A simple prognostic score predicts one-year mortality of alert and calm emergency department patients: A prospective two-center observational study

Predictive value and interrater reliability of mental status and mobility assessment in the emergency department

AIM

To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team.

METHOD

Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team.

RESULTS

4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility.

CONCLUSION

Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.

Development and inter-rater reliability of a simple prehospital mobility score for use in emergency patients

BACKGROUND

Mobility assessment enhances the ability of vital sign-based early warning scores to predict risk. Currently mobility is not routinely assessed in a standardized manner in Denmark during the ambulance transfer of unselected emergency patients. The aim of this study was to develop and test the inter-rater reliability of a simple prehospital mobility score for pre-hospital use in ambulances and to test its inter-rater reliability.

METHOD

Following a pilot study, we developed a 4-level prehospital mobility score based of the question"How much help did the patient need to be mobilized to the ambulance trolley". Possible scores were no-, a little-, moderate-, and a lot of help. A cross-sectional study of inter-rater agreement among ambulance personnel was then carried out. Paramedics on ambulance runs in the North- and Central Denmark Region, as well as The Fareoe Islands, were included as a convenience sample between July 2020-May 2021. The simple prehospital mobility score was tested, both by the paramedics in the ambulance and by an additional observer. The study outcomes were inter-rater agreements by weighted kappa between the paramedics and between observers and paramedics.

RESULTS

We included 251 mobility assessments where the patient mobility was scored. Paramedics agreed on the mobility score for 202 patients (80,5%). For 47 (18.7%), there was a deviation of one between scores, in two (< 1%) there was a deviation of two and none had a deviation of three (Table 1). Inter-rater agreement between paramedics in all three regions showed a kappa-coefficient of 0.84 (CI 95%: 0.79;0.88). Between observers and paramedics in North Denmark Region and Faroe Islands the kappa-coefficient was 0.82 (CI 95%: 0.77;0.86).

CONCLUSION

We developed a simple prehospital mobility score, which was feasible in a prehospital setting and with a high inter-rater agreement between paramedics and observers.

A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study

BACKGROUND

Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity patients should divert care and resources to more urgent cases.

AIM

The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients' acuity.

DESIGN

This is a prospective observational study of consecutive patients presenting to a Swiss academic ED.

METHODS

Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%.

RESULTS

The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score.

CONCLUSION

Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.

Recognition of Critically Ill Patients by Acute Health Care Providers: A Multicenter Observational Study

OBJECTIVES

Although the Modified Early Warning Score (MEWS) is increasingly being used in the acute care chain to recognize disease severity, its superiority compared with clinical gestalt remains unproven. Therefore, the aim of this study was to compare the accuracy of medical caregivers and MEWS in predicting the development of critical illness.

DESIGN

This was a multicenter observational prospective study.

SETTING

It was performed in a level-1 trauma center with two different sites and emergency departments (EDs) with a combined capacity of about 50.000 patients annually.

PATIENTS

It included all adult patients presented to the ED by Emergency Medical Services (EMS).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

For all patients, the acute caregivers were asked several standardized questions regarding clinical predicted outcome (clinical gestalt), and the MEWS was calculated. The primary outcome was the occurrence of critical illness, defined as ICU admission, serious adverse events, and mortality within 72 hours. The sensitivity, specificity, and discriminative power of both clinical gestalt and MEWS for the occurrence of critical illness were calculated as the area under the receiver operating characteristic curve (AUROC). Among the total of 800 included patients, 113 patients (14.1%) suffered from critical illness. The specificity for predicting three-day critical illness for all caregivers (for EMS nurses, ED nurses, and physicians) was 93.2%; 97.3%, and 96.8%, respectively, and was significantly (p < 0.01) better than an MEWS score of 3 or higher (70.4%). The sensitivity was significantly lower for EMS and ED nurses, but not significantly different for physicians compared with MEWS. The AUROCs for prediction of 3-day critical illness by both the ED nurses (AUROC = 0.809) and the physicians (AUROC = 0.848) were significantly higher (p = 0.032 and p = 0.010, respectively) compared with MEWS (AUROC = 0.731).

CONCLUSIONS

For patients admitted to the ED by EMS, medical professionals can predict the development of critical illness within 3 days significantly better than the MEWS. Although MEWS is able to correctly predict those patients that become critically ill, its use leads to overestimation due to a substantial number of false positives.

