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Tamsett Z, Douglas N, King C, Johnston T, Bentley C, Hao B, Prinsloo D, Bourke EM. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension? Emerg Med Australas 2024; 36:340-347. [PMID: 38018391 DOI: 10.1111/1742-6723.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/26/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.
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Affiliation(s)
- Zacchary Tamsett
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Ned Douglas
- Department of Anaesthesia, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cathy King
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Tanya Johnston
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Connor Bentley
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Brian Hao
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Duron Prinsloo
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
| | - Elyssia M Bourke
- Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Maldonado NG, Thompson M, Srihari C, Holtzman L, Liu J, Otero R, Chowdhury MAB, Fernandez R. Institution of a difficult airway response team for emergency department patients with anticipated or encountered difficult airways: Descriptive analysis of a 5-year experience at an academic teaching hospital. J Am Coll Emerg Physicians Open 2024; 5:e13175. [PMID: 38707982 PMCID: PMC11066591 DOI: 10.1002/emp2.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
Objectives This study aimed to describe characteristics and outcomes associated with difficult airway response team (DART) encounters in the emergency department (ED). Methods We performed a descriptive analysis of a prospective, single-center database of DART encounters in the ED from April 1, 2016 to March 31, 2021 cross-referenced with retrospective chart review. Adult ED patients ≥18 years old for whom a DART was activated were eligible. We prospectively collected activation characteristics, intubation indications, operator characteristics, and intubation methods used for DART encounters. Retrospective chart review was conducted to obtain patient demographics and outcome variables. Descriptive analyses were computed for all outcomes. Results We analyzed 89 DART encounters. No intubation attempts were made prior to DART activation in 52 cases (58.4%). The most common indications for intubation were angioedema (n = 17, 19.1%) or other airway obstruction (n = 15, 16.9%). A definitive airway was established by anesthesiology (n = 46, 51.7%), emergency medicine (n = 25, 28.1%), trauma surgery (n = 9, 10.1%), and ENT (n = 5, 5.6%). The most common method of intubation used to establish a definitive airway was video laryngoscopy with a bougie or D-blade (n = 29, 32.6%) followed by flexible fiberoptic intubation (n = 19, 21.3%). A surgical airway was required in eight encounters (cricothyrotomy [n = 4, 4.5%]; tracheostomy [n = 4, 4.5%]). Cases were managed in the ED (n = 73, 82%), operating room (OR) (n = 10, 11.2%), and intensive care unit (ICU) (n = 1, 1.1%). All patients requiring intubation had an endotracheal or surgical airway established. Conclusion Our findings provide important insights regarding ED DART utilization and have implications when considering institution of a DART in the ED.
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Affiliation(s)
- Nicholas G. Maldonado
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Meredith Thompson
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Caroline Srihari
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Liam Holtzman
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Jonathan Liu
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Rolando Otero
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | | | - Rosemarie Fernandez
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
- University of Florida College of Medicine Center for Experiential Learning and SimulationGainesvilleFloridaUSA
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Ouchi K, Haimovich A, Bowman J. Prognostic awareness of seriously ill older adults in the emergency department. Emerg Med J 2024; 41:350-351. [PMID: 38658054 PMCID: PMC11267243 DOI: 10.1136/emermed-2024-214007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Adrian Haimovich
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason Bowman
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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4
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Burke LG, Fehnel CR, Burke RC, Orav EJ, Caplan LR, Edlow J, Kumar S. Frequency of Intubation for Medicare Beneficiaries With Acute Stroke and Association With Patient Outcomes. Neurology 2024; 102:e208031. [PMID: 38295353 DOI: 10.1212/wnl.0000000000208031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 10/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intubation for acute stroke is common in the United States, with few established guidelines. METHODS This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions. RESULTS There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients (p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality. DISCUSSION Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.
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Affiliation(s)
- Laura G Burke
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Corey R Fehnel
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Ryan C Burke
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Endel J Orav
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Louis R Caplan
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Jonathan Edlow
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
| | - Sandeep Kumar
- From the Department of Emergency Medicine (L.G.B., R.C.B., J.E.); Department of Neurology (C.R.F., L.R.C., S.K.), Beth Israel Deaconess Medical Center and Harvard Medical School; Division of General Internal Medicine (E.J.O.), Brigham and Women's Hospital; and The Harvard T.H. Chan School of Public Health in Boston (L.G.B., J.E.), MA
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Chuang E, Gugliuzza S, Ahmad A, Aboodi M, Gong MN, Barnato AE. "Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital. Am J Hosp Palliat Care 2023:10499091231222926. [PMID: 38111300 PMCID: PMC11182887 DOI: 10.1177/10499091231222926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. OBJECTIVE This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. METHODS A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. RESULTS 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level. CONCLUSION Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.
