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Siner JM. Tele-Critical Care Support Outside the Intensive Care Unit. Crit Care Clin 2024; 40:599-608. [PMID: 38796230 DOI: 10.1016/j.ccc.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.
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Affiliation(s)
- Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA.
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2
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Carvey MMT, Omidvar AA, Wan EE, Hynes AM, Lentz SA. Effectiveness of the Introduction to Critical Care in Emergency Medicine Curriculum's Implementation Among Trainees Interested in Intensive Care. J Emerg Med 2024; 67:e80-e88. [PMID: 38806349 DOI: 10.1016/j.jemermed.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/11/2024] [Accepted: 03/06/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Emergency physicians and trainees provide the initial care for critically ill patients. In times of emergency department boarding, this care may extend beyond the first few hours. To meet the needs of this population, a standardized novel critical care curriculum targeting third- and fourth-year medical students was developed. OBJECTIVES We hypothesized that the institution of such a curriculum is feasible and will provide an increased understanding of the underlying critical care principles within this learner population. METHODS We developed a 2-month-long critical care curriculum (February-April) and carried out the course twice from 2022-2023. Our pilot study deployed this curriculum to medical students interested in critical care through the American Academy of Emergency Medicine/Resident and Student Association. The primary outcome included was the overall composite score comparison of the pre- and post-course evaluations, with a higher score indicating that the student improved their comprehension. Secondary outcomes included the individual factors of the pre- and post-course surveys. RESULTS Fifty-one trainees completed the pilot course, including 11/51 (21.6%) third-year medical students and 40/51 (78.4%) fourth-year medical students. Overall, 39 had "no experience" in critical care and 12 indicated that they had "previous experience." The students' baseline pre-course from the pooled 2022 and 2023 Introduction to Critical Care in Emergency Medicine (ICCEM) curriculum data was 3 (interquartile range 4-3) and their post-course score was 9 (interquartile range 9-9), p-value 0.015 for the 51/54 students who completed the course. CONCLUSIONS The novel curriculum was found to be effective during its implementation in third- and fourth-year medical students. As such, it indicated that a critical care fundamentals course improves confidence in these topics for students with and without prior experience. Further work is necessary to understand the generalizability and knowledge retention of the proposed pilot curriculum.
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Affiliation(s)
- Matthew M T Carvey
- Department of Emergency Medicine, MetroHealth/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ava A Omidvar
- St. George's University, School of Medicine, St. George, Grenada
| | - Elias E Wan
- Department of Surgery, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Allyson M Hynes
- Department of Emergency Medicine; Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Skyler A Lentz
- Department of Emergency Medicine and Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
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3
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Cornelius AP. Sepsis in Brazilian emergency departments. Intern Emerg Med 2024:10.1007/s11739-024-03680-x. [PMID: 38900238 DOI: 10.1007/s11739-024-03680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Angela Pettit Cornelius
- Office of the Medical Director Metropolitan Area EMS Authority, Fort Worth, TX, USA.
- John Peter Smith Hospital Fort Worth Emergency Medicine Residency, 1500 South Main St, Fort Worth, TX, 76104, USA.
- Oschner Louisiana State University Health, Shreveport, LA, USA.
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4
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Barskaya A, Abrukin L, McStay C. Rearranging the furniture: A blueprint for reappropriating fixed resources to create an emergency department resuscitative care unit. J Am Coll Emerg Physicians Open 2024; 5:e13211. [PMID: 38841296 PMCID: PMC11150082 DOI: 10.1002/emp2.13211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 06/07/2024] Open
Abstract
Emergency department (ED) care teams face challenges in providing timely, high-quality care to critically ill patients because of competing patient care priorities and a multitude of system strains, including patient boarding. Patients who are boarding in the ED experience increased morbidity and mortality, and this is particularly true for those who are critically ill. Geography-based models for critical care delivery in the ED range from resuscitation bays to full-fledged ED intensive care units. Studies have shown that such models can improve patient survival without affecting cost. Here, we describe how we reappropriated limited fixed resources to create a critical care resuscitation unit in a busy, urban, academic ED. Our objective is to provide a blueprint for similar models, paying particular attention to operations, clinical care, education, and financial stability.
