Identifying infected emergency department patients admitted to the hospital ward at risk of clinical deterioration and intensive care unit transfer

Antibiotic Guideline Adherence at the Emergency Department: A Descriptive Study from a Country with a Restrictive Antibiotic Policy

BACKGROUND

Denmark has a low level of antimicrobial resistance (AMR). Patients hospitalized with suspected infection often present with unspecific symptoms. This challenges the physician between using narrow-spectrum antibiotics in accordance with guidelines or broad-spectrum antibiotics to compensate for diagnostic uncertainty. The aim of this study was to investigate adherence to a restrictive antibiotic guideline for the most common infection in emergency departments (EDs), namely community-acquired pneumonia (CAP).

METHOD

This multicenter descriptive cross-sectional study included adults admitted to Danish EDs with a suspected infection. Data were collected prospectively from medical records.

RESULTS

We included 954 patients in the analysis. The most prescribed antibiotics were penicillin with beta-lactamase inhibitor at 4 h (307 (32.2%)), 48 h (289 (30.3%)), and day 5 after admission (218 (22.9%)). The empirical antibiotic treatment guidelines for CAP were followed for 126 (31.3%) of the CAP patients. At 4 h, antibiotics were administered intravenously to 244 (60.7%) of the CAP patients. At day 5, 218 (54.4%) received oral antibiotics.

CONCLUSION

Adherence to CAP guidelines was poor. In a country with a restrictive antibiotic policy, infections are commonly treated with broad-spectrum antibiotics against recommendations.

Predicting patient decompensation from continuous physiologic monitoring in the emergency department

Anticipation of clinical decompensation is essential for effective emergency and critical care. In this study, we develop a multimodal machine learning approach to predict the onset of new vital sign abnormalities (tachycardia, hypotension, hypoxia) in ED patients with normal initial vital signs. Our method combines standard triage data (vital signs, demographics, chief complaint) with features derived from a brief period of continuous physiologic monitoring, extracted via both conventional signal processing and transformer-based deep learning on ECG and PPG waveforms. We study 19,847 adult ED visits, divided into training (75%), validation (12.5%), and a chronologically sequential held-out test set (12.5%). The best-performing models use a combination of engineered and transformer-derived features, predicting in a 90-minute window new tachycardia with AUROC of 0.836 (95% CI, 0.800-0.870), new hypotension with AUROC 0.802 (95% CI, 0.747-0.856), and new hypoxia with AUROC 0.713 (95% CI, 0.680-0.745), in all cases significantly outperforming models using only standard triage data. Salient features include vital sign trends, PPG perfusion index, and ECG waveforms. This approach could improve the triage of apparently stable patients and be applied continuously for the prediction of near-term clinical deterioration.

An Evaluation of the Predictive Value of Sepsis Patient Evaluation in the Emergency Department (SPEED) Score in Estimating 28-Day Mortality Among Patients With Sepsis Presenting to the Emergency Department: A Prospective Observational Study

Background and objective

Sepsis is a life-threatening medical emergency and a significant cause of mortality. Risk stratification scores for sepsis can be unsuitable for use in the emergency department (ED) due to their complexity, and an appropriate solution has yet to be found. In this study, the predictive value of the Sepsis Patient Evaluation in the Emergency Department (SPEED) score in estimating 28-day mortality was assessed among patients with sepsis presenting to the ED, in order to determine its suitability as an efficient risk stratification system.

Materials and methods

This was a single-center, prospective observational study conducted at an urban tertiary care center. We included patients presenting to the ED with suspected or confirmed sepsis who met the inclusion and exclusion criteria of our study. The patients were evaluated with the following scoring systems on arrival: the SPEED score; Predisposition, Infection, Response, and Organ dysfunction (PIRO) score; and Mortality in Emergency Department Sepsis (MEDS) score; the patients were subsequently followed up on the 28th day to record the final outcomes with regard to mortality and discharge rates.

Results

This study included 127 patients in total. The median age of the study population was 49 years, and the 28-day mortality rate was 50.4%. The area under the receiver operating characteristic (AUROC) curve for the SPEED score for predicting mortality was 0.899 (95% CI: 0.847-0.951). In comparison, the AUROC for MEDS and PIRO scores was 0.857 (95% CI: 0.793-0.92) and 0.895 (95% CI: 0.838-0.951), respectively. Based on the DeLong test, no significant difference was found in the diagnostic performances with respect to these scores.

Conclusion

The SPEED score is a simple and handy parameter that can be used for the early and appropriate risk stratification of patients with sepsis in the ED.

Delays to Initiate Interfacility Transfer for Patients Transported by a Critical Care Transport Organization

OBJECTIVE

The time to initiate an interfacility transfer is an important and understudied cause of delay to definitive management. This study identifies characteristics associated with delays to initiate interfacility transfer of critically ill patients.

METHODS

We performed a retrospective cohort study of adult patients who underwent interfacility transfer by a provincial critical care transport organization over a 3-year period. The primary outcome was the time to initiate interfacility transfer. Quantile regression explored the impact of patient, environmental, and institutional characteristics.

RESULTS

In total 11,231 patients were included. Cardiac (+1.45 hours), gastrointestinal (+3.28 hours), respiratory (+4.90 hours), or sepsis (+3.03 hours) reasons for transfer; vasopressor requirements (+2.31 hours); and evening time (+3.67 hours) were associated with longer times to initiate interfacility transfer at the 90th quantile. Neurologic (-1.45 hours), obstetric (-1.56 hours), or trauma (-3.14 hours) reasons for transfer; Glasgow Coma Scale < 8 (-0.98 hours); blood transfusion requirement (-1.47 hours); and smaller sending sites were associated with shorter times to initiate transfer.

CONCLUSION

The time to initiate interfacility transfer represents a modifiable delay in a patient's transport journey. This study highlights important patient, environmental, and institutional characteristics associated with increased time to initiate transfer. Collaboration between transport organizations and hospitals in developing regional bypass criteria and prearranged transfer agreements may help facilitate timely patient transfer.

Improved diagnostics of infectious diseases in emergency departments: a protocol of a multifaceted multicentre diagnostic study

BACKGROUND

The major obstacle in prescribing an appropriate and targeted antibiotic treatment is insufficient knowledge concerning whether the patient has a bacterial infection, where the focus of infection is and which bacteria are the agents of the infection. A prerequisite for the appropriate use of antibiotics is timely access to accurate diagnostics such as point-of-care (POC) testing.The study aims to evaluate diagnostic tools and working methods that support a prompt and accurate diagnosis of hospitalised patients suspected of an acute infection. We will focus on the most common acute infections: community-acquired pneumonia (CAP) and acute pyelonephritis (APN). The objectives are to investigate (1) patient characteristics and treatment trajectory of the different acute infections, (2) diagnostic and prognostic accuracy of infection markers, (3) diagnostic accuracy of POC urine flow cytometry on diagnosing and excluding bacteriuria, (4) how effective the addition of POC analysis of sputum to the diagnostic set-up for CAP is on antibiotic prescriptions, (5) diagnostic accuracy of POC ultrasound and ultralow dose (ULD) computerized tomography (CT) on diagnosing CAP, (6) diagnostic accuracy of specialist ultrasound on diagnosing APN, (7) diagnostic accuracy of POC ultrasound in diagnosing hydronephrosis in patients suspected of APN.

