Respiratory Support of Adults in the Emergency Department : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, [Auckland], New Zealand
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Date
2024-11
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Massey University
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Abstract
Introduction:
Adult emergency department (ED) patients frequently require respiratory support (RS), yet limited research on RS, particularly nasal high-flow (NHF) therapy, is available in this setting. This doctoral research aimed to analyse the nature of ED-based RS and its impact on adult patient outcomes, focusing on NHF therapy. Grounded in an evidence-based practice (EBP) framework, this research proposes to bridge a theory-practice gap and inform NHF clinical decision-making in the ED.
Methodology:
This thesis was informed by a positivist philosophical paradigm and methodology underpinned by an EBP theoretical framework. The research approach was quantitative, the research strategy was non-experimental, the design was multi-method, and the time horizon was cross-sectional, using two methods. The two methods were a systematic review (SR) with meta-analysis (MA) and a point prevalence study (PPS). Each method was conducted in parallel and as per the multi-method design, and the results were integrated to form the thesis findings and answer the research questions.
Results:
In the first method, the SR provided five MAs involving 18 ED RCTs reporting on 1874 participants. A 45% reduction in escalation relative risk (RR) was seen for NHF vs conventional oxygen therapy (COT) (RR 0.55; 95% CI, 0.33 to 0.92; p = 0.02), with no difference in mortality or adverse event risk. For NHF vs non-invasive ventilation (NIV), NHF increased escalation risk by 81% (RR 1.81; 95% CI, 1.19 to 2.75; p < 0.01). Mortality risk was not different for NHF vs NIV.
In the second method, the PPS characterised 76 patients receiving RS from a total of 898 ED-presenting patients. The PPS was underpowered and unable to support its planned inferential analyses. The mean age of the participants was 67.38 years (SD ± 17.4); 52% (n = 40) were male, 48.6% (n = 37) had greater than three comorbidities, and 44% (n = 34) had primary respiratory diagnoses.
By ethnicity, the Indigenous New Zealand Māori were overrepresented in the data (n = 18, 23%). Of those receiving RS, the minority (n = 12, 15.7%) received NHF; however, all these required subsequent hospitalisation. The absolute prevalence of the requirement for escalation of RS was n = 22 (28.9%). The hospitalisation rate was 22% higher, and the hospital length of stay was 42% longer for those requiring RS escalation in the ED. Māori demonstrated a 5.8% higher risk of requiring escalation of care on an absolute scale (n = 6, 33.3%) vs (n = 16, 27.5%), and a 22% increased risk on a relative scale (RR 1.22; 95% CI 0.56 to 2.67; p = 0.60) than non-Māori.
Conclusions:
When the results from the two methods were integrated, the main finding was that nearly a third of those receiving RS required escalation of their RS, with those receiving NHF requiring less escalation than those receiving all other forms of RS combined. These findings align with the meta-analysis of studies for the comparison of NHF compared to COT but not the comparison of NHF compared to NIV.
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Keywords
Emergency Department, respiratory, pulmonary, Hospitals, Emergency services, New Zealand, Respiratory therapy, Oxygen therapy, Nursing, Decision making