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Affiliation(s)
- Angela Barskaya
- Department of Emergency MedicineColumbia UniversityNew YorkNew YorkUSA
- Division of PulmonaryAllergy and Critical Care MedicineDepartment of MedicineColumbia UniversityNew YorkNew YorkUSA
| | - Liliya Abrukin
- Department of Emergency MedicineColumbia UniversityNew YorkNew YorkUSA
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5
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Baymon DE, Shappell E, Park YS, Aaronson E, Egan DJ, Raja AS, Yun BJ. Measuring Emergency Department Workload Perception Using Electronic Medical Record Measures of Patient Volume and Acuity. J Emerg Med 2024; 66:e374-e380. [PMID: 38423864 DOI: 10.1016/j.jemermed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 09/18/2023] [Accepted: 10/01/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Workload in the emergency department (ED) fluctuates and there is no established model for measurement of clinician-level ED workload. OBJECTIVE The aim of this study was to measure perceived ED workload and assess the relationship between perceived workload and objective measures of workload from the electronic medical record (EMR). METHODS This study was conducted at a tertiary care, academic ED from July 1, 2020 through April 13, 2021. Attending workload perceptions were collected using a 5-point scale in three care areas with variable acuity. We collected eight EMR measures thought to correlate with perceived workload. EMR values were compared across areas of the department using ANOVA and correlated with attending workload ratings using linear regression. RESULTS We collected 315 unique workload ratings, which were normally distributed. For the entire department, there was a weak positive correlation between reported workload perception and mean percentage of inpatient admissions (r = 0.23; p < 0.001), intensive care unit admissions (r = 0.2; p < 0.001), patient arrivals per shift (r = 0.14; p = 0.017), critical care billed visits (r = 0.22; p < 0.001), cardiopulmonary resuscitation code activations (r = 0.2; p < 0.001), and level 5 visits (r = 0.13; p = 0.02). There was weak negative correlation for ED discharges (r = -0.23; p < 0.001). Several correlations were stronger in individual care areas, including percent admissions in the lowest-acuity area (r = 0.43; p = 0.033) and patient arrivals in the highest-acuity area (r = 0.44; p < .01). No significant correlation was found in any area for observation admissions or trauma activations. CONCLUSIONS In this study, EMR measures of workload were not closely correlated with ED attending physician workload perception. Future study should examine additional factors contributing to physician workload outside of the EMR.
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Affiliation(s)
- DaMarcus E Baymon
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Eric Shappell
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Yoon Soo Park
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Aaronson
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel J Egan
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ali S Raja
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Brian J Yun
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
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6
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Zahran TE, Al Hassan S, Al Karaki V, Hammoud L, Helou CE, Khalifeh M, Al Hariri M, Tamim H, Majzoub IE. Outcomes of critically ill COVID-19 patients boarding in the emergency department of a tertiary care center in a developing country: a retrospective cohort study. Int J Emerg Med 2023; 16:73. [PMID: 37833683 PMCID: PMC10576402 DOI: 10.1186/s12245-023-00551-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Boarding of critically ill patients in the emergency department (ED) has long been known to compromise patient care and affect outcomes. During the COVID-19 pandemic, multiple hospitals worldwide experienced overcrowded emergency rooms. Large influx of patients outnumbered hospital beds and required prolonged length of stay (LOS) in the ED. Our aim was to assess the ED LOS effect on mortality and morbidity, in addition to the predictors of in-hospital mortality, intubation, and complications of critically ill COVID-19 ED boarder patients. METHODS This was a retrospective cohort study, investigating 145 COVID-19-positive adult patients who were critically ill, required intensive care unit (ICU), and boarded in the ED of a tertiary care center in Lebanon. Data on patients who boarded in the emergency from January 1, 2020, till January 31, 2021, was gathered and studied. RESULTS Overall, 66% of patients died, 60% required intubation, and 88% developed complications. Multiple risk factors were associated with mortality naming age above 65 years, vasopressor use, severe COVID pneumonia findings on CT chest, chemotherapy treatment in the previous year, cardiovascular diseases, chronic kidney diseases, prolonged ED LOS, and low SaO2 < 95% on triage. In addition, our study showed that staying long hours in the ED increased the risk of developing complications. CONCLUSION To conclude, all efforts need to be drawn to re-establish mitigation strategies and models of critical care delivery in the ED to alleviate the burden of critical boarders during pandemics, thus decreasing morbidity and mortality rates. Lessons from this pandemic should raise concern for complications seen in ED ICU boarders and allow the promotion of health measures optimizing resource allocation in future pandemic crises.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Sally Al Hassan
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Victoria Al Karaki
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lina Hammoud
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Christelle El Helou
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Malak Khalifeh
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Moustafa Al Hariri
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- QU Health, Qatar University, Doha, Qatar
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Imad El Majzoub
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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7
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Tolentino AP, Gaus KS, Gao Y, Chronowski KJ, Brice JH, Quackenbush EB. Transition of care from the emergency department to skilled nursing facility: Retrospective case-control study. J Am Coll Emerg Physicians Open 2023; 4:e13022. [PMID: 37662441 PMCID: PMC10472214 DOI: 10.1002/emp2.13022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 09/05/2023] Open
Abstract
Objective The primary objective of this study is to describe associations between emergency department (ED)-to-skilled nursing facility (SNF) transition and ED length-of-stay (LOS). The secondary objective is to explore how social determinants of health (SDOH) influence ED-to-SNF transition visit parameters. In 2020, The Centers for Medicare & Medicaid Services issued the "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers" eliminating the requirement of a 3-day qualifying hospital stay before SNF placement. The waiver allowed ED patients to be transitioned directly to an SNF from the ED. Methods We conducted a descriptive retrospective case-control study of adult patients who sought care in the University of North Carolina Hospitals (UNCH) ED between March 1, 2020, and March 1, 2022, lived in a non-SNF residence before their ED visit, and were transitioned directly to an SNF from the ED (n 1 = 27), compared with a group seen in the ED and admitted to hospital for SNF placement (n 2 = 54). Results The ED-to-SNF group experienced a significantly longer ED LOS compared to the ED-to-Inpatient-to-SNF group: 72.8 hours (95% confidence interval [CI], 59.2-86.4) compared to 14.5 hours (95% CI, 12.1-16.9). We found no significant differences in SDOH between the ED-to-SNF group and the ED-to-Inpatient-to-SNF group. Conclusion Patients who transition from the ED to an SNF experience long ED stays that may adversely affect health and well-being. Transitioning directly from the ED to an SNF may contribute to ED boarding and overcrowding.