METHODS AND ANALYSIS

It is a multifaceted multicentre diagnostic study, including 1000 adults admitted with suspicion of an acute infection. Participants will, within the first 24 hours of admission, undergo additional diagnostic tests including infection markers, POC urine flow cytometry, POC analysis of sputum, POC and specialist ultrasound, and ULDCT. The primary reference standard is an assigned diagnosis determined by a panel of experts.

ETHICS, DISSEMINATION AND REGISTRATION

Approved by Regional Committees on Health Research Ethics for Southern Denmark, Danish Data Protection Agency and clinicaltrials.gov. Results will be presented in peer-reviewed journals, and positive, negative and inconclusive results will be published.

TRIAL REGISTRATION NUMBERS

NCT04661085, NCT04681963, NCT04667195, NCT04652167, NCT04686318, NCT04686292, NCT04651712, NCT04645030, NCT04651244.

Factors for return to emergency department and hospitalization in elderly urinary tract infection patients

BACKGROUND

Appropriate decision of emergency department (ED) disposition is essential for improving the outcome of elderly urinary tract infection (UTI) patients. However, studies on early return visit (ERV) to the ED in elderly UTI patients are limited. Therefore, we aimed to identify factors for ERV and hospitalization after return visit (HRV) in this population.

METHODS

Elderly patients discharged from the ED with International Classification of diseases 10th Revision codes of UTI were selected from the registry for evaluation of ED revisit in 6 urban teaching hospitals. Retrospective data were extracted from the electronic medical records and ERV and hospitalization to scheduled revisit (SRV) were compared.

RESULT

Among a total of 419 patients found in the study period, 45 were ERV patients and 24 were HRV patients. Absence of UTI-specific symptoms (odds ratio [OR] 2.789; 95% confidence interval [CI] 1.368-5.687; P = 0.005), C-reactive protein (CRP) levels >30 mg/L (OR 2.436; 95% CI 1.017-3.9; P = 0.024), and body temperature ≥ 38 °C (OR 1.992; 95% CI 1.017-3.9; P = 0.044) were independent risk factors for ERV, and absence of UTI-specific symptoms (OR 3.832; 95% CI 1.455-10.088; P = 0.007), CRP levels >30 mg/L (OR 3.224; 95% CI 1.235-8.419; P = 0.017), and systolic blood pressure ≤ 100 mmHg (OR 3.795;95% CI 1.156-12.462; P = 0.028) were independent risk factors for HRV. However, there was no significant difference in empirical antibiotic resistance in ERV and HRV patients, compared to SRV patients.

CONCLUSION

The independent risk factors of ERV and HRV should be considered for ED disposition in elderly UTI patients; the resistance to empirical antibiotics was not found to affect ERV or HRV within 3 days.

Duration and management of sepsis-associated hypotension at rapid response team call-outs to patients subsequently admitted to the intensive care unit: A case series

BACKGROUND

Sepsis-related hypotension in hospital patients is a common reason for rapid response team (RRT) attendance and transfer to intensive care, but little is known about the duration and management of hypotension during these RRT call-outs.

OBJECTIVES

We aimed to describe the duration and management of hypotension during RRT call-outs to patients with sepsis-related hypotension who required transfer to intensive care.

METHODS

RRT call-outs during 2018 for hypotension with transfer to intensive care were identified from a prospectively maintained database of RRT call-outs at a single tertiary hospital. From these, the records of a random sample of 60 cases were reviewed, and those attributed to sepsis and without missing data were described. Hypotension was defined as systolic blood pressure < 90 mmHg.

RESULTS

There were 117 RRT call-outs for hypotension with transfer to intensive care, and of the 60 cases randomly chosen for further review, 41 were deemed sepsis related and were not missing data. The average age of the patients was 62 years, and 18 (44%) were already receiving antibiotics. The median time to arrival in the intensive care unit was 47 minutes. Patients were hypotensive for approximately two-thirds of their RRT time, despite 88% receiving some initial resuscitative treatments (fluids and/or vasopressors). Thirty-two (78%) were treated with intravenous fluids, and 20 (49%), with vasopressors. Patients spent 3 [2-4] days in intensive care, and 7 (17%) died in hospital.

CONCLUSIONS

Patients with sepsis-related hypotension requiring an RRT call and transfer to intensive care remain hypotensive for a substantial duration of the call. This concept of adequacy of resuscitation after rapid response calls needs further exploration in a larger study.

Prognostic tools for elderly patients with sepsis: in search of new predictive models

As a tool to support clinical decision-making, Mortality Prediction Models (MPM) can help clinicians stratify and predict patient risk. There are numerous scoring systems for patients with sepsis that predict sepsis-related mortality and the severity of sepsis. But there are currently no MPMs for adults with sepsis who meet the criteria of "good." Clinicians are unlikely to use complex MPMs that require extensive or expensive data collection to impede workflow. Machine learning applied to minimal medical records of patients diagnosed with sepsis can be a useful tool. Progress is needed in the development and validation of clinical decision support tools that can assist in patient risk stratification, prognosis, discussion of patient outcomes, and shared decision making.

Abnormal Vital Sign Recognition and Provider Notification in the Pediatric Emergency Department

INTRODUCTION

Vital signs measurements aid in the early identification of patients at risk of clinical deterioration and determining the severity of illness. Health care providers rely on registered nurses to document vital signs and communicate abnormalities. The purpose of this project was to improve the provider notification process regarding abnormal vital signs in a pediatric emergency department.

METHOD

A best practice advisory (BPA) was piloted by the advanced practice providers in the pediatric emergency department. To evaluate the effects of the BPA, a mixed-methods study was employed.

RESULTS

Implementation of the BPA improved the provider notification process and enhanced clinical decision making. The percentage of patients discharged home with abnormal respiratory rates (10.9% vs. 5.9%, p = .31), abnormal temperatures (15.6% vs. 7.5%, p = .14), and abnormal heart rates (25% vs. 11.9%, p = .11) improved.

DISCUSSION

Creation and implementation of the BPA improved the abnormal vital sign communication process to providers at this single institution.

Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality

PURPOSE

Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition.

METHODS

We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition.

RESULTS

Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload.

