V, Tronstad O, Patterson S. A protocol for tracking outcomes post intensive care. Nurs Crit Care 2021; 27:341-347. [PMID: 33609311 DOI: 10.1111/nicc.12613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Critically ill patients are more likely to survive intensive care than ever before due to advances in treatment. However, a proportion subsequently experiences post-intensive care syndrome (PICS) incurring substantial personal, social, and economic costs. PICS is a debilitating set of physical, psychological, and cognitive sequelae but the size and characteristics of the affected population have been difficult to describe, impeding progress in intensive care rehabilitation. AIMS AND OBJECTIVES The aim of this protocol is to describe recovery after admission to intensive care unit (ICU) and the predictors, correlates, and patient-reported outcomes for those experiencing PICS. The study will support the development of screening, diagnostic, and outcome measures to improve post-ICU recovery. DESIGN A prospective, multi-site observational study in three ICUs in Brisbane, Australia. Following consent, data will be collected from clinical records and using validated self-report instruments from 300 patients, followed up at 6 weeks and 6 months post ICU discharge. METHODS TOPIC is a prospective, multi-site observational study using self-report and clinical data on risk factors, including comorbidities, and outcomes. Data will be collected with consent from hospital records and participants 6 weeks and 6months post ICU discharge. RESULTS The main outcome measures will be self-reported physical, cognitive, and psychological function 6 weeks and 6 months post-ICU discharge. RELEVANCE TO CLINICAL PRACTICE This protocol provides a methodological framework to measure recovery and understand PICS. Data analysis will describe characteristics associated with recovery and PICS. The subsequent prediction and screening tools developed then aim to improve the effectiveness of post-ICU prevention and rehabilitation through more targeted screening and prediction and found a program of research developing a more tailored approach to PICS.
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Affiliation(s)
- Dylan F Flaws
- Department of Mental Health, Metro North Mental Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John Fraser
- Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jiville Latu
- Department of Intensive Care, Intensive Care Unit, Redcliffe Hospital, Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Department of Intensive Care, Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Alexis Tabah
- Department of Intensive Care, Intensive Care Unit, Redcliffe Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Vivienne Tippett
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Oystein Tronstad
- Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Physiotherapy Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sue Patterson
- Department of Mental Health, Metro North Mental Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Dentistry, University of Queensland, Brisbane, Queensland, Australia
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Cullen L, Aldous S, Than M, Greenslade JH, Tate JR, George PM, Hammett CJ, Richards AM, Ungerer JP, Troughton RW, Brown AF, Flaws DF, Lamanna A, Pemberton CJ, Florkowski C, Pretorius CJ, Chu K, Parsonage WA. Comparison of high sensitivity troponin T and I assays in the diagnosis of non-ST elevation acute myocardial infarction in emergency patients with chest pain. Clin Biochem 2014; 47:321-6. [DOI: 10.1016/j.clinbiochem.2013.11.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 01/17/2023]
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Cullen L, Greenslade JH, Than M, Brown AF, Hammett CJ, Lamanna A, Flaws DF, Chu K, Fowles LF, Parsonage WA. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Am J Emerg Med 2014; 32:129-34. [DOI: 10.1016/j.ajem.2013.10.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/16/2013] [Accepted: 10/07/2013] [Indexed: 01/15/2023] Open
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Cullen L, Mueller C, Parsonage WA, Wildi K, Greenslade JH, Twerenbold R, Aldous S, Meller B, Tate JR, Reichlin T, Hammett CJ, Zellweger C, Ungerer JPJ, Rubini Gimenez M, Troughton R, Murray K, Brown AFT, Mueller M, George P, Mosimann T, Flaws DF, Reiter M, Lamanna A, Haaf P, Pemberton CJ, Richards AM, Chu K, Reid CM, Peacock WF, Jaffe AS, Florkowski C, Deely JM, Than M. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 2013; 62:1242-1249. [PMID: 23583250 DOI: 10.1016/j.jacc.2013.02.078] [Citation(s) in RCA: 235] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/05/2013] [Accepted: 02/25/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The study objective was to validate a new high-sensitivity troponin I (hs-TnI) assay in a clinical protocol for assessing patients who present to the emergency department with chest pain. BACKGROUND Protocols using sensitive troponin assays can accelerate the rule out of acute myocardial infarction in patients with low-risk (suspected) acute coronary syndrome (ACS). METHODS This study evaluated 2 prospective cohorts of patients in the emergency department with ACS in an accelerated diagnostic pathway integrating 0- and 2-h hs-TnI results, Thrombolysis In Myocardial Infarction (TIMI) risk scores, and electrocardiography. Strategies to identify low-risk patients incorporated TIMI risk scores= 0 or ≤ 1. The primary endpoint was a major adverse cardiac event (MACE) within 30 days. RESULTS In the primary cohort, 1,635 patients were recruited and had 30-day follow-up. A total of 247 patients (15.1%) had a MACE. The finding of no ischemic electrocardiogram and hs-TnI ≤ 26.2 ng/l with the TIMI = 0 and TIMI ≤ 1 pathways, respectively, classified 19.6% (n = 320) and 41.5% (n = 678) of these patients as low risk; 0% (n = 0) and 0.8% (n = 2) had a MACE, respectively. In the secondary cohort, 909 patients were recruited. A total of 156 patients (17.2%) had a MACE. The TIMI = 0 and TIMI ≤ 1 pathways classified 25.3% (n = 230) and 38.6% (n = 351), respectively, of these patients as low risk; 0% (n = 0) and 0.8% (n = 1) had a MACE, respectively. Sensitivity, specificity, and negative predictive value for TIMI = 0 in the primary cohort were 100% (95% confidence interval [CI]: 98.5% to 100%), 23.1% (95% CI: 20.9% to 25.3%), and 100% (95% CI: 98.8% to 100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI ≤ 1 in the primary cohort were 99.2 (95% CI: 97.1 to 99.8), 48.7 (95% CI: 46.1 to 51.3), and 99.7 (95% CI: 98.9 to 99.9), respectively. Sensitivity, specificity, and negative value for TIMI ≤ 1 in the secondary cohort were 99.4% (95% CI: 96.5 to 100), 46.5% (95% CI: 42.9 to 50.1), and 99.7% (95% CI: 98.4 to 100), respectively. CONCLUSIONS An early-discharge strategy using an hs-TnI assay and TIMI score ≤ 1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study, NCT00470587; A 2 hr Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker [ADAPT]: a prospective observational validation study, ACTRN12611001069943).