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Affiliation(s)
- Alec P. Tolentino
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kelli S. Gaus
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina Chapel HillChapel HillNorth CarolinaUSA
| | - Yingqiu Gao
- School of NursingUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Kevin J Chronowski
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jane Helen Brice
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Eugenia B. Quackenbush
- Department of Emergency MedicineSchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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8
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Boulitsakis Logothetis S, Green D, Holland M, Al Moubayed N. Predicting acute clinical deterioration with interpretable machine learning to support emergency care decision making. Sci Rep 2023; 13:13563. [PMID: 37604974 PMCID: PMC10442440 DOI: 10.1038/s41598-023-40661-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 08/16/2023] [Indexed: 08/23/2023] Open
Abstract
The emergency department (ED) is a fast-paced environment responsible for large volumes of patients with varied disease acuity. Operational pressures on EDs are increasing, which creates the imperative to efficiently identify patients at imminent risk of acute deterioration. The aim of this study is to systematically compare the performance of machine learning algorithms based on logistic regression, gradient boosted decision trees, and support vector machines for predicting imminent clinical deterioration for patients based on cross-sectional patient data extracted from electronic patient records (EPR) at the point of entry to the hospital. We apply state-of-the-art machine learning methods to predict early patient deterioration, based on their first recorded vital signs, observations, laboratory results, and other predictors documented in the EPR. Clinical deterioration in this study is measured by in-hospital mortality and/or admission to critical care. We build on prior work by incorporating interpretable machine learning and fairness-aware modelling, and use a dataset comprising 118, 886 unplanned admissions to Salford Royal Hospital, UK, to systematically compare model variations for predicting mortality and critical care utilisation within 24 hours of admission. We compare model performance to the National Early Warning Score 2 (NEWS2) and yield up to a 0.366 increase in average precision, up to a [Formula: see text] reduction in daily alert rate, and a median 0.599 reduction in differential bias amplification across the protected demographics of age and sex. We use Shapely Additive exPlanations to justify the models' outputs, verify that the captured data associations align with domain knowledge, and pair predictions with the causal context of each patient's most influential characteristics. Introducing our modelling to clinical practice has the potential to reduce alert fatigue and identify high-risk patients with a lower NEWS2 that might be missed currently, but further work is needed to trial the models in clinical practice. We encourage future research to follow a systematised approach to data-driven risk modelling to obtain clinically applicable support tools.
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Affiliation(s)
| | - Darren Green
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, University of Bolton, Bolton, UK
| | - Noura Al Moubayed
- Department of Computer Science, University of Durham, Durham, UK.
- Evergreen Life Ltd, Manchester, UK.
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9
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Wu L, Chen X, Khalemsky A, Li D, Zoubeidi T, Lauque D, Alsabri M, Boudi Z, Kumar VA, Paxton J, Tsilimingras D, Kurland L, Schwartz D, Hachimi-Idrissi S, Camargo CA, Liu SW, Savioli G, Intas G, Soni KD, Junhasavasdikul D, Cabello JJT, Rathlev NK, Tazarourte K, Slagman A, Christ M, Singer AJ, Lang E, Ricevuti G, Li X, Liang H, Grossman SA, Bellou A. The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study. J Clin Med 2023; 12:4750. [PMID: 37510865 PMCID: PMC10381297 DOI: 10.3390/jcm12144750] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/28/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h <t≤ 8 h (1.84%). Special attention should be given to patients admitted after a short stay in the ED and a long BT, and new concepts of ED care processes including specific areas and teams dedicated to older patients care could be proposed to policymakers.
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Affiliation(s)
- Lijuan Wu
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Medical Research Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xuanhui Chen
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Anna Khalemsky
- Management Department, Hadassah Academic College, Jerusalem 91010, Israel
| | - Deyang Li
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Taoufik Zoubeidi
- Department of Statistics, College of Business and Economics, UAE University, Al Ain 1555, United Arab Emirates
| | - Dominique Lauque
- Department of Emergency of Medicine, Beth Israel Deaconess Medical Center, Teaching Hospital of Harvard Medical School, Boston, MA 02115, USA
- Department of Emergency Medicine, Purpan Hospital and Toulouse III University, 31300 Toulouse, France
| | - Mohammed Alsabri