CONCLUSIONS

Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Critically Ill Health Care-Associated Urinary Tract Infection: Broad vs. Narrow Antibiotics in the Emergency Department Have Similar Outcomes

BACKGROUND

Urinary tract infection (UTI) is the second most common infection requiring intensive care unit (ICU) admission in emergency department (ED) patients. Optimal empiric management for health care-associated (HCA) UTI is unclear, particularly in the critically ill.

OBJECTIVE

To compare clinical failure of broad vs. narrow antibiotic selection in the ED for patients presenting with HCA UTI admitted to the ICU.

METHODS

Observational cohort of patients started on empiric antibiotic for UTI with at least one HCA risk factor (recurrent UTI, chronic urinary catheter or dialysis, urologic procedures, previous antibiotic exposure, hospitalization, or group facility residence). Broad antibiotics covered Pseudomonas spp. and extended-spectrum beta-lactamase. Clinical failure was a composite of multiorgan dysfunction (MODS) by day 2 and in-hospital mortality. Secondary outcomes were length of stay (LOS), readmission, recurrent infection, development of multidrug-resistant organisms, and Clostridium difficile infection. Associations were reported with odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

There were 272 patients included; 196 (72.1%) received broad and 76 (27.9%) received narrow therapy. There was no association between antibiotic selection and clinical failure (OR 1.05, 95% CI 0.5-2.25, p = 0.89) or between antibiotic selection and number of HCA risk factors (OR 0.98, 95% CI 0.73-1.31, p = 0.87). There was an association between clinical failure and MODS on ICU admission (OR 9.14, 95% CI 4.70-17.78, p < 0.001). Hospital LOS and readmission did not differ between antibiotic groups.

CONCLUSION

Initial empiric broad or narrow antibiotic coverage in HCA UTI patients who presented to the ED and required ICU admission had similar clinical outcomes.

Development and Validation of the Quick COVID-19 Severity Index: A Prognostic Tool for Early Clinical Decompensation

STUDY OBJECTIVE

The goal of this study is to create a predictive, interpretable model of early hospital respiratory failure among emergency department (ED) patients admitted with coronavirus disease 2019 (COVID-19).

METHODS

This was an observational, retrospective, cohort study from a 9-ED health system of admitted adult patients with severe acute respiratory syndrome coronavirus 2 (COVID-19) and an oxygen requirement less than or equal to 6 L/min. We sought to predict respiratory failure within 24 hours of admission as defined by oxygen requirement of greater than 10 L/min by low-flow device, high-flow device, noninvasive or invasive ventilation, or death. Predictive models were compared with the Elixhauser Comorbidity Index, quick Sequential [Sepsis-related] Organ Failure Assessment, and the CURB-65 pneumonia severity score.

RESULTS

During the study period, from March 1 to April 27, 2020, 1,792 patients were admitted with COVID-19, 620 (35%) of whom had respiratory failure in the ED. Of the remaining 1,172 admitted patients, 144 (12.3%) met the composite endpoint within the first 24 hours of hospitalization. On the independent test cohort, both a novel bedside scoring system, the quick COVID-19 Severity Index (area under receiver operating characteristic curve mean 0.81 [95% confidence interval {CI} 0.73 to 0.89]), and a machine-learning model, the COVID-19 Severity Index (mean 0.76 [95% CI 0.65 to 0.86]), outperformed the Elixhauser mortality index (mean 0.61 [95% CI 0.51 to 0.70]), CURB-65 (0.50 [95% CI 0.40 to 0.60]), and quick Sequential [Sepsis-related] Organ Failure Assessment (0.59 [95% CI 0.50 to 0.68]). A low quick COVID-19 Severity Index score was associated with a less than 5% risk of respiratory decompensation in the validation cohort.

CONCLUSION

A significant proportion of admitted COVID-19 patients progress to respiratory failure within 24 hours of admission. These events are accurately predicted with bedside respiratory examination findings within a simple scoring system.

Predictive factors for secondary intensive care unit admission within 48 hours after hospitalization in a medical ward from the emergency room

BACKGROUND

Unplanned transfer to an ICU within 48 hours of admission from the emergency department (ED) can be considered an adverse event. Screening at risk for such an event is a challenge for ED staff. Our purpose was to identify the clinical and biological variables which may be identified in the ED setting and can predict short-term unplanned secondary transfer to the intensive care setting.

METHODS

This was a three-year retrospective case controlled monocentric study. The cases were patients transferred to a medical ICU within 48 hours of admission to the general wards from the ED. Each case was matched to two controls (patients not transferred to the ICU) based on age, gender, year of admission, and hospital unit. A conditional logistic regression was performed.

RESULTS

Three hundred nineteen patients, including 107 cases and 212 controls, were studied. Community-acquired pneumonia (CAP) was the most frequent diagnosis (23% of cases) followed by sepsis (16%). We identified six predictive factors of an unplanned short-term transfer to the ICU. Former smoking status, fever between 38°C and 40°C, dyspnea as the chief complaint in the ED, a lower MEDS score, an elevated acute physiology age chronic health evaluation score, and the ordering of an arterial blood gas each correlate with secondary transfer to an intensive care setting.

CONCLUSION

We report a higher risk of short-term unscheduled ICU transfer in patients meeting these criteria. These patients should be closely monitored and frequently re-evaluated before being transferred to a general ward.

A Retrospective Case-Control Study to Identify Predictors of Unplanned Admission to Pediatric Intensive Care Within 24 Hours of Hospitalization

OBJECTIVES

To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours.

DESIGN

A retrospective case-control study.

SETTING

A pediatric hospital in Ottawa, ON, Canada.

PATIENTS

Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not.

INTERVENTIONS

None.

MAIN RESULTS

Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6).

CONCLUSIONS

We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.

Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?

Objective

The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff.

Patients and methods

This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records.

Results

We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620).

Conclusion

Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of ‘treat first what kills first’ can be supplemented with ‘judge first and calculate later’.

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

OBJECTIVES

To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).

DESIGN

Preplanned, secondary analysis of a prospective observational study.

SETTING

Tertiary care, academic ED.

PARTICIPANTS

A total of 424 patients in the ED, 65 years or older, including all chief complaints.

MEASUREMENTS

We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.

RESULTS

Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.

CONCLUSIONS

The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Multicentric Standardized Flow Cytometry Routine Assessment of Patients With Sepsis to Predict Clinical Worsening

BACKGROUND

In this study, we primarily sought to assess the ability of flow cytometry to predict early clinical deterioration and overall survival in patients with sepsis admitted in the ED and ICU.

METHODS

Patients admitted for community-acquired acute sepsis from 11 hospital centers were eligible. Early (day 7) and late (day 28) deaths were notified. Levels of CD64^pos granulocytes, CD16^pos monocytes, CD16^dim immature granulocytes (IGs), and T and B lymphocytes were assessed by flow cytometry using an identical, cross-validated, robust, and simple consensus standardized protocol in each center.