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Affiliation(s)
- Elizabeth Chuang
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabrina Gugliuzza
- Department of Internal Medicine, NYU Langone Health, Mineola, NY, USA
| | - Ammar Ahmad
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York, NY, USA
| | - Michael Aboodi
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Ng Gong
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Elkbuli A, Breeding T, Ngatuvai M, Patel H, Andrade R, Rosander A, Knowlton LM, Liu H, Ang D. Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines. Am Surg 2023; 89:6098-6113. [PMID: 37515511 DOI: 10.1177/00031348231192062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
INTRODUCTION This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines. METHODS We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10. RESULTS In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score. CONCLUSION A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | | | | | - Heli Patel
- NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Ryan Andrade
- School of Osteopathic Medicine, A.T. Still University, Mesa, AZ, USA
| | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | - Lisa M Knowlton
- Department of Surgery, Division of Trauma and Surgical Critical Care, Stanford University Medical Center, Palo Alto, CA, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Upchurch CP, Wessman BT, Roberts BW, Fuller BM. Arterial to end-tidal carbon dioxide gap and its characterization in mechanically ventilated adults in the emergency department. Am J Emerg Med 2023; 73:154-159. [PMID: 37683313 DOI: 10.1016/j.ajem.2023.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE To evaluate early measurement of the arterial to end-tidal carbon dioxide (PaCO2-PetCO2) gap, a surrogate for physiologic dead space, and its association with clinical outcomes in intubated adults in the emergency department (ED). MATERIALS AND METHODS Observational cohort study of invasively mechanically ventilated adults in an academic medical center (years 2009 to 2016). The association of the PaCO2-PetCO2 gap was evaluated with respect to clinical outcomes; the primary outcome was in-hospital mortality. RESULTS 519 patients were included. 325 (63%) patients had an elevated (>5 mmHg) PaCO2-PetCO2. Patients with an elevated PaCO2-PetCO2 were significantly older, had higher APACHE II scores, more frequently had chronic obstructive pulmonary disease (COPD), had lower arterial oxygen to fraction of inspired oxygen (P:F) ratios, and were more likely to be intubated for exacerbation of COPD or sepsis. There was no difference in mortality for patients with an elevated PaCO2-PetCO2 (25% vs 26%) in unadjusted analysis (p = 0.829) or adjusted analysis (aOR = 0.81 [95% CI: 0.53-1.26]), as compared to a non-elevated PaCO2-PetCO2. CONCLUSIONS An elevated PaCO2-PetCO2 gap is common in the post-intubation period in the ED, but not significantly associated with clinical outcomes.
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Affiliation(s)
- Cameron P Upchurch
- Department of Medicine, Division of Pulmonary and Critical Care. MSC 8052-43-14. Washington University School of Medicine. 660 S. Euclid Ave. St. Louis, MO 63110, USA.
| | - Brian T Wessman
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
| | - Brian W Roberts
- Cooper University Hospital Department of Emergency Medicine One Cooper Plaza Camden, NJ 08103, USA
| | - Brian M Fuller
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
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Chary AN, Cameron-Comasco L, Shankar KN, Samuels-Kalow ME. Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient. Clin Geriatr Med 2023; 39:673-686. [PMID: 37798072 PMCID: PMC10775156 DOI: 10.1016/j.cger.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, 2450 Holcombe Boulevard, Suite 01Y, Houston, TX 77021, USA; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, 2450 Holcombe Boulevard, Suite 01Y, Houston, TX 77021, USA.
| | - Lauren Cameron-Comasco
- Department of Emergency Medicine, Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA
| | - Kalpana N Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA
| | - Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 9206, Boston, MA 02114, USA
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Ouchi K, George N, Bowman J, Block SD. Empower Emergency Physicians to Make Patient-Centered Recommendations Regarding Code Status With Serious Illness Communication Training-Resident-Desired, Standard of Emergency Care in 2023. Ann Emerg Med 2023; 82:594-597. [PMID: 37462599 PMCID: PMC11267587 DOI: 10.1016/j.annemergmed.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/30/2022] [Accepted: 06/01/2023] [Indexed: 10/23/2023]
Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.
