慢性阻塞性肺疾病患者在急诊科管理中严重结局风险量表的临床验证。
Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department.
机构信息
Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta.
出版信息
CMAJ. 2018 Dec 3;190(48):E1406-E1413. doi: 10.1503/cmaj.180232.
BACKGROUND
The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS), which consists of 10 criteria, was previously derived to identify patients in the emergency department with COPD who were at high risk for short-term serious outcomes. We sought to validate, prospectively and explicitly, the OCRS when applied by physicians in the emergency department.
METHODS
We conducted this prospective cohort study involving patients in the emergency departments at 6 tertiary care hospitals and enrolled adults with acute exacerbation of COPD from May 2011 to December 2013. Physicians evaluated patients for the OCRS criteria, which were recorded on a data form along with the total risk score. We followed patients for 30 days and the primary outcome, short-term serious outcomes, was defined as any of death, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI) or relapse with hospital admission.
RESULTS
We enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for a score of 10. Compared with current practice, an OCRS score threshold of greater than 1 would increase sensitivity for short-term serious outcomes from 51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being admitted.
INTERPRETATION
In this clinical validation of a risk-stratification tool for COPD in the emergency department, we found that OCRS showed better sensitivity for short-term serious outcomes compared with current practice. This risk scale can now be used to help emergency department disposition decisions for patients with COPD, which should lead to a decrease in unnecessary admissions and in unsafe discharges.
背景
渥太华慢性阻塞性肺疾病（COPD）风险评分（OCRS）由 10 项标准组成，用于识别急诊科 COPD 患者中短期严重结局风险较高的患者。我们旨在通过急诊科医生前瞻性和明确地验证 OCRS。
方法
我们进行了这项前瞻性队列研究，纳入了 6 家三级保健医院的急诊科患者，纳入了 2011 年 5 月至 2013 年 12 月间急性加重的 COPD 成年患者。医生评估患者的 OCRS 标准，这些标准记录在数据表格上，同时记录总风险评分。我们随访患者 30 天，主要结局是短期严重结局，定义为任何死亡、入住监测单位、插管、无创通气、心肌梗死（MI）或住院复发。
结果
我们纳入了 1415 例平均年龄为 70.6（10.6）岁、50.2%为女性的患者。135 例（9.5%）发生短期严重结局。总评分 0 至 10 时，短期严重结局的发生率从 4.6%至 100%。与当前实践相比，OCRS 评分阈值大于 1 将短期严重结局的敏感性从 51.9%提高到 79.3%，住院率从 45.0%提高到 56.6%。阈值大于 2 将敏感性提高到 71.9%，47.9%的患者入院。
解释
在这项对急诊科 COPD 风险分层工具的临床验证中，我们发现 OCRS 对短期严重结局的敏感性优于当前实践。现在可以使用这个风险评分来帮助急诊科 COPD 患者的处置决策，这应该会减少不必要的住院和不安全的出院。
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