RESULTS

Among 1,062 patients screened, 781 patients with confirmed sepsis were studied (age, 67 ± 48 years; Simplified Acute Physiology Score II, 36 ± 17; Sequential Organ Failure Assessment, 5 ± 4). Patients were divided into three groups (sepsis, severe sepsis, and septic shock) on day 0 and on day 2. On day 0, patients with sepsis exhibited increased levels of CD64^pos granulocytes, CD16^pos monocytes, and IGs with T-cell lymphopenia. Clinical severity was associated with higher percentages of IGs and deeper T-cell lymphopenia. IG percentages tended to be higher in patients whose clinical status worsened on day 2 (35.1 ± 35.6 vs 43.5 ± 35.2, P = .07). Increased IG percentages were also related to occurrence of new organ failures on day 2. Increased IG percentages, especially when associated with T-cell lymphopenia, were independently associated with early (P < .01) and late (P < .01) death.

CONCLUSIONS

Increased circulating IGs at the acute phase of sepsis are linked to clinical worsening, especially when associated with T-cell lymphopenia. Early flow cytometry could help clinicians to target patients at high risk of clinical deterioration.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01995448; URL: www.clinicaltrials.gov.

Internal Validation of the Sepsis in Obstetrics Score to Identify Risk of Morbidity From Sepsis in Pregnancy

OBJECTIVE

To prospectively validate the Sepsis in Obstetrics Score, a pregnancy-specific sepsis scoring system, to identify risk for intensive care unit (ICU) admission for sepsis in pregnancy.

METHODS

This is a prospective validation study of the Sepsis in Obstetrics Score. The primary outcome was admission to the ICU for sepsis. Secondary outcomes included admission to a telemetry unit and time to administration of antibiotic therapy. We evaluated test characteristics of a predetermined score of 6 or greater.

RESULTS

Between March 2012 and May 2015, 1,250 pregnant or postpartum women presented to the emergency department and met systemic inflammatory response syndrome criteria. Of those, 425 (34%) had a clinical suspicion or diagnosis of an infection, 14 of whom (3.3%) were admitted to the ICU. The Sepsis in Obstetrics Score had an area under the curve of 0.85 (95% CI 0.76-0.95) for prediction of ICU admission for sepsis. This is within the prespecified 15% margin of the area under the curve of 0.97 found in the derivation cohort. A score of 6 or greater had a sensitivity of 64%, specificity of 88%, positive predictive value of 15%, and negative predictive value of 98.6%. Women with a score 6 or greater were more likely to be admitted to the ICU (15% compared with 1.4%, P<.01), admitted to a telemetry unit (37.3% compared with 7.2%, P<.01), and have antibiotic therapy initiated (90% compared with 72.9%, P<.01), initiated more quickly (3.2 compared with 3.7 hours, P=.03), although not within 1 hour (5.6 compared with 3.4%, P=.44).

CONCLUSION

The Sepsis in Obstetrics Score is a validated pregnancy-specific score to identify risk of ICU admission for sepsis with the threshold score of 6 having a negative predictive value of 98.6%. Adherence to antibiotic administration guidelines is poor.

Unexpected intensive care transfer of admitted patients with severe sepsis

Background

Patients with severe sepsis generally respond well to initial therapy administered in the emergency department (ED), but a subset later decompensate and require unexpected transfer to the intensive care unit (ICU). This study aimed to identify clinical factors that can predict patients at increased risk for delayed transfer to the ICU and the association of delayed ICU transfer with mortality.

Methods

This is a nested case-control study in a prospectively collected registry of patients with severe sepsis and septic shock at two EDs. Cases had severe sepsis and unexpected ICU transfer within 48 h of admission from the ED; controls had severe sepsis but remained in a non-ICU level of care. Univariate and multivariate regression analyses were used to identify predictors of unexpected transfer to the ICU, which was the primary outcome. Differences in mortality between these two groups as well as a cohort of patients directly admitted to the ICU were also calculated.

Results

Of the 914 patients in our registry, 358 patients with severe sepsis were admitted from the ED to non-ICU level of care; 84 (23.5%) had unexpected ICU transfer within 48 h. Demographics and baseline co-morbidity burden were similar for patients requiring versus not requiring delayed ICU transfer. In unadjusted analysis, lactate ≥4 mmol/L and infection site were significantly associated with unexpected ICU upgrade. In forward selection multivariate logistic regression analysis, lactate ≥4 mmol/L (OR 2.0, 95% CI 1.03, 3.73; p = 0.041) and night (5 PM to 7 AM) admission (OR 1.9, 95% CI 1.07, 3.33; p = 0.029) were independent predictors of unexpected ICU transfer. Mortality of patients who were not upgraded to the ICU was 8.0%. Patients with unexpected ICU upgrade had similar mortality (25.0%) to those patients with severe sepsis/septic shock (24.6%) who were initially admitted to the ICU, despite less severe indices of illness at presentation.

Conclusions

Serum lactate ≥4 mmol/L and nighttime admissions are associated with unexpected ICU transfer in patients with severe sepsis. Mortality among patients with delayed ICU upgrade was similar to that for patients initially admitted directly to the ICU.

Clinical Characteristics and Outcomes of Patients With Cellulitis Requiring Intensive Care

Importance

Cellulitis is a commonly occurring skin and soft tissue infection and one of the most frequently seen dermatological diseases in the intensive care unit (ICU). However, clinical characteristics of patients with cellulitis requiring intensive care treatment are poorly defined. Necrotizing fasciitis is often confused for cellulitis at initial presentation and is considered to be more severe and thus has previously been described in more detail.

Objective

To describe the clinical presentation and outcomes of patients with ICU-necessitating cellulitis and to compare them with patients with necrotizing fasciitis.

Design, Setting, and Participants

This prospective cohort study includes all ICU admissions from 2 tertiary hospitals in the Netherlands. Of 2562 sepsis admissions, 101 had possible, probable, or definite cellulitis or soft tissue infections. Retrospective review identified severe cellulitis was the reason for ICU admission in 23 patients, necrotizing fasciitis in 31 patients, and other diagnoses in 47 patients.

Main Outcomes and Measures

Patient and disease characteristics, cultured pathogens, lengths of stay, and short-term and long-term mortality.

