Prehospital risk stratification in patients with chest pain

OBJECTIVES: The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital. METHODS: In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018. RESULTS: Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4-99.3), a positive predictive value (PPV) of 35.5% (31.8-39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78-0.85). The preHEART Score had an NPV of 99.3% (98.1-99.8), a PPV of 49.4% (42.0-56.9) and an AUC of 0.85 (0.82-0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort. CONCLUSIONS: The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting

Inter-observer variability in APACHE II scoring: Effect of strict guidelines and training

Objective: To assess the effect of strict guidelines and a rigorous training program on variability in scoring the revised Acute Physiology and Chronic Health Evaluation (APACHE II). Design and setting: Prospective survey and intervention in the surgical ICU of a university teaching hospital. Measurements: Seven experienced intensivists and nine residents determined APACHE II scores in one set of patients before and in another set 4 months after a rigorous training program, following strict guidelines for using the APACHE II. Results: APACHE II scores were 14.3 ± 4.4 before the training program (n = 12) and 18.9 ± 2.4 after (n = 11). Interobserver agreement rates increased significantly from 59.7% to 76.5% and the interobserver reliability coefficient (weighted κ) from 0.72 to 0.85 after our training program was implemented. The changes were significantly greater in experienced intensivists than in less experienced residents, indicating that more experienced physicians profited to a greater degree from our training program. Conclusion: Interobserver variability in APACHE II scoring decreases markedly when strict guidelines and a regular training program are implemented, particularly among more experienced physicians. However, in our study a degree of variability (10-15%) persisted even in experienced intensivists with similar training, experience, and background, suggesting that a degree of variability is inherent in APACHE II scoring