| | - Naomi George
- Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, NM
| | - Jason Bowman
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Susan D Block
- Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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10
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Ohbe H, Ouchi K, Miyamoto Y, Ishigami Y, Matsui H, Yasunaga H, Sasabuchi Y. One-Year Functional Outcomes After Invasive Mechanical Ventilation for Older Adults With Preexisting Long-Term Care-Needs. Crit Care Med 2023; 51:584-593. [PMID: 36847518 PMCID: PMC11297629 DOI: 10.1097/ccm.0000000000005822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVES To examine 1-year functional outcomes after invasive mechanical ventilation for adults greater than or equal to 65 years with preexisting long-term care-needs. DESIGN We used medical and long-term care administrative databases. The database included data on functional and cognitive impairments that were assessed with the national standardized care-needs certification system and were categorized into seven care-needs levels based on the total daily estimated care minutes. Primary outcome was mortality and care-needs at 1 year after invasive mechanical ventilation. Outcome was stratified by preexisting care-needs at the time of invasive mechanical ventilation: no care-needs, support level 1-2 and care-needs level 1 (estimated care time 25-49 min), care-needs level 2-3 (50-89 min), and care-needs level 4-5 (≥90 min). SETTING A population-based cohort study in Tochigi Prefecture, one of 47 prefectures in Japan. PATIENTS Among people greater than or equal to 65 years old registered between June 2014 and February 2018, patients who received invasive mechanical ventilation were identified. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 593,990 eligible people, 4,198 (0.7%) received invasive mechanical ventilation. The mean age was 81.2 years, and 55.5% were male. The 1-year mortality rates after invasive mechanical ventilation in patients with no care-needs, support level 1-2 and care-needs level 1, care-needs level 2-3, and care-needs level 4-5 at the time of invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1%, respectively. Similarly, those with worsened care-needs were 22.8%, 24.2%, 11.4%, and 1.9%, respectively. CONCLUSIONS Among patients in preexisting care-needs levels 2-5 who received invasive mechanical ventilation, 76.0-79.2% died or had worsened care-needs within 1 year. These findings may aid shared decision-making among patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichiro Ishigami
- Department of Transitional and Palliative Care, Aso Iizuka Hospital, Fukuoka, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Busch JM, Arnold I, Kellett J, Brabrand M, Bingisser R, Nickel CH. Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients. Int J Clin Pract 2022; 2022:7281693. [PMID: 36225535 PMCID: PMC9525775 DOI: 10.1155/2022/7281693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Jeannette-Marie Busch
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H. Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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12
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Sarbazi-Golezari A, Namdar P, Yousefian S, Mirzadeh M, Farnood A, Modirian E. Prognosis of patients with tracheal intubation in the emergency department. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021; 41:81-84. [PMID: 38620921 PMCID: PMC8321958 DOI: 10.1016/j.tacc.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/22/2022]
Abstract
Background Intubation of critically ill patients is one of the increasing emergency procedures. We designed this study to determine age and sex-related mortality rates after emergency intubation. Methods This retrospective study collected and analyzed non-trauma intubated patients in a referral hospital from the years 2017-2019 and before the appearance of COVID-19. Patients who were intubated outside of emergency by EMS technicians were excluded. We recorded data of intubated patients, like sex, age, length of being intubated and final diagnosis. P values of less than 0.05 were significant. Results Data of 520 non-trauma intubated patients were collected and analyzed. More than 64% of the patients were over 65 years old and had a higher mortality rate (86.7%; P < 0.001) than younger patients. The overall in-hospital mortality rate was 80%. More than three quarters of the decedents died within a week of intubation (P < 0.001). There was no significant relationship between sex and mortality rate (P = 0.535). Conclusion Our data showed that with increased age there was a decrease in the chance of being extubated.
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Affiliation(s)
| | - Peyman Namdar
- Department of Emergency Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Shiva Yousefian
- Department of Emergency Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Monirsadat Mirzadeh
- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Afsaneh Farnood
- Department of Emergency Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Ehsan Modirian
- Department of Emergency Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
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13
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Ruiz VR, Grande-Ratti MF, Martínez B, Midley A, Sylvestre V, Mayer GF. In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department. ENFERMERIA INTENSIVA 2021; 32:145-152. [PMID: 34340950 DOI: 10.1016/j.enfie.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/04/2020] [Indexed: 10/20/2022]
Abstract
AIMS To identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED). METHODS Retrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders. RESULTS A total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95% CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95% CI 1.91-10.04), Charlson index (OR 1.19; 95% CI 1.02-1.38), APACHE II score (OR 1.07; 95% CI 1.02-1.12), and SOFA score (OR 1.14; 95% CI 1.03-1.27). DISCUSSION Our IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States. CONCLUSIONS Although the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.
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Affiliation(s)
- V R Ruiz
- Sección de Rehabilitación y Cuidados Respiratorios del Paciente Crítico, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M F Grande-Ratti
- Área de Investigación en Medicina Interna, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - B Martínez
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Midley