Results

Overall, 54 patients with cellulitis (n = 23; mean [SD] age, 57.2 [17.7] years) or necrotizing fasciitis (n = 31; mean [SD] age, 54.3 [13.5]) were included in this study. Patients with cellulitis were found to be less severely ill than patients with necrotizing fasciitis. This is reflected in rates of shock (7 [30.4%] vs 19 [61.3%]; P = .03), need for mechanical ventilation (12 [52.2%] vs 19 [93.5%]; P = .003) and slightly lower mean Sequential Organ Failure Assessment scores (8 vs 10; P = .046). Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation IV scores did not differ significantly (82 [75-98] vs 76 [70-96]; P = .16). Patients with cellulitis had more chronic comorbidities than patients with necrotizing fasciitis (20 [87.0%] vs 17 [54.8%]; P = .02), especially cardiovascular insufficiencies (10 [43.5%] vs 4 [12.9%]; P = .02) and immunodeficiencies (9 [39.1%] vs 3 [9.7%]; P = .02). Among patients with cellulitis and patients with patients with necrotizing fasciitis, Staphylococcus aureus (10 [43.5%] vs 4 [12.9%]; P = .02), Streptococcus pyogenes (2 [8.7%] vs 19 [61.3%]; P < .001) and Escherichia coli (4 [17.4%] vs 5 [16.2%]; P = .90) were the most frequently observed pathogens. Median (IQR) length of ICU stay was shorter for patients with cellulitis vs patients with necrotizing fasciitis (3 [2-5] vs 5 [3-11]; P = .01), while median (IQR) hospital length of stay did not differ significantly (22 [10.25-32] vs 36 [14.25-40]; P = .16); and the in-hospital mortality rate (26.1% vs 22.6%, P > .99) and 90-day mortality rate (30.4% vs 22.6%; P = .54) were similar.

Conclusions and Relevance

Patients with cellulitis patients are seldom admitted to the ICU. However, while these patients are less critically ill on admission than patients with necrotizing fasciitis, they have more chronic comorbidities and most notably similar short-term and long-term mortality.

Trial Registration

clinicaltrials.gov Identifier: NCT01905033.

Risk factors for unplanned transfer to the intensive care unit after emergency department admission

INTRODUCTION

Unplanned Intensive Care Unit (ICU) admission has been used as a surrogate marker of adverse events, and is used by the Australian Council of Healthcare Accreditation as a reportable quality indicator. If we can identify independent variables predicting deterioration which require ICU transfer within 24h after emergency department (ED) admission, direct ICU admission should be considered. This may improve patient safety and reduce adverse events by appropriate disposition of patients presenting to the ED.

OBJECTIVE(S)

The aim of this study was to identify independent variables predicting deterioration which require ICU transfer within 24h after ED admission.

METHODS

A case control study was performed to examine characteristics of patients who underwent an unplanned transfer to the ICU within 24h after ED admission.

RESULTS

There were significantly more hypercapnia patients in the ICU admission group (n=17) compared to the non-ICU group (n=5) (p=0.028). There were significantly greater rates of tachypnea in septic patients (p=0.022) and low oxygen saturation for patients with pneumonia (p=0.045). The level of documentation of respiratory rate was poor.

CONCLUSIONS

In patients presenting to the ED, hypercapnia was a predictor for deterioration which requires ICU transfer within 24h after ED admission. Additional predicting factors in patients with sepsis or pneumonia were respectively tachypnea and low oxygen saturation. For these patient groups direct ICU admission should be considered to prevent unplanned ICU admission. This data emphasizes the importance of measuring the vital signs, particularly the respiratory rate.

Suspected infection in afebrile patients: Are they septic?

We prospectively evaluated afebrile patients admitted to an emergency department (ED), with suspected infection and only tachycardia or tachypnea.The white blood cell count (WBC) was obtained, and patients were considered septic if leukocyte count was >12,000 μL-1 or <4000 μL-1 or with >10% of band forms. Clinical data were collected to examine whether sepsis could be predicted.Seventy patients were included and 37 (52.86%) met sepsis criteria. Self-measured fever showed an odds ratio (OR) of 5.936 (CI95% 1.450-24.295; P = 0.0133) and increased pulse pressure (PP) showed an OR of 1.405 (CI95% 1.004-1.964; P = 0.0471) on multivariate analysis. When vital signs were included in multivariate analysis, the heart rate showed an OR of 2.112 (CI95% 1.400-3.188; P = 0.0004). Self-measured fever and mean arterial pressure <70 mm Hg had high positive likelihood ratios (3.86 and 2.08, respectively). The nomogram for self-measured fever showed an increase of sepsis chance from 53% (pretest) to approximately 80% (post-test).The recognition of self-measured fever, increased PP, and the intensity of heart rate response may improve sepsis recognition in afebrile patients with tachycardia or tachypnea. These results are important for medical assessment of sepsis in remote areas, crowded and low-resourced EDs, and low-income countries, where WBC may not be readily available.

Pitfalls in the Treatment of Sepsis

Sepsis is a challenging, dynamic, pathophysiology requiring expertise in diagnosis and management. Controversy exists as to the most sensitive early indicators of sepsis and sepsis severity. Patients presenting to the emergency department often lack complete history or clinical data that would point to optimal management. Awareness of these potential knowledge gaps is important for the emergency provider managing the septic patient. Specific areas of management including the initiation and management of mechanical ventilation, the appropriate disposition of the patient, and consideration of transfer to higher levels of care are reviewed.

Hospital ward transfer to intensive care unit as a quality marker in emergency medicine

BACKGROUND

Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging.

OBJECTIVE

To investigate the utility of tracking patients transferred to the ICU within 24h of admission from the ED as a marker of preventable errors and adverse events.

METHODS

From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement.

RESULTS

Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%).

CONCLUSION

Tracking patients admitted to the hospital from the ED who are transferred to the ICU <24h after admission may be a valuable marker for adverse events and preventable errors in the ED.

A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure

HYPOTHESIS

Unplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes.

OBJECTIVE

The objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality.

DESIGN

This is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs).

RESULTS

A total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI.

CONCLUSIONS

Unplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality.

Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis

Background

Progression from nonsevere sepsis—i.e., sepsis without organ failure or shock—to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis.

Methods

This is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death.

Results

In this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40–9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57–13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation.

Conclusions

In our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.

The prognostic role of non-critical lactate levels for in-hospital survival time among ED patients with sepsis

OBJECTIVE

This study describes emergency department (ED) sepsis patients with non-critical serum venous lactate (LAC) levels (LAC <4.0 mmol/L) who suffered in-hospital mortality and examines LAC in relation to survival times.

METHODS

An ED based retrospective cohort study accrued September 2010 to August 2014. Inclusion criteria were ED admission, LAC sampling, >2 systemic inflammatory response syndrome criteria with an infectious source (sepsis), and in-hospital mortality. Kaplan-Meier curves were used for survival estimates. An a priori sub-group analysis for patients with repeat LAC within 6 hours of initial sampling was undertaken. The primary outcome was time to in-hospital death evaluated using rank-sum tests and regression models.