- Department of Emergency of Medicine, Beth Israel Deaconess Medical Center, Teaching Hospital of Harvard Medical School, Boston, MA 02115, USA
- Department of Pediatrics, Brookdale University Hospital and Medical Center, 1 Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates
- Global Network on Emergency Medicine, Brookline, MA 02446, USA
| | - Vijaya Arun Kumar
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - James Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Dionyssios Tsilimingras
- Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Lisa Kurland
- Department of Medical Sciences, Örebro University, 70182 Örebro, Sweden
| | - David Schwartz
- Information Systems Department, Graduate School of Business Administration, Bar-Ilan University, Ramat-Gan 529002, Israel
| | - Said Hachimi-Idrissi
- Global Network on Emergency Medicine, Brookline, MA 02446, USA
- Department of Emergency Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Gabriele Savioli
- Emergency Department, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Geroge Intas
- Department of Critical Care, General Hospital of Nikaia Agios Panteleimon, 18454 Athens, Greece
| | - Kapil Dev Soni
- Jai Prakash Narayan Apex Trauma Center, Ring Road, New Delhi 110029, India
| | - Detajin Junhasavasdikul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | | | - Niels K Rathlev
- Department of Emergency Medicine, University of Massachusetts Medical School, Baystate, Springfield, MA 01199, USA
| | - Karim Tazarourte
- Department of Health Quality, University Hospital, Hospices Civils, 69002 Lyon, France
- Department of Emergency Medicine, University Hospital, Hospices Civils, 69002 Lyon, France
| | - Anna Slagman
- Division of Emergency and Acute Medicine, Campus Virchow Klinikum and Charité Campus Mitte, Charité Universitätsmedizin, 10117 Berlin, Germany
| | - Michael Christ
- Department of Emergency Medicine, 6000 Lucerne, Switzerland
| | - Adam J Singer
- Department of Emergency Medicine, Renaissance Scholl of Medicine at Stony Brook University, Stony Brook, NY 11794, USA
| | - Eddy Lang
- Department of Emergency Medicine, Emergency Medicine Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, AB T2N 1N4, Canada
| | - Giovanni Ricevuti
- Emergency Medicine, School of Pharmacy, University of Pavia, 27100 Pavia, Italy
| | - Xin Li
- Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huiying Liang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Shamai A Grossman
- Department of Emergency of Medicine, Beth Israel Deaconess Medical Center, Teaching Hospital of Harvard Medical School, Boston, MA 02115, USA
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency of Medicine, Beth Israel Deaconess Medical Center, Teaching Hospital of Harvard Medical School, Boston, MA 02115, USA
- Global Network on Emergency Medicine, Brookline, MA 02446, USA
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
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10
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Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010032. [PMID: 36614835 PMCID: PMC9821325 DOI: 10.3390/jcm12010032] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.
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11
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Pelaez CA, Jackson JA, Hamilton MY, Omerza CR, Capella JM, Trump MW. High flow nasal cannula outside the ICU provides optimal care and maximizes hospital resources for patients with multiple rib fractures. Injury 2022; 53:2967-2973. [PMID: 35667887 DOI: 10.1016/j.injury.2022.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND High flow nasal cannula (HFNC) use reduces work of breathing and improves oxygenation for patients with hypoxemic respiratory failure. Limited prior work has explored protocolized use of HFNC for trauma patients outside the Intensive Care Unit (ICU). The purpose of this study is to describe and evaluate use of HFNC for patients with rib fractures when therapy was standard of care on all floors of the hospital. METHODS In 2018, the study hospital expanded use of HFNC (AIRVO; Fisher Paykel, Auckland, NZ) to all floors of the hospital, making it available in the ICU, Emergency Department (ED), and on general inpatient floors. The study group included adult patients with three or more rib fractures who received HFNC at any location in the hospital (Phase 2: January 2018-December 2019). The study group was compared to a historical control group when HFNC was available only in the ICU (Phase 1: March 2013-July 2015). Patients were excluded from the study if they received invasive mechanical ventilation prior to HFNC. Primary outcomes were mechanical ventilation rates, ICU days, length of hospitalization, and mortality. RESULTS During the study period, 63 patients received HFNC, with 35% of patients (n = 22) receiving the duration of therapy outside the ICU. When compared to the control group (N = 63), there were no significant differences in total hospital days (9 vs. 9, p=.64), mechanical ventilation (19% vs. 13%, p=.47), or mortality (3% vs. 5%, p = 1.00). Twenty-seven percent of patients (n = 17) in the study group avoided the ICU during hospitalization. CONCLUSIONS Findings suggest that HFNC therapy can be safely initiated and managed on all hospital floors for patients with multiple rib fractures. Making the therapy available outside the ICU may reduce healthcare resource use without adversely affecting patient outcomes.