- Sección de Rehabilitación y Cuidados Respiratorios del Paciente Crítico, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - V Sylvestre
- Central de Emergencias del Adulto, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G F Mayer
- Sección de Rehabilitación y Cuidados Respiratorios del Paciente Crítico, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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14
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Factores asociados a mortalidad intrahospitalaria en pacientes adultos mayores con asistencia ventilatoria mecánica invasiva en el servicio de urgencias. ENFERMERIA INTENSIVA 2021. [DOI: 10.1016/j.enfi.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Saeed MA, Almoosawi BM, Awainati MA, Barni MA, Abbas F. Characteristics and outcomes of mechanically ventilated elderly patients in the absence of an end-of-life care policy: a retrospective study from Bahrain. Ann Saudi Med 2021; 41:222-231. [PMID: 34420398 PMCID: PMC8380277 DOI: 10.5144/0256-4947.2021.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Globally, the percentage of elderly patients has been increasing, leading to a higher demand for healthcare resources and intensive care. Bahrain has a majority Muslim population and Islam governs most policies, including end-of-life care. All patients at our institute receive full resuscitative measures regardless of the prognosis, leading to a high number of mechanically ventilated patients. OBJECTIVES Assess characteristics, outcomes, theoretical costs, and use of antibiotics in critically ill elderly patients requiring mechanical ventilation. DESIGN Retrospective. SETTING Intensive care unit and general ward of a tertiary medical care center. PATIENTS AND METHODS We studied all elderly patients (≥60 years old) admitted under general medicine in the period of January to June 2018 who needed intensive care and were intubated. MAIN OUTCOME MEASURES The duration of mechanical ventilation, theoretical costs, antibiotic usage. SAMPLE SIZE 140 patients. RESULTS Of 140 patients, 136 died (97%) and half of the deaths (n=69, 50.7%) occurred within the first 24 hours of intubation. Sixty-nine (79.3%) of the patients on short-term ventilation (≤96 hours) died within 24 hours of intubation, while the four survivors were on long-term ventilation (>96 hours) (P<.001). All the nonsurviving patients (n=136) were on antimicrobial therapy, mostly for hospital-acquired infections. The median (interquartile range) APACHE II score was relatively high at 28.0 (8.0) with significantly higher scores in the early mortality group compared to the late mortality group (30 [10] vs 26 [7], P=.013) and higher scores in the short-term vs long-term ventilation group (29 [10] vs 26 [7], P=.029). The median theoretical cost per patient in the early and late mortality groups was USD 10 731 and USD 30 660, respectively (P<.001). CONCLUSIONS Given that less than 3% of patients had a favorable outcome, 50% of the cases died within 24 hours after intubation, hospital costs and antimicrobial use were high, the current policy of "full resuscitative measures for all" should be revised. We suggest implementing an end-of-life care policy, since the goal of resuscitation is to reverse premature death, not prolong the dying process. LIMITATIONS Small sample size and absence of long-term follow-up. Theoretical costs were used as no direct calculated costs were available in our hospital. CONFLICT OF INTEREST None.
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Affiliation(s)
- Mahmood Al Saeed
- From the Department of Internal Medicine, Salmaniya Medical Complex, Manama, Bahrain
| | | | | | - Mohammed Al Barni
- From the Department of Internal Medicine, Salmaniya Medical Complex, Manama, Bahrain
| | - Fadhel Abbas
- From the Department of Internal Medicine, Salmaniya Medical Complex, Manama, Bahrain
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16
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Simon NR, Jauslin AS, Rueegg M, Twerenbold R, Lampart M, Osswald S, Bassetti S, Tschudin-Sutter S, Siegemund M, Nickel CH, Bingisser R. Association of Frailty with Adverse Outcomes in Patients with Suspected COVID-19 Infection. J Clin Med 2021; 10:jcm10112472. [PMID: 34199572 PMCID: PMC8199640 DOI: 10.3390/jcm10112472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/27/2021] [Accepted: 05/30/2021] [Indexed: 12/17/2022] Open
Abstract
Older age and frailty are predictors of adverse outcomes in patients with COVID-19. In emergency medicine, patients do not present with the diagnosis, but with suspicion of COVID-19. The aim of this study was to assess the association of frailty and age with death or admission to intensive care in patients with suspected COVID-19. This single-centre prospective cohort study was performed in the Emergency Department of a tertiary care hospital. Patients, 65 years and older, with suspected COVID-19 presenting to the Emergency Department during the first wave of the pandemic were consecutively enrolled. All patients underwent nasopharyngeal SARS-CoV-2 PCR swab tests. Patients with a Clinical Frailty Scale (CFS) > 4, were considered to be frail. Associations between age, gender, frailty, and COVID-19 status with the composite adverse outcome of 30-day-intensive-care-admission and/or 30-day-mortality were tested. In the 372 patients analysed, the median age was 77 years, 154 (41.4%) were women, 44 (11.8%) were COVID-19-positive, and 125 (33.6%) were frail. The worst outcome was seen in frail COVID-19-patients with six (66.7%) adverse outcomes. Frailty (CFS > 4) and COVID-19-positivity were associated with an adverse outcome after adjustment for age and gender (frailty: OR 5.01, CI 2.56–10.17, p < 0.001; COVID-19: OR 3.47, CI 1.48–7.89, p = 0.003). Frailty was strongly associated with adverse outcomes and outperformed age as a predictor in emergency patients with suspected COVID-19.
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Affiliation(s)
- Noemi R. Simon
- Emergency Department, University Hospital Basel, 4031 Basel, Switzerland; (N.R.S.); (A.S.J.); (M.R.); (C.H.N.)
| | - Andrea S. Jauslin
- Emergency Department, University Hospital Basel, 4031 Basel, Switzerland; (N.R.S.); (A.S.J.); (M.R.); (C.H.N.)
| | - Marco Rueegg
- Emergency Department, University Hospital Basel, 4031 Basel, Switzerland; (N.R.S.); (A.S.J.); (M.R.); (C.H.N.)
| | - Raphael Twerenbold
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland; (R.T.); (M.L.); (S.O.)
| | - Maurin Lampart
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland; (R.T.); (M.L.); (S.O.)
