How does this compare to previous work?
This prevalence estimate of
at least 5.2% from majors
and minors is higher than previous ED reports [
1,
3,
5]. The 9% reported by Langlo and colleagues, [
4] like this study, excludes presentations to the minor injuries unit; much lower than the 20.2% reported here. However, previous studies used clinical record review rather than patient self-report; our study showed only two-thirds of study participants had any entry related to breathlessness in the clinical record. Although breathlessness at the time of the decision to present was rated by participants as “severe”, in the ED, this settled to “mild”. Therefore, by the time they were assessed by the clinician, they might have had no visible signs. Breathlessness may be “invisible” unless it is severe enough to be a clinical sign [
16,
17].
Further, previous work noted the primary presenting complaint; in this study a third had “breathing difficulties” noted by the triage nurse, but the “chest pain” noted in others may have taken precedence as a reported primary reason even if they were breathless as well.
The prevalence of breathlessness as a reason to present to the ED is higher than that found for documented reason to attend the family practitioner (at least 5.2%
versus approximately 1%) [
18,
19]. However, if breathlessness was the “reason for encounter”, patients were 2.5 times more likely to be referred urgently to hospital by the family practitioner than those for whom breathlessness was not the “reason for encounter” [
18].
The prevalence of hospital admissions for people attending the ED due to breathlessness was an estimated 7.6% of all admissions; lower than that found in other studies [
5,
8]. This is likely to be an underestimate as patients who were too clinically unstable to complete the survey were excluded; a significant number of these may have had breathlessness, and be more likely to be admitted. In our study people presenting due to breathlessness were twice as likely to be admitted as others presenting to the ED for other reasons. This increased risk is consistent with previous findings [
1,
5,
7,
9].
Most presentations by patients with chronic breathlessness were made by people with non-malignant cardio-respiratory disease. Although this is a single site study, the proportions of presentation by people with cardiorespiratory conditions are similar to the findings from the National Hospital Ambulatory Medical Care Survey and the AANZDEM observational study [
5,
20]. However compared with the prevalence of such diseases in the community served by the hospital ED in this study, these are over-represented in the ED [
21]. In contrast, the survey data regarding presentations by people with cancer was very similar to Quality Outcomes Framework [
21] data relating to cancer in the local community. The reasons for this discrepancy are not clear, but it is interesting to reflect that the multi-disciplinary, cross-setting coordinated approach to the management of chronic non-malignant conditions in the UK has been slower to enter policy [
22‐
24] and service delivery than for cancer care [
25].
Three quarters of those presenting due to breathlessness scored grade 3 or above on the mMRC Dyspnea scale representing levels associated with significant activity limitation and negative consequences for well-being. Optimal care for such people should include quality management for both their underlying medical condition
and their breathlessness, for which there are evidence-based interventions [
26]. Although most participants say they discuss their breathlessness with their family practitioner few said they talked to specialist doctors, nurses or friends and family. It is surprising that few patients mentioned nurses as respiratory nurses, community matrons and long term conditions nurses have a liaison role and would be well-placed to help co-ordinate cross-setting care. Importantly, it identifies the family practitioner as a pivotal health professional with potential to co-ordinate optimal management [
16]. In keeping with the pivotal role of the family doctor, two thirds of presentations to the ED occurred at times when their regular healthcare professional (family doctor, specialist nurse or physiotherapist) was not available. Some out-of-hours presentations such as those driven mainly by anxiety rather than serious exacerbation of the underlying pathology might be reduced if individual management plans included breathing crisis management, and training was given to both the patient and carer [
10]. Healthcare professionals in the community available outside usual working hours also need to be skilled in the recognition and management of those with acute-on-chronic breathlessness episodes which could be managed in the community.
Implications for clinical practice
It is important that ED clinicians assess a patient’s breathlessness routinely. Breathlessness is a stronger predictor of five year survival than tests of pulmonary function [
27]. It is also associated with ED re-attendance and hospital admission and can therefore identify a group of people at higher risk for repeat presentation/admission. Knowledge of patients’ self-rated breathlessness can enable optimal care and symptom management; routine assessment of breathlessness in hospital is feasible [
28]. Routine assessment of breathlessness in the ED may enable better management of patients both in the hospital and post discharge. Additionally approximately a third of presentations due to breathlessness resulted in discharge home from the ED. Some of these individuals may be those where anxiety and/or lack of self-management knowledge or skills is a significant factor. This issue can be challenging to discern during an episode of acute-on-chronic breathlessness, and may be better assessed in the community or clinic by the primary healthcare team. For these people presentation might have been avoided with optimised breathlessness care in the community and co-ordination of care between primary and secondary care [
11].
Strengths and limitations of this study
This survey was consecutive, including 24 h days and weekends, thus minimizing selection bias. There was a very high response rate (90%) and minimal missing data giving confidence that the sample was representative of those eligible to participate. However, the survey was administered during spring and a seasonal variation has been found by others, with the highest prevalence of breathlessness-related presentations during winter [
5]. It was also conducted in a single site, however although there will inevitably be findings specific to this site, there are sufficient similarities to other published work to support their relevance. This study was performed in a city in the northeast of England which has a higher prevalence of COPD than the rest of England [
21]. Owing to the wide variation in prevalence of these conditions nationally the study would need to be repeated before assuming generalizability. Furthermore, primary care is under-resourced in the study area; in the lowest quintile for number of family doctors per 100,000 of the population [
29] and this may influence the number of presentations to the ED.
The survey was in English with no resources available for translation and therefore some patients may not have been able to take part. Only patients presenting to majors were surveyed and therefore a few patients who presented to minors but who were not re-directed to majors may have been missed. However, having used this method, we are able to comment on the impact on ambulance services. Further, patients who were too sick, or did not have mental capacity to complete the survey were excluded, and this group is likely to include people with breathlessness and those more likely to be admitted to hospital. Thus, if anything, our findings will be an underestimate of the total burden of acute-on-chronic breathlessness in the ED. Only 72% of the potential participants gave consent for clinical record review, which may have caused some selection bias in the clinical record data.
This study cannot determine whether presentation to the ED was appropriate or potentially avoidable. The assumption cannot be made that home discharge within a few hours equates to a preventable presentation. However, given other work to indicate that case-based complex interventions can reduce unscheduled hospital presentation for a variety of chronic medical conditions, [
30] then further delineation and understanding of the needs of this patient group warrants further investigation.