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Affiliation(s)
- Louise Cullen
- Royal Brisbane and Women's Hospital, Herston, Australia; Queensland University of Technology, Brisbane, Australia.
| | | | - William A Parsonage
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | - Karin Wildi
- University Hospital Basel, Basel, Switzerland
| | - Jaimi H Greenslade
- Royal Brisbane and Women's Hospital, Herston, Australia; Queensland University of Technology, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | | | - Sally Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Tobias Reichlin
- University Hospital Basel, Basel, Switzerland; Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Anthony F T Brown
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | | | - Peter George
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | | | - Arvin Lamanna
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Philip Haaf
- University Hospital Basel, Basel, Switzerland
| | | | | | - Kevin Chu
- Royal Brisbane and Women's Hospital, Herston, Australia; University of Queensland, Brisbane, Australia
| | | | | | | | | | - Joanne M Deely
- Canterbury District Health Board, Christchurch, New Zealand
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
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Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, Peacock WF, Parsonage WA, Ho HF, Ko HF, Kasliwal RR, Bansal M, Soerianata S, Hu D, Ding R, Hua Q, Seok-Min K, Sritara P, Sae-Lee R, Chiu TF, Tsai KC, Chu FY, Chen WK, Chang WH, Flaws DF, George PM, Richards AM. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet 2011; 377:1077-84. [PMID: 21435709 DOI: 10.1016/s0140-6736(11)60310-3] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome. METHODS This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279. FINDINGS 3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a specificity of 11.0% (10.0-12.2). INTERPRETATION This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide. FUNDING Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International (Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand, and Progressive Group (Taiwan).
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Affiliation(s)
- Martin Than
- Christchurch Hospital, Christchurch, New Zealand.
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Than MP, Flaws DF. Communicating diagnostic uncertainties to patients: the problems of explaining unclear diagnosis and risk. ACTA ACUST UNITED AC 2009; 14:66-7. [PMID: 19483015 DOI: 10.1136/ebm.14.3.66] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Than MP, Helm J, Calder K, Ardagh MW, Smith M, Flaws DF, Beckert L. Comparison of high specificity with standard versions of a quantitative latex D-dimer test in the assessment of community pulmonary embolism: HaemosIL D-dimer HS and pulmonary embolism. Thromb Res 2009; 124:230-5. [PMID: 19380159 DOI: 10.1016/j.thromres.2008.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 10/30/2008] [Accepted: 10/31/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND D-dimer assays are sensitive but have poor specificity. False positive results lead to extra imaging and hospital admissions. OBJECTIVES To make a pilot comparison of the diagnostic accuracy of the standard quantitative latex HemosIL D-dimer assay with a newer HemosIL D-dimer HS version designed to have improved specificity. PATIENTS / METHODS: Consecutive patients presenting from the community to an Emergency Department that were investigated for suspected pulmonary embolism using a D-dimer test were included in the study. Standard and D-dimer HS tests were performed. Pulmonary Embolism was diagnosed on the basis of imaging studies or post-mortem at any time from presentation to 90 days thereafter. RESULTS The prevalence of Pulmonary Embolism was 4.5% (18/402). The sensitivity, specificity, negative predictive value, and positive predictive value for the standard quantitative D-dimer test was 100% (81.5 - 100.0), 49.2% (44.1 - 54.3),100% (98.1 - 100.0), and 8.5% (5.1 - 13.0), respectively, and 100% (81.5 - 100.0), 58.3% (53.2 - 63.3),100% (98.4 - 100.0), and 10.1% (6.1 - 15.5), for the D-dimer HS test. There were 35 (16%) fewer 'false positives' using the D-dimer HS assay compared with the standard assay. CONCLUSIONS D-dimer HS has superior specificity to the standard quantitative D-dimer test without any loss of sensitivity. The generation of fewer false positive results should lead to less unnecessary diagnostic imaging; the use of which is associated with increased hospital admissions and length of stay. The HS assay may therefore have significant health economic benefits.
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Affiliation(s)
- Martin P Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand.
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