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland; (R.T.); (M.L.); (S.O.)
| | - Stefano Bassetti
- Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland;
| | - Sarah Tschudin-Sutter
- Division of Infectious Disease & Hospital Epidemiology, University Hospital Basel, 4031 Basel, Switzerland;
- Department of Clinical Research, University of Basel, C/O University Hospital Basel, 4031 Basel, Switzerland;
| | - Martin Siegemund
- Department of Clinical Research, University of Basel, C/O University Hospital Basel, 4031 Basel, Switzerland;
- Department of Intensive Care, University Hospital Basel, 4031 Basel, Switzerland
| | - Christian H. Nickel
- Emergency Department, University Hospital Basel, 4031 Basel, Switzerland; (N.R.S.); (A.S.J.); (M.R.); (C.H.N.)
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, 4031 Basel, Switzerland; (N.R.S.); (A.S.J.); (M.R.); (C.H.N.)
- Correspondence: ; Tel.: +41-61-265-58-30
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17
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Colleran CA, Brewster CT, Kroemer AJ, Miccio B, Brown Iii CA, Carlson JN. Factors Associated With Poor Long-Term Outcomes After Emergency Department Intubation. Cureus 2021; 13:e15178. [PMID: 34178499 PMCID: PMC8216642 DOI: 10.7759/cureus.15178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction While immediate complications of ED patients undergoing endotracheal intubation (ETI) have been explored, the relationship between ED ETI and patient status at hospital discharge is unknown. Methods We performed a retrospective review of all intubations performed in our ED for one calendar year in adult patients (>18 years of age). We abstracted patient and ETI factors (indication, complications, etc.) to determine their impact on patient outcomes. We defined a poor outcome as either (1) death or discharge to a nursing home if admitted to the hospital from home or (2) death if admitted to the hospital from a nursing home. We examined the univariate odds ratios for poor outcomes. Results We identified 122 intubations; 64 (52.5%) had a poor outcome and 58 (47.5%) did not have a poor outcome. Age in years (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07) and ETI performed for an indication of "cardiac arrest" (OR 4.49, 95% CI 1.55-13.01) were the only variables associated with a poor outcome. Other patients and intubation variables were not associated with a poor outcome including; gender, difficult airway characteristics, intubator skill level, first attempt success, airway complications, and post-intubation hypoxia or hypotension. Conclusion In our sample from a single ED, over 50% of patients who undergo ED ETI either died in the hospital or failed to return home. While age and an ETI indication of "cardiac arrest" were associated with poor outcomes, future work is required to validate our findings in a larger cohort.
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Affiliation(s)
- Caroline A Colleran
- Emergency Medicine, Allegheny Health Network (AHN) Saint Vincent Hospital, Erie, USA.,Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Craig T Brewster
- Emergency Medicine, Allegheny Health Network (AHN) Saint Vincent Hospital, Erie, USA.,Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Andrew J Kroemer
- Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA.,Emergency Medicine, Allegheny Health Network (AHN) Saint Vincent Hospital, Erie, USA
| | - Brendan Miccio
- Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA.,Emergency Medicine, Allegheny Health Network (AHN) Saint Vincent Hospital, Erie, USA
| | - Calvin A Brown Iii
- Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Jestin N Carlson
- Emergency Medicine, Allegheny Health Network (AHN) Saint Vincent Hospital, Erie, USA.,Emergency Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
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18
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Zirulnik A, Chary A, Thatphet P, Wongtangman T, Gacioch B, Ouchi K, Kennedy M, Liu SW. The Interface of Emergency and Palliative Care. JOURNAL OF GERIATRIC EMERGENCY MEDICINE 2021; 2:4. [PMID: 34296215 PMCID: PMC8294785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Alexander Zirulnik
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anita Chary
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Phraewa Thatphet
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thiti Wongtangman
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Brian Gacioch
- Section of Hospice and Palliative Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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19
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Khoujah D, Cimino-Fiallos N. The geriatric emergency literature 2020: COVID and beyond. Am J Emerg Med 2021; 44:177-183. [PMID: 33905980 DOI: 10.1016/j.ajem.2021.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 01/11/2023] Open
Abstract
Older adults are a rapidly growing patient population with unique characteristics and health considerations. Over the past few years, emergency physicians have started to recognize the complexities and importance of Geriatric Emergency Medicine. Several noteworthy elements of their healthcare were brought to the forefront of emergency medicine because this especially vulnerable patient population was disproportionately affected by the pandemic. Clinical topics such as delirium, telehealth, end-of-life care, and elder abuse came into focus; select relevant articles are reviewed. We also highlight equally notable literature which address clinically challenging topics, such as hip fractures and syncope. Finally, articles about improving the experience of and decreasing recidivism in geriatric emergency department patients are reviewed. In short, this review article summarizes geriatric emergency medicine literature that can help you improve your practice while caring for older adults.