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Affiliation(s)
- Carlos A Pelaez
- Trauma Surgery, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America; Trauma Services, UnityPoint Health, Des Moines, IA, United States of America.
| | - Julie A Jackson
- Respiratory Therapy, UnityPoint Health, 1200 Pleasant St, Des Moines, IA, United States of America
| | - Mikayla Y Hamilton
- Doctor of Osteopathic Medicine Program, Des Moines University, 3200 Grand Ave, Des Moines, IA, United States of America
| | - Christopher R Omerza
- General Surgery Residency Program, 1415 Woodland Ave, UnityPoint Health, Des Moines, IA, United States of America
| | - Jeannette M Capella
- Trauma Surgery, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America; Trauma Services, UnityPoint Health, Des Moines, IA, United States of America
| | - Matthew W Trump
- Pulmonary and Critical Care Medicine, The Iowa Clinic, 1200 Pleasant St, Des Moines, IA, United States of America
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Ward J, Noel C. Basic Modes of Mechanical Ventilation. Emerg Med Clin North Am 2022; 40:473-488. [DOI: 10.1016/j.emc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4083494. [PMID: 35146022 PMCID: PMC8822318 DOI: 10.1155/2022/4083494] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/27/2022] [Indexed: 01/09/2023]
Abstract
Delayed admission of patients to the intensive care unit (ICU) is increasing worldwide and can be followed by adverse outcomes when critical care treatment is not provided timely. This systematic review and meta-analysis appraised and synthesized the published literature about the association between delayed ICU admission and mortality of adult patients. Articles published from inception up to August 2021 in English-language, peer-reviewed journals indexed in CINAHL, PubMed, Scopus, Cochrane Library, and Web of Science were searched by using key terms. Delayed ICU admission constituted the intervention, while mortality for any predefined time period was the outcome. Risk for bias was evaluated with the Newcastle-Ottawa Scale and additional criteria. Study findings were synthesized qualitatively, while the odds ratios (ORs) for mortality with 95% confidence intervals (CIs) were combined quantitatively. Thirty-four observational studies met inclusion criteria. Risk for bias was low in most studies. Unadjusted mortality was reported in 33 studies and was significantly higher in the delayed ICU admission group in 23 studies. Adjusted mortality was reported in 18 studies, and delayed ICU admission was independently associated with significantly higher mortality in 13 studies. Overall, pooled OR for mortality in case of delayed ICU admission was 1.61 (95% CI 1.44-1.81). Interstudy heterogeneity was high (I2 = 66.96%). According to subgroup analysis, OR for mortality was remarkably higher in postoperative patients (OR, 2.44, 95% CI 1.49-4.01). These findings indicate that delayed ICU admission is significantly associated with mortality of critically ill adults and highlight the importance of providing timely critical care in non-ICU settings.
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15
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Puls HA, Haas NL, Cranford JA, Medlin RP, Bassin BS. Emergency department length of stay and outcomes of emergency department-based intensive care unit patients. J Am Coll Emerg Physicians Open 2022; 3:e12684. [PMID: 35229083 PMCID: PMC8861538 DOI: 10.1002/emp2.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED-based intensive care units (ED-ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED-ICU on patient outcomes. METHODS We retrospectively analyzed adult ED patients managed in the ED-ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48-hour mortality, and hospital mortality. Multivariable analyses' covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). RESULTS We included 5859 ED visits with subsequent care in the ED-ICU. Median age, CCI, eSAPS3, ED LOS, and ED-ICU LOS were 62 years (interquartile range [IQR], 48-73 years), 5 (IQR, 2-8), 46 (IQR, 36-56), 3.6 hours (IQR, 2.5-5.3 hours), and 8.5 hours (IQR, 5.3-13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = -3.4; 95% confidence interval [CI], -5.9 to -1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84-0.88), 48-hour mortality (OR, 0.89; 95% CI, 0.82-0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85-0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88-0.93), but no associations with other outcomes. CONCLUSIONS We observed no significant associations between ED LOS before ED-ICU transfer and worsened outcomes, suggesting an ED-ICU may mitigate the risks of ED boarding of patients who are critically ill.