RESULTS

One hundred ninety-seven patients met inclusion criteria. Pulmonary infections were the most common (44%) and median LAC was 1.9 mmol/L (1.5, 2.5). Thirteen patients (7%) died within 24 hours and 79% by ≤28 days. Median survival was 11 days (95% CI, 8.0-13). Sixty-two patients had repeat LAC sampling with 14 (23%) and 48 (77%) having decreasing increasing levels, respectively. No significant differences were observed in treatment requirements between the LAC subgroups. Among patients with decreasing LAC, median survival was 24 days (95% CI, 5-32). For patients with increasing LAC median survival was significantly shorter (7 days; 95% CI, 4-11, P = .04). Patients with increasing LAC had a non-significant trend toward reduced survival (HR = 1.6 95% CI, 0.90-3.0, P = .10).

CONCLUSIONS

In septic ED patients experiencing in-hospital death, non-critical serum venous lactate may be utilized as a risk-stratifying tool for early mortality, while increasing LAC levels may identify those in danger of more rapid deterioration.

The Impact of Implementation of an ICU Consult Service on Hospital-Wide Outcomes and ICU-Specific Outcomes

BACKGROUND

Rapid response teams (RRTs) were developed to promote assessment of and early intervention for clinically deteriorating hospitalized patients. Although the ideal composition of RRTs is not known, their implementation does require significant resources.

OBJECTIVE

To test the effectiveness of a dedicated daytime/weekday intensive care unit (ICU) consult service without formal training of ward teams.

METHODS

Pre- and postintervention study with weekends/nights during implementation period acting as a concurrent control.

SETTING

An adult tertiary care university center in Montreal without an RRT.

INTERVENTION

A daytime/weekday ICU consult service with a dedicated intensivist.

RESULTS

Total hospital mortality rate did not differ between the control and the implementation period (6.65% vs 6.60%; P = .84). The hospital code blue rates also did not differ (1.21/1000 vs 1.14/1000 patient days; P = .58). In contrast, 30-day mortality of patients admitted to the ICU following an ICU consult decreased (39% vs 24% P = .01). Multivariate analysis confirmed this effect on 30-day mortality (odds ratio for implementation period: 0.53 [95% confidence interval: 0.33-0.85] P = .009). The 14-day ICU readmission rate was reduced with the intervention (5.1% vs 4.1%; P < .001). The effect on 30-day mortality and ICU readmissions were only present during daytime/weekdays.

CONCLUSION

Implementation of an ICU consult service without any formal afferent limb training was associated with decreased mortality and 14-day readmission rates of patients admitted to the ICU. In contrast, hospital-wide mortality and code blue rates were unaffected.

A predictive rule for mortality of inpatients with Staphylococcus aureus bacteraemia: A classification and regression tree analysis

OBJECTIVE

To create a predictive rule to identify risk factors for mortality among patients with Staphylococcus aureus bacteraemia (SAB).

DESIGN, SETTING AND PATIENTS

This was a retrospective cohort study of all adult patients with SAB at a large community hospital in Tokyo, Japan, from April 1, 2004 to March 31, 2011. Baseline data and clinically relevant factors were collected from electronic charts. The primary outcome was in-hospital mortality. All candidate predictors were included in a classification and regression tree (CART) analysis. A receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was obtained. A cross-validation analysis was performed.

MEASUREMENTS AND MAIN RESULTS

A total of 340 patients had SAB during the study period. Of these, 118 (34.7%) patients died in hospital. Among 41 potential variables, the CART analysis revealed that underlying malignancy, serum blood glucose level, methicillin resistance, and low serum albumin were predictors of mortality. The AUC was 0.73 (95% CI: 0.67-0.79). For validation, the estimated risk was 0.26 (± SE: 0.02) in the resubstitution analysis and 0.33 (± SE: 0.03) in the cross-validation analysis.

CONCLUSION

We propose a predictive model for the mortality of patients with SAB consisting of four predictors: underlying malignancy, low serum albumin, high glucose, and methicillin resistance. This model may facilitate appropriate preventative management for patients with SAB who are at high risk of mortality.

Epidemiology and outcomes in patients with severe sepsis admitted to the hospital wards

PURPOSE

The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non-intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes.

MATERIAL AND METHODS

This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality.

RESULTS

Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome.

CONCLUSIONS

Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.

The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy

OBJECTIVE

We sought to design an emergency department sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women.

STUDY DESIGN

The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S. was applied to a retrospective cohort of pregnant and postpartum patients from February 2009 through May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic curves were constructed to estimate the optimal score for identification of risk of ICU admission.

RESULTS

In all, 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an area under the curve of 0.97 for ICU admission. An S.O.S. ≥6 (maximum score 28) had an area under the curve of 0.92 with sensitivity of 88.9%, specificity of 95.2%, positive predictive value of 16.7%, and negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18-661). An S.O.S. ≥6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia.

CONCLUSION

A sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.

Prognosis and risk factors for deterioration in patients admitted to a medical emergency department

Objective

Patients that initially appear stable on arrival to the hospital often have less intensive monitoring of their vital signs, possibly leading to excess mortality. The aim was to describe risk factors for deterioration in vital signs and the related prognosis among patients with normal vital signs at arrival to a medical emergency department (MED).

Design and setting

Single-centre, retrospective cohort study of all patients admitted to the MED from September 2010-August 2011.

Subjects

Patients were included when their vital signs (systolic blood pressure, pulse rate, respiratory rate, Glasgow Coma Scale, oxygen saturation and temperature) were within the normal range at arrival. Deterioration was defined as a deviation from the defined normal range 2–24 hours after arrival.

Results

4292 of the 6257 (68.6%) admitted to the MED had a full set of vital signs at first presentation, 1440/4292 (33.6%) had all normal vital signs and were included in study, 44.0% were male, median age 64 years (5th/95th percentile: 21–90 years) and 446/1440 (31.0%) deteriorated within 24 hours. Independent risk factors for deterioration included age 65–84 years odds ratio (OR): 1.79 (95% confidence interval [CI]: 1.27–2.52), 85+ years OR 1.67 (95% CI: 1.10–2.55), Do-not-attempt-to-resuscitate order OR 3.76 (95% CI: 1.37–10.31) and admission from the open general ED OR 1.35 (95% CI: 1.07–1.71). Thirty-day mortality was 7.9% (95% CI: 5.5–10.7%) among deteriorating patients and 1.9% (95% CI: 1.2–3.0%) among the non-deteriorating, hazard ratio 4.11 (95% CI: 2.38–7.10).