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Affiliation(s)
- Danya Khoujah
- Department of Emergency Medicine, Franklin Square Medical Center, Adjunct Volunteer Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Nicole Cimino-Fiallos
- Department of Emergency Medicine, Meritus Medical Center, US Acute Care Solutions, Hagerstown, MD, United States of America
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20
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Pellatt RAF, Bolot R, Sweeny AL, Gibbs C, O'Gorman J. Rural and Remote Intubations in an Australian Air Medical Retrieval Service: A Retrospective Cohort Study. Air Med J 2021; 40:251-258. [PMID: 34172233 DOI: 10.1016/j.amj.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Critically unwell patients in rural and remote areas of Queensland, Australia, often require airway management with rapid sequence intubation before retrieval to a tertiary center. Retrieval Services Queensland coordinate retrievals and support rural hospitals, including via telehealth. This study compared the demographics of patients intubated by a retrieval team including a LifeFlight Retrieval Medicine doctor with those intubated by the local hospital team. METHODS This was a retrospective cohort study of patients intubated in hospitals in Queensland, Australia, requiring subsequent air medical retrieval between January and December 2019. The data collected included the time of day, mission priority, geographic location, diagnosis, and failure/assistance with intubation. Descriptive statistics were complemented by regression analyses. RESULTS In 2019, 684 patients were intubated in hospitals in Queensland, Australia, requiring air medical retrieval by a team including a LifeFlight Retrieval Medicine doctor. One hundred thirty-one (19.2%) were intubated by the retrieval team, and 553 (80.8%) were intubated by the hospital team. In the most rural and remote areas, 64 (43.2%) of the patients were intubated by the retrieval team compared with 84 (56.8%) by the hospital team. CONCLUSION A retrieval team is more likely to intubate patients in remote hospitals in Queensland, Australia. Remote hospitals should be given preference for dispatch of the retrieval team for assistance with critical patients.
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Affiliation(s)
- Richard A F Pellatt
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia; Bond University, Gold Coast, Queensland, Australia; Griffith University, Southport, Gold Coast, Queensland, Australia.
| | - Renee Bolot
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
| | - Amy L Sweeny
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia; Bond University, Gold Coast, Queensland, Australia; Griffith University, Southport, Gold Coast, Queensland, Australia
| | - Clinton Gibbs
- Retrieval Services Queensland, Townsville, Queensland, Australia
| | - Jacob O'Gorman
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia; Emergency Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Emergency Department, Gladstone Hospital, Gladstone, Queensland, Australia; Royal Flying Doctor Service, Queensland Section, Brisbane, Australia
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21
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Elías MN, Munro CL, Liang Z. Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors. Am J Crit Care 2021; 30:e40-e47. [PMID: 33644810 PMCID: PMC10467820 DOI: 10.4037/ajcc2021221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit. OBJECTIVE To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors. METHODS The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates. RESULTS The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = -0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = -0.373, P = .008) were negatively associated with DCCST scores. CONCLUSIONS The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.
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Affiliation(s)
- Maya N Elías
- Maya N. Elías is a postdoctoral research fellow, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
| | - Cindy L Munro
- Cindy L. Munro is dean and a professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
| | - Zhan Liang
- Zhan Liang is an assistant professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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22
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Morales A, Schultz KC, Gao S, Murphy A, Barnato AE, Fanning JB, Hall DE. Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations. Palliat Med Rep 2021; 2:71-83. [PMID: 33860283 PMCID: PMC8043084 DOI: 10.1089/pmr.2020.0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.
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Affiliation(s)
- Andre Morales
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevan C. Schultz
- University Center for Social and Urban Research (UCSUR), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shasha Gao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | | | - Amber E. Barnato
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Joseph B. Fanning
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E. Hall
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Chary AN, Naik AD, Ouchi K. It Takes Courage to Pause: Rapid Goals-of-Care Conversations in the Emergency Department. JOURNAL OF GERIATRIC EMERGENCY MEDICINE 2021; 2:4. [PMID: 35036995 PMCID: PMC8759756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine
| | - Aanand D Naik
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital
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Ribeiro SCDC. Decreased Glasgow Coma Scale score in medical patients as an indicator for intubation in the Emergency Department: Why are we doing it? Clinics (Sao Paulo) 2021; 76:e2282. [PMID: 33681943 PMCID: PMC7920397 DOI: 10.6061/clinics/2021/e2282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/02/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sabrina Correa da Costa Ribeiro
- Emergencias Clinicas, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Elías MN, Munro CL, Liang Z. Sleep Quality Associated With Motor Function Among Older Adult Survivors of Critical Illness. Nurs Res 2020; 69:322-328. [PMID: 31972850 PMCID: PMC11080999 DOI: 10.1097/nnr.0000000000000418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Poor sleep is associated with worse motor function in older adults. Sleep may affect motor function specifically among older adults recovering from critical illness after transfer out of an intensive care unit (ICU). OBJECTIVES Describe motor function (grip strength) of older ICU survivors and explore relationships between sleep and ICU-acquired weakness in the early post-ICU transition period. METHODS We enrolled 30 older adults who were functionally independent prior to hospitalization, mechanically ventilated while in ICU, and within 24-48 hours post-ICU discharge. Handgrip dynamometry assessed post-ICU motor function (fully corrected T score on the National Institutes of Health Motor Battery Grip Strength Test). Actigraphy estimated post-ICU sleep duration (total sleep time [TST]) and fragmentation (wake after sleep onset) over two consecutive nights from 22:00 p.m. to 06:00 a.m.. We identified differences in grip strength by history of obstructive sleep apnea (OSA) using independent-samples t tests. We examined associations between sleep duration and grip strength using exploratory multivariate regression analyses, after adjustment for clinically relevant covariates. RESULTS Grip strength among this cohort of older ICU survivors was almost 2 SDs below the norm for healthy older adults, indicating considerable ICU-acquired weakness. Grip strength was lower among subjects with history of OSA than those without OSA. Greater TST was associated with worse grip strength, after adjusting for history of OSA and Pittsburgh Sleep Quality Index global score. Moreover, among the subset of male subjects (n = 19), greater TST was significantly and negatively associated with grip strength, after adjusting for Acute Physiology, Age, and Chronic Health Evaluation III score, and Pittsburgh Sleep Quality Index global score. DISCUSSION Sleep promotion may be a potentially modifiable risk factor to mitigate ICU-acquired weakness in older ICU survivors. We propose that improving sleep throughout recovery from critical illness may indirectly promote better outcomes, as poor grip strength is linked to longer length of hospital stay, higher acuity of discharge disposition, and worsened functional decline in older adults.
