Short summary

We aim to investigate if the proportion of correctly diagnosed patients at the time 4 hours after arrival to the Emergency Department (ED) increases when patients are diagnosed with standard diagnostics and focused ultrasonography examination (f-US) of the heart and lungs compared to standard diagnostics alone when the study is undertaken as a multicenter study.

The study group will comprise patients admitted to Danish Emergency Departments with symptoms of respiratory problems.

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Rationale

Patients arriving to the Emergency Department with acute symptoms of respiratory problems are a diagnostic challenge. Their symptoms can be very similar and at times life threatening. The respiratory problems can be due to many different pathological conditions in various organs. But despite the similarity of symptoms many of these pathological conditions require different specific treatments.  The assessment of a fast and correct diagnosis is therefore of high importance in these patients where a correct and instant treatment can be lifesaving.

In 2014 Lancet Respiratory Medicine published an article written by Laursen et al. They presented at Danish study that showed that by using a focused ultra sonographic examination as a complementary tool to the regular diagnostic assessment of patients with respiratory symptoms they increased not only the percentage of patients receiving a correct diagnosis but also the percentage of patients receiving correct treatment within 4 hours after admittance to the Emergency Department. The study advocates for the implementation of focused ultra sonographic examination as a complementary tool to the regular diagnostic tools in the Emergency Departments in Denmark.

The study was performed at an emergency department at a Danish university hospital. The investigator, C. B. Laursen, who prior to this study had performed a vast amount of ultra sonographic examinations, executed all ultra sonographic examinations himself. This has led to critique of the design as well as to the results of the study. The critique primarily focuses on the fact that the results come from a single physician who was, at the time of inclusion, very competent at ultra sonographic examinations. Moreover the study is criticized for being a single center study. The conclusion of the critique is therefore that the results are not directly transferrable to the Danish emergency departments and their physicians in general.

Several studies have investigated the diagnostic accuracy of ultra sonographic examinations within specific respiratory and cardiovascular diseases. Many of these studies have found a great diagnostic accuracy - several studies even proved an even greater diagnostic accuracy with ultrasonography than with a plain chest X-ray.

Ultrasonography is a fast, non-invasive, free of radiation and mobile method of investigation, the ultra sonographic examination is without side effects and has the advantage of an immediate answer and opportunity of a repeated bedside examination. Internationally the use of ultrasonography is studied and used primarily on critically ill patients at intensive care units, emergency departments and in several medical specialties.

Despite the above-mentioned ultrasonography on patients with symptoms of respiratory problems is not an integrated part of the clinical practice in the Danish emergency departments.

It is therefore necessary to study if the significant difference in diagnostic accuracy found in the study of Laursen et al. can be reproduced accommodating some of the points of criticism.

Consequently this study is an expansion of the study of Laursen et al. It will be executed as a multicenter study in several Danish emergency departments. The ultra sonographic examination will be performed and interpreted by the medical physicians who already work at the emergency departments.

Our aim with this study is therefore to investigate if the proportion of correctly diagnosed patients 4 hours after arrival to the Emergency Department (ED) increases when patients are diagnosed with standard diagnostics and focused ultrasonography examination (f-US) of the heart and lungs compared to standard diagnostics alone when the study is undertaken as a multicenter study.

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Description of the cohort

The study group consists of patients arriving to the internal medicine emergency department with difficulties of respiration. These patients are further screened for participation using the in- and exclusion criteria:

• The patient is at least 18 years old.
• The patient has acutely arrived to the Emergency Department.
• The patient presents with at least one of the following symptoms:
• Cough
• Dyspnea
• Chest pain
• Respiration frequency > 20 breaths/minute
• Peripheral arterial saturation < 95%
• Written informed consent obtained from habile patient 

Data and biological material

We collect data on:

1. The patient's former medical history and medical treatment upon admission at the Emergency Department
2. Ultrasonography findings
3. Tentative diagnoses made by the attending physician at admission as well as 4 hours after admission at the ED
4. Prescribed treatment and further diagnostic examinations ordered 4 hours after admission.

Once the patient is discharged from hospital we will make a blinded audit of the medical patient journal in which we determine and register the final diagnosis.  The ultrasonography findings will be included in the assessment of the final diagnosis. Finally we will collect data on the patient flow in and out of the Emergency Department.

Collaborating researchers and departments

Research Unit at Surgical Department A, Svendborg Hospital

• PhD-student and Projetc Manager Minna Riishede, MD
• Professor and Main Supervisor Gunnar Baatrup

Research Unit at the Department of Clinical Research, Svendborg Hospital

• Clinical Associate Professor and Co-supervisor Lars Stubbe Teglbjærg, MD, PhD, MiAH

Emergency Department, Odense University Hospital

• Co-supervisor: Christian Borbjerg Laursen MD, PhD
• Clinical Associate Professor and Collaborator Annmarie Touborg Lassen, MD

Participating centers: Emergency departments at the following hospitals will be participating: OUH, OUH-Svendborg, Esbjerg, Aabenraa, Viborg, Aalborg, Koege, Hvidovre