Conclusions

Among acutely admitted medical patients who arrive with normal vital signs, 31.0% showed signs of deterioration within 24 hours. Risk factors included old age, Do-not-attempt-to-resuscitate order, admission from the open general ED. Thirty-day mortality among patients with deterioration was four times higher than among non-deteriorating patients. Further research is needed to determine whether intensified monitoring of vital signs can help to prevent deterioration or mortality among medical emergency patients.

Comparison of risks factors for unplanned ICU transfer after ED admission in patients with infections and those without infections

Background. The objectives of this study were to compare the risk factors for unplanned intensive care unit (ICU) transfer after emergency department (ED) admission in patients with infections and those without infections and to explore the feasibility of using risk stratification tools for sepsis to derive a prediction system for such unplanned transfer. Methods. The ICU transfer group included 313 patients, while the control group included 736 patients randomly selected from those who were not transferred to the ICU. Candidate variables were analyzed for association with unplanned ICU transfer in the 1049 study patients. Results. Twenty-four variables were associated with unplanned ICU transfer. Sixteen (66.7%) of these variables displayed association in patients with infections and those without infections. These common risk factors included specific comorbidities, physiological responses, organ dysfunctions, and other serious symptoms and signs. Several common risk factors were statistically independent. Conclusions. The risk factors for unplanned ICU transfer in patients with infections were comparable to those in patients without infections. The risk factors for unplanned ICU transfer included variables from multiple dimensions that could be organized according to the PIRO (predisposition, insult/infection, physiological response, and organ dysfunction) model, providing the basis for the development of a predictive system.

High-sensitivity cardiac troponin T is an independent predictor of inhospital mortality in emergency department patients with suspected infection: a prospective observational derivation study

INTRODUCION

To assess the prognostic and discriminative accuracy of high-sensitivity cardiac troponin T (hs-cTnT) for prediction of inhospital mortality in emergency department (ED) patients with suspected infection.

METHODS

Prospective observational derivation study in ED patients with suspected infection. Prognostic performance of hs-cTnT (divided in four quartiles because of non-linearity) for prediction of inhospital mortality was assessed using multivariable logistic regression, correcting for predisposition, infection, response and organ failure (PIRO) score as a measure of illness severity and quality of ED treatment as quantified by the number of 'Surviving Sepsis Campaign' goals achieved. Discriminative power of hs-cTnT was assessed by receiver operator characteristics with area under the curve (AUC) analysis.

RESULTS

Hs-cTnT (median (IQR) was 57 (25-90) ng/L (n=23) in non-survivors, significantly higher than the 15 (7-28) ng/L in survivors (n=269, p<0.001). Additionally, the lowest quartile of hs-cTnT was a perfect predictor of survival because zero death occurred. Therefore, the second quartile was used as a reference category in the multivariable logistic regression analysis showing that hs-cTnT was an independent predictor of inhospital mortality: Corrected ORs were 2.2 (95% CI 0.4 to 12.1) and 5.8 (1.2 to 27.3) for the 3rd and 4th quartile compared with the 2nd hs-cTnT quartile. The AUCs of hs-TnT was 0.81 (0.74 to 0.88), similar to the AUC of 0.78 (0.68 to 0.87) of the PIRO score (p>0.05). Overall negative predictive value of hs-cTnT was 99%.

CONCLUSIONS

In ED patients with suspected infection, the routinely used biomarker hs-cTnT is an independent predictor of inhospital mortality with excellent discriminative performance. Future studies should focus on the additional value of hs-cTnT to existing risk stratification tools.

Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study

AIM

Early warning scores (EWS) are widely used in well-resourced healthcare settings to identify patients at risk of mortality. The Modified Early Warning Score (MEWS) is a well-known EWS used comprehensively in the United Kingdom. The HOTEL score (Hypotension, Oxygen saturation, Temperature, ECG abnormality, Loss of independence) was developed and tested in a European cohort; however, its validity is unknown in resource limited settings. This study compared the performance of both scores and suggested modifications to enhance accuracy.

METHODS

A prospective cohort study of adults (≥18 yrs) admitted to medical wards at a Malawian hospital. Primary outcome was mortality within three days. Performance of MEWS and HOTEL were assessed using ROC analysis. Logistic regression analysis identified important predictors of mortality and from this a new score was defined.

RESULTS

Three-hundred-and-two patients were included. Fifty-one (16.9%) died within three days of admission. With a cut-point ≥2, the HOTEL score had sensitivity 70.6% (95% CI: 56.2 to 82.5) and specificity 59.4% (95% CI: 53.0 to 65.5), and was superior to MEWS (cut-point ≥5); sensitivity: 58.8% (95% CI: 44.2 to 72.4), specificity: 56.2% (95% CI: 49.8 to 62.4). The new score, dubbed TOTAL (Tachypnoea, Oxygen saturation, Temperature, Alert, Loss of independence), showed slight improvement with a cut-point ≥2; sensitivity 76.5% (95% CI: 62.5 to 87.2) and specificity 67.3% (95% CI: 61.1 to 73.1).

CONCLUSION

Using an EWS generated in developed healthcare systems in resource limited settings results in loss of sensitivity and specificity. A score based on predictors of mortality specific to the Malawian population showed enhanced accuracy but not enough to warrant clinical use. Despite an assumption of common physiological responses, disease and population differences seem to strongly determine the performance of EWS. Local validation and impact assessment of these scores should precede their adoption in resource limited settings.

Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis

BACKGROUND

It is not known whether lack of recognition of organ failure explains the low compliance with the "Surviving Sepsis Campaign" (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure.

METHODS

Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1-7, 8-14, 15-24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier.

RESULTS

One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08-10.64), 2.37 (1.07-5.23) and 4.18 (1.92-9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113-141) min; ICU 94 (80-108) min (P = 0.005)].

CONCLUSIONS

The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward.

Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system

BACKGROUND

Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions.

DESIGN, SETTING, PATIENTS

Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED.

METHODS

Evaluation of 178,315 ED non-ICU admissions to 13 US community hospitals. We tabulated the outcome of unplanned ICU transfer by patient characteristics and hospital volume. We present factors associated with unplanned ICU transfer after adjusting for patient and hospital differences in a hierarchical logistic regression.

RESULTS

There were 4,252 (2.4%) non-ICU admissions transferred to the ICU within 24 hours. Admitting diagnoses most associated with unplanned transfer, listed by descending prevalence were: pneumonia (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2-1.9), myocardial infarction (MI) (OR 1.5; 95% CI 1.2-2.0), chronic obstructive pulmonary disease (COPD) (OR 1.4; 95% CI 1.1-1.9), sepsis (OR 2.5; 95% CI 1.9-3.3), and catastrophic conditions (OR 2.3; 95% CI 1.7-3.0). Other significant predictors included: male sex, Comorbidity Points Score >145, Laboratory Acute Physiology Score ≥7, arriving on the ward between 11 PM and 7 AM. Decreased risk was found with admission to monitored transitional care units (OR 0.83; 95% CI 0.77-0.90) and to higher volume hospitals (OR 0.94 per 1,000 additional annual ED inpatient admissions; 95% CI 0.91-0.98).