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Affiliation(s)
- Maya N Elías
- Maya N. Elías, PhD, RN, is Postdoctoral Research Fellow; Cindy L. Munro, PhD, RN, ANP-BC, FAAN, FAANP, FAAAS, is Dean and Professor; and Zhan Liang, PhD, RN, is Assistant Professor, University of Miami School of Nursing and Health Studies, Coral Gables, Florida
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26
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Elías MN, Munro CL, Liang Z. Executive Function, Dexterity, and Discharge Disposition in Older Intensive Care Unit Survivors. Am J Crit Care 2020; 29:484-488. [PMID: 33130868 PMCID: PMC10467841 DOI: 10.4037/ajcc2020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Dexterity is a component of motor function. Executive function, a subdomain of cognition, may affect dexterity in older adults recovering from critical illness after discharge from an intensive care unit (ICU). OBJECTIVES To explore associations between executive function (attention and cognitive flexibility) and dexterity (fine motor coordination) in the early post-ICU period and examine dexterity by acuity of discharge disposition. METHODS The study involved 30 older adults who were functionally independent before hospitalization, underwent mechanical ventilation in the ICU, and had been discharged from the ICU 24 to 48 hours previously. Dexterity was evaluated with the National Institutes of Health Toolbox (NIHTB) Motor Battery 9-Hole Pegboard Dexterity Test (PDT); attention, with the NIHTB Cognition Battery Flanker Inhibitory Control and Attention Test (FICAT); and cognitive flexibility, with the NIHTB Cognition Battery Dimensional Change Card Sort Test (DCCST). Exploratory regression was used to examine associations between executive function and dexterity (fully corrected T scores). Independent-samples t tests were used to compare dexterity between participants discharged home and those discharged to a facility. RESULTS FICAT (β = 0.375, P = .03) and DCCST (β = 0.698, P = .001) scores were independently and positively associated with PDT scores. Further, PDT scores were worse among participants discharged to a facility than among those discharged home (mean [SD], 26.71 [6.14] vs 36.33 [10.30]; t24 = 3.003; P = .006). CONCLUSIONS Poor executive function is associated with worse dexterity; thus, dexterity may be a correlate of both post-ICU cognitive impairment and functional decline. Performance on dexterity tests could identify frail older ICU survivors at risk for worse discharge outcomes.
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Affiliation(s)
- Maya N Elías
- Maya N. Elías is a postdoctoral research fellow, Cindy L. Munro is dean and a professor, and Zhan Liang is an assistant professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
| | - Cindy L Munro
- Maya N. Elías is a postdoctoral research fellow, Cindy L. Munro is dean and a professor, and Zhan Liang is an assistant professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
| | - Zhan Liang
- Maya N. Elías is a postdoctoral research fellow, Cindy L. Munro is dean and a professor, and Zhan Liang is an assistant professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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Ouchi K, Lo Bello J, Moseley E, Lindvall C. Long-Term Prognosis of Older Adults Who Survive Emergency Mechanical Ventilation. J Pain Symptom Manage 2020; 60:1019-1026. [PMID: 32540468 PMCID: PMC8164382 DOI: 10.1016/j.jpainsymman.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Emergent mechanical ventilation represents an important inflection point in seriously ill older adults' illness trajectories. Data are lacking on the long-term prognosis after surviving mechanical ventilation to inform shared decision making in serious illness conversations. OBJECTIVES Describe the long-term prognosis of older adults who survive emergency mechanical ventilation to inform shared decision making. METHODS This is a retrospective cohort study from a single-center intensive care unit in an academic, urban, and tertiary care medical center. We included adults aged 75 years and older consecutively admitted with mechanical ventilation between 2008 and 2012 in the Multiparameter Intelligent Monitoring of Intensive Care III database. We excluded patients who were electively admitted. Our primary outcome was the long-term prognosis after leaving the hospital stratified by discharge location. Our secondary outcome was the frequency of documented serious illness conversations within 48 hours of hospitalization recommended by the National Quality Forum. RESULTS We identified 415 patients (454 hospital admissions) consecutively admitted to the intensive care unit. The median age was 82.6 years, 54.0% were female, 78.2% were white, non-Hispanic, and in-hospital mortality rate was 36.6%. Among the survivors, the median survival after hospital discharge was 163.5 days (interquartile range 37.5-476.8). Only 49.1% of patients had documented serious illness conversations within 48 hours of hospitalization. About 63.4% of patients (59 of 93) who were discharged to long-term acute care hospitals died by six months. CONCLUSION This study demonstrated the long-term prognosis of older adults who underwent emergent mechanical ventilation. These data could be used to inform shared decision making in serious illness conversations.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA; Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA.