Are changes in vital signs, mobility and mental status while in hospital measures of the quality of care?

INTRODUCTION

Little is known of the changes in patients' health condition while in hospital in low-resource settings. The aim of this exploratory study is to examine dependency of patients on hospital admission and discharge in a low-resource sub-Saharan hospital.

METHODS

We carried out a retrospective observational study of changes in the health condition, as reflected by their mental status, mobility and vital signs, of 5,888 consecutive patients between hospital admission and discharge.

RESULTS

Mental status, mobility and vital signs were normal in 25% of patients on hospital admission and 30% of patients at discharge. Although very few patients with normal mental status, mobility and vital signs on admission died in hospital, the condition of 40% of them deteriorated.

CONCLUSION

No comparative data on changes in health condition between hospital admission and discharge have been published. Our proposed health condition categories identify changes that may matter most to patients and should be considered as a standard metric of hospital care.

The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older

Objective

To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI).

Methods

Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS.

Results

In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model.

Conclusion

The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients

BACKGROUND

Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit.

METHODS

Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa.

RESULTS

Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%.

CONCLUSION

In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Assessment of patient mobility improves the risk stratification of triage with the Emergency Severity Index: a prospective cohort study

BACKGROUND AND IMPORTANCE

Formal triage may assign a low acuity to patients at high risk of deterioration and mortality. A patient's mobility can be easily assessed at triage.

OBJECTIVE

To investigate if a simple assessment of mobility at triage can improve the Emergency Severity Index's (ESI) prediction of adverse outcomes.

DESIGN, SETTING AND PARTICIPANTS

Prospective observational study of all patients attending the emergency department (ED) of a single academic hospital in Switzerland over a period of 3 weeks.

OUTCOME MEASURES AND ANALYSIS

Triage clinicians classified participants as having normal or impaired mobility at triage. Impaired mobility was defined as the lack of a stable independent gait, regardless of its cause or duration (e.g. any patient who needed help to walk). The primary outcome was 30-day mortality. We performed a survival analysis stratified by mobility and ESI level. We compared the performance of regression models including the ESI alone or in combination with mobility as predictors of mortality using the Bayesian information criterion (BIC).

MAIN RESULTS

2523 patients were included in the study and 880 (34.9%) had impaired mobility. Patients with impaired mobility had a lower median 30-day survival in ESI levels 1-3. Survival of patients with normal mobility was similar regardless of their ESI level.

CONCLUSION

The assessment of mobility at triage improves the ESI algorithm's risk stratification.

Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings

BACKGROUND

The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error.

AIM

to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients.

METHODS

A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation.

RESULTS

Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS.

CONCLUSION

Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.

COVID-19 Triage and Test Center: Safety, Feasibility, and Outcomes of Low-Threshold Testing

This prospective observational study evaluated the safety and feasibility of a low threshold testing process in a Triage and Test Center (TTC) during the early course of the coronavirus disease 19 (COVID-19) pandemic. In addition, we aimed to identify clinical predictors for a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab result. Patients underwent informal triage, standardized history taking, and physician evaluation, only where indicated. Patients were observed for 30 days. Safety was the primary outcome and was defined as a COVID-19-related 30 day re-presentation rate <5% and mortality rate <1% in patients presenting to the TTC. Feasibility was defined as an overruling of informal triage <5%. Among 4815 presentations, 572 (11.9%) were tested positive for SARS-CoV-2, and 4774 were discharged. Mortality at 30-days was 0.04% (2 patients, one of which related to COVID-19). Fever (OR 2.03 [95% CI 1.70;2.42]), myalgia (OR 1.94 [1.63;2.31]), chills (OR 1.77 [1.44;2.16]), headache (OR 1.61 [1.34;1.94]), cough (OR 1.50 [1.24;1.83]), weakness (OR 1.46 [1.21;1.76]), and confusion (OR 1.39 [1.06;1.80]) were associated with test positivity. Re-presentation rate was 8% overall and 1.4% in COVID-19 related re-presentation (69 of 4774). The overruling rate of informal triage was 1.5%. According to our study, a low-threshold testing process in a TTC appeared to be safe (low re-presentation and low mortality) and is feasible (low overruling of informal triage). A COVID-19 diagnosis based on clinical parameters only does not appear possible.