CONCLUSIONS

ED patients admitted with respiratory conditions, MI, or sepsis are at modestly increased risk for unplanned ICU transfer and may benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute decompensation. More research is needed to determine how intermediate care units, hospital volume, time of day, and sex affect unplanned ICU transfer. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.

Validation of a clinical prediction model for early admission to the intensive care unit of patients with pneumonia

OBJECTIVES

The Risk of Early Admission to the Intensive Care Unit (REA-ICU) index is a clinical prediction model that was derived based on 4,593 patients with community-acquired pneumonia (CAP) for predicting early admission to the intensive care unit (ICU; i.e., within 3 days following emergency department [ED] presentation). This study aimed to validate the REA-ICU index in an independent sample.

METHODS

The authors retrospectively stratified 850 CAP patients enrolled in a multicenter prospective randomized trial conducted in Switzerland, using the REA-ICU index, alternate clinical prediction models of severe pneumonia (SMART-COP, CURXO-80, and the 2007 IDSA/ATS minor severity criteria), and pneumonia severity assessment tools (the Pneumonia Severity Index [PSI] and CURB-65).

RESULTS

  The rate of early ICU admission did not differ between the validation and derivation samples within each risk class of the REA-ICU index, ranging from 1.1% to 1.8% in risk class I to 27.1% to 27.6% in risk class IV. The areas under the receiver operating characteristic (ROC) curve were 0.76 (95% confidence interval [CI] = 0.70 to 0.83) and 0.80 (95% CI = 0.77 to 0.83) in the validation and derivation samples, respectively. In the validation sample, the REA-ICU index performed better than the pneumonia severity assessment tools, but failed to demonstrate an accuracy advantage over alternate prediction models in predicting ICU admission.

CONCLUSIONS

The REA-ICU index reliably stratifies CAP patients into four categories of increased risk for early ICU admission within 3 days following ED presentation. Further research is warranted to determine whether inflammatory biomarkers may improve the performance of this clinical prediction model.

Functional status does not predict complicated clinical course in older adults in the emergency department with infection

OBJECTIVES

To identify the relationship between functional status and complicated clinical course in older adults in the emergency department (ED) with suspected infection and to identify other independent predictors of complicated clinical course.

DESIGN

A prospective observational cohort study.

SETTING

An academic, tertiary care ED with 70,000 visits per year.

PARTICIPANTS

Aged 65 and older, blood cultures obtained in the ED, and final ED physician diagnosis of acute infection.

MEASUREMENTS

Functional status was obtained using the Older Americans Resources Scale (OARS). Complicated clinical course was defined as in-hospital mortality, need for intensive care unit (ICU)-level care, or worsening in sepsis criteria within 48 hours. Analysis was performed using multivariable logistic regression.

RESULTS

One hundred five participants were enrolled, 34 with the primary outcome. OARS was not predictive of complicated clinical course in univariate (P = .13) or multivariable (P = .90) models. An OARS score of 25 or less was also not significant (P = .22). Independent predictors were immunosuppression (odds ratio (OR) = 3.45, 95% confidence interval (CI) = 1.06-11.20), systolic blood pressure (OR = 0.98, 95% CI = 0.96-1.00), pulse (OR = 1.03, 95% CI = 1.00-1.06), metabolic acidosis (OR = 3.46, 95% CI = 1.08-11.09), severe sepsis or septic shock (OR = 10.24, 95% CI = 1.44-72.79), and suspected bloodstream infection (OR = 3.56, 95% CI = 1.13-11.16).

CONCLUSION

For older adults admitted to the ED with infection, functional status did not predict complicated clinical course, but several other variables were predictive, including immunosuppression, several variables associated with hypoperfusion, and suspected bloodstream infection. Emergency physicians could consider these variables as potential indicators of complicated clinical course when making disposition decisions for this population.

Burden of facial cellulitis: estimates from the Nationwide Emergency Department Sample

OBJECTIVE

Multitude of maxillofacial infections from odontogenic and nonodontogenic origins can progress to facial cellulitis, which may require an emergency department (ED) visit for appropriate care. The aim of this study was to investigate national prevalence of ED visits attributed primarily to facial cellulitis, to quantify the associated hospital charges, and to identify a cohort of population presenting to the ED with facial cellulitis.

STUDY DESIGN

The Nationwide Emergency Department Sample (NEDS) for the year 2007, a component database of the health care cost and utilization project was used for this study. All ED visits that had a primary diagnosis of facial cellulitis (ICD-9-CM code 682.0) were selected for analysis. All estimates were projected to national levels using the discharge weight variables.

RESULTS

In 2007, a total of 302,507 ED visits were attributed primarily to facial cellulitis in the USA. The average age of the patients was 35.0 years. The mean hospital charge for each ED visit was $1,024, with a total charge of $241,541,694. A total of 17.8% of ED visits were admitted into the same hospital for inpatient care, and 78.5% of ED visits were discharged routinely; 67.6% of ED visits occurred on weekdays. Private insurance payers comprised the largest proportion (31.6%).

CONCLUSIONS

This study highlights the prevalence of hospital-based ED visits primarily due to facial cellulitis in the USA in year 2007, its significant associated hospital resource utilization for treatment, and characteristics of the patient population who are likely to visit a hospital-based ED for treatment of facial cellulitis.

A prospective registry of emergency department patients admitted with infection

Background

Patients with infections account for a significant proportion of Emergency Department (ED) workload, with many hospital patients admitted with severe sepsis initially investigated and resuscitated in the ED. The aim of this registry is to systematically collect quality observational clinical and microbiological data regarding emergency patients admitted with infection, in order to explore in detail the microbiological profile of these patients, and to provide the foundation for a significant programme of prospective observational studies and further clinical research.

Methods/design

ED patients admitted with infection will be identified through daily review of the computerised database of ED admissions, and clinical information such as site of infection, physiological status in the ED, and components of management abstracted from patients' charts. This information will be supplemented by further data regarding results of investigations, microbiological isolates, and length of stay (LOS) from hospital electronic databases. Outcome measures will be hospital and intensive care unit (ICU) LOS, and mortality endpoints derived from a national death registry.

Discussion

This database will provide substantial insights into the characteristics, microbiological profile, and outcomes of emergency patients admitted with infections. It will become the nidus for a programme of research into compliance with evidence-based guidelines, optimisation of empiric antimicrobial regimens, validation of clinical decision rules and identification of outcome determinants. The detailed observational data obtained will provide a solid baseline to inform the design of further controlled trials planned to optimise treatment and outcomes for emergency patients admitted with infections.