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Affiliation(s)
- Henrique A. Puls
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Nathan L. Haas
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Division of Critical Care, Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Michigan Center for Integrative Research in Critical CareAnn ArborMichiganUSA
| | - James A. Cranford
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Richard P. Medlin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Benjamin S. Bassin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Division of Critical Care, Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Michigan Center for Integrative Research in Critical CareAnn ArborMichiganUSA
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16
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Weiner SG, Salmasian H, Mendu ML. The glaring omission in hospital ranking and quality grading programs: emergency department boarding. Int J Qual Health Care 2021; 33:6444463. [PMID: 34849973 DOI: 10.1093/intqhc/mzab156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/31/2021] [Accepted: 11/26/2021] [Indexed: 11/15/2022] Open
Abstract
Hospitals in the United States are assessed and ranked by several agencies and services, including U.S. News & World Report. Frequently, though, the key hospital throughput metric of inpatient boarding time in the emergency department (ED) is not considered when ranking hospitals. As a result, there is a discordance in which highly ranking hospitals may be poor performers in boarding of patients, a practice with known adverse safety effects. This article outlines the rationale for considering ED boarding in hospital ranking and quality assessments.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Division of Health Policy and Public Health, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Hojjat Salmasian
- Department of Quality and Safety, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mallika L Mendu
- Department of Medicine, Nephrology Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Intensive Care Unit prioritization: The impact of ICU bed availability on mortality in critically ill patients who requested ICU admission in court in a Brazilian cohort. J Crit Care 2021; 66:126-131. [PMID: 34544015 DOI: 10.1016/j.jcrc.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE To assess hospital mortality in patients who requested ICU admission in court due to the scarcity of ICU beds in the Brazilian public health system and the consequences of these judicial litigations. MATERIAL AND METHODS Retrospective cohort study that included adult patients from the public health system of the Federal District, Brazil, who claimed ICU admission in court from January 2017 to December 2019. RESULTS Of the 1752 patients, 1031 were admitted to ICU (58.8%). Hospital mortality was 61.1% (1071/1752). Of the requests, 768 (43.8%) were made by patients with priority levels III or IV, resulting in the ICU admission of 33.9% of these patients. Denial of ICU admission (p < 0.001) increased mortality. ICU admission reduced hospital mortality in patients classified as priority level I (p < 0.001), priority level II (p < 0.001), and priority level III (p < 0.001), but not as priority level IV (p = 0.619). CONCLUSION A large proportion of patients was denied ICU admission and it was associated with an increased mortality. A considerable portion of the ICU-admitted patients were classified as priority level III and IV, impairing the ICU admission of patients with priority level I which are the ones with the greatest benefit from it.
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18
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This Health Care Problem Needs a Collaborative Closing of the Gap. Ann Emerg Med 2021; 77:553-555. [PMID: 33902834 DOI: 10.1016/j.annemergmed.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Indexed: 11/24/2022]
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Barnicle RN, Weingart SD, Bracey A, Gordon DH, Dasgupta NK, Lu C, Tichauer MB, Duncan LJ, Wright BJ. Resuscitation Fellowships Can Close the Gap. Ann Emerg Med 2021; 77:552-553. [PMID: 33902833 DOI: 10.1016/j.annemergmed.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Ryan N Barnicle
- Department of Emergency Medicine, Division of Emergency Critical Care, Stony Brook University Hospital, Stony Brook, NY
| | - Scott D Weingart
- Department of Emergency Medicine, Division of Emergency Critical Care, Stony Brook University Hospital, Stony Brook, NY
| | - Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, NY
| | - David H Gordon
- Critical Care Medicine, University of Maryland Medical Center, Baltimore, MD
| | - Neil K Dasgupta
- Department of Emergency Medicine, Division of Emergency Critical Care, Emergency Critical Care, Nassau University Medical Center, East Meadow, NY
| | - Christina Lu
- Department of Emergency Medicine, Division of Emergency Critical Care, Hartford Hospital, Hartford, CT
| | - Matthew B Tichauer
- Departments of Emergency Medicine and Critical Care, Division of Emergency Critical Care, Hartford Hospital, Hartford, CT
| | - Luke J Duncan
- Division of Emergency Critical Care, Departments of Emergency Medicine and Surgical Critical Care, Albany Medical Center, Albany, NY
| | - Brian J Wright
- Departments of Emergency Medicine and Neurosurgery, Division of Emergency Critical Care, Stony Brook University Hospital, Stony Brook, NY
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Lykins V JD, Kuttab HI, Rourke EM, Hughes MD, Keast EP, Kopec JA, Ward BL, Pettit NN, Ward MA. The effect of delays in second-dose antibiotics on patients with severe sepsis and septic shock. Am J Emerg Med 2021; 47:80-85. [PMID: 33784532 DOI: 10.1016/j.ajem.2021.03.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. METHODS ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. RESULTS In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81-3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95-4.57; 12-h- OR 2.46, 95% CI 1.72-3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06-1.90), and renal failure (OR 2.57, 95% CI 1.50-4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58-1.29) or other outcomes. CONCLUSIONS Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.
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Affiliation(s)
- Joseph D Lykins V
- Department of Emergency Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA 23298, United States
| | - Hani I Kuttab
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States.
| | - Erron M Rourke
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Michelle D Hughes
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Eric P Keast
- Division of Emergency Medicine, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Jason A Kopec
- Division of Emergency Medicine, Carle Foundation Hospital, Urbana, IL 61801, United States
| | - Brooke L Ward
- Department of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Natasha N Pettit
- Department of Pharmacy, University of Chicago, Chicago, IL 60637, United States
| | - Michael A Ward
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States
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Kao CC, Chen YC, Huang HH, Hsu TF, Yen DHT, Fan JS. Prognostic significance of emergency department modified early warning score trend in critical ill elderly patients. Am J Emerg Med 2021; 44:14-19. [PMID: 33571750 DOI: 10.1016/j.ajem.2021.01.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To explore the relationship between trends in emergency department modified early warning score (EDMEWS) and the prognosis of elderly patients admitted to the intensive care unit (ICU). METHODS Consecutive non-traumatic elderly ED patients (≥65 years old) admitted to the ICU between July 2018 and June 2019 were enrolled in this retrospective cohort study. The selected patients had at least 2 separate MEWS during their ED stay. Detailed patient information was retrieved initially from the ICU database of our hospital and then crosschecked with electronic medical recording system to confirm the completeness and correctness of the data. Patients who had do-not-resuscitate order and those with incomplete data of EDMEWS, acute physiology and chronic health evaluation (APACHE) II score, or survival information (7-day and 30-day mortality) were excluded. The trends in EDMEWS were determined using the regression line of multiple MEWS measured during ED stay, in which EDMEWS trend progression was defined as the slope of the regression line > zero. The relationship between EDMEWS trend and prognosis was assessed using univariate and multivariate analyses (multiple logistic regression analysis). RESULTS Of the 1423 selected patients, 499 (35.1%) had worsening 24-h APACHE II score, 110 (7.7%) died within 7 days, and 233 (16.4%) died within 30 days. Factors that were significantly associated with worsening 24-h APACHE II score, 7-day mortality, and 30-day mortality in univariate analysis were selected for inclusion into multiple logistic regression analyses. After adjusting for other covariates, EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality. CONCLUSIONS EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality in elderly ED patients admitted to the ICU. EDMEWS is a simple and useful tool for precisely monitoring patients' ongoing condition and predicting prognosis.
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Affiliation(s)
- Chih-Chun Kao
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - The-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
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