| | - Josephine Lo Bello
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Ann Emerg Med 2020; 76:751-756. [PMID: 32747084 DOI: 10.1016/j.annemergmed.2020.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 11/21/2022]
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Haas LEM, Bakhshi-Raiez F, van Dijk D, de Lange DW, de Keizer NF. Outcomes of Intensive Care Patients Older Than 90 Years: An 11-Year National Observational Study. J Am Geriatr Soc 2020; 68:1842-1846. [PMID: 32592608 DOI: 10.1111/jgs.16624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVES Many intensive care unit (ICU) physicians are reluctant to admit patients aged 90 years and older, although evidence to support these decisions is scarce. Although the body of evidence on outcomes of patients aged 80 years and older is growing, it does not include patients aged 90 years and older. The aim of this study was to compare the short- and long-term mortality of ICU patients aged 90 years and older in the Netherlands with ICU patients aged 80 to 90 years, that is, octogenarians. DESIGN Multicenter national cohort study over an 11-year period (2008-2018), using data of the National Intensive Care Evaluation (NICE) registry and the Dutch insurance claims registry. SETTING All 82 ICUs in the Netherlands. PARTICIPANTS All patients aged 80 years and older at the time of ICU admission. MEASUREMENTS A total of 104,754 patients aged 80 years and older, of whom 9,495 (9%) were 90 years and older, were admitted to Dutch ICUs during the study period. RESULTS ICU mortality of the patients aged 90 years and older was lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P = .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001) and after 1-year mortality was 55.0% vs 42.7%; P < .001. CONCLUSION In the Netherlands, mortality rates of patients aged 90 years and older admitted to the ICU are not as disappointing as often assumed. They have a lower ICU mortality and a similar hospital mortality compared with octogenarians. Nevertheless, their longer term mortality is higher compared with octogenarians. However, almost 3 of 4 patients leave the hospital alive, and almost half of the patients aged 90 years and older are still alive 1 year after their ICU admission. J Am Geriatr Soc 68:1842-1846, 2020.
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Affiliation(s)
- Lenneke E M Haas
- Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diederik van Dijk
- Department of Intensive Care, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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Kaeppeli T, Rueegg M, Dreher-Hummel T, Brabrand M, Kabell-Nissen S, Carpenter CR, Bingisser R, Nickel CH. Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department. Ann Emerg Med 2020; 76:291-300. [PMID: 32336486 DOI: 10.1016/j.annemergmed.2020.03.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale. METHODS This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher. RESULTS A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880). CONCLUSION The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.
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Affiliation(s)
- Tobias Kaeppeli
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Marco Rueegg
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Søren Kabell-Nissen
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
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Siuba MT, Dugar S, Shekar K. Treading Lightly in a Pandemic: #Zentensivist Reflections on COVID-19. Chest 2020; 158:471-473. [PMID: 32330460 PMCID: PMC7172855 DOI: 10.1016/j.chest.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Matthew T Siuba
- Cleveland Clinic, Department of Critical Care Medicine, Respiratory Institute, Cleveland, OH.
| | - Siddharth Dugar
- Cleveland Clinic, Department of Critical Care Medicine, Respiratory Institute, Cleveland, OH
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Queensland, Australia; University of Queensland, Brisbane, Bond University, Gold Coast, Queensland, Australia
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Meagher AD, Lin A, Mandell SP, Bulger E, Newgard C. A Comparison of Scoring Systems for Predicting Short- and Long-term Survival After Trauma in Older Adults. Acad Emerg Med 2019; 26:621-630. [PMID: 30884022 DOI: 10.1111/acem.13727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/18/2019] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems. METHODS This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS). RESULTS There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI). CONCLUSIONS Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.
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Affiliation(s)
- Ashley D. Meagher
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
- Division of General Surgery Department of Surgery Indiana University Indianapolis IN
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
| | - Samuel P. Mandell
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
| | - Eileen Bulger
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
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Montoneri G, Noto P, Trovato FM, Mangano G, Malatino L, Carpinteri G. Outcomes of non-invasive ventilation in 'very old' patients with acute respiratory failure: a retrospective study. Emerg Med J 2019; 36:303-305. [PMID: 30944114 DOI: 10.1136/emermed-2018-207563] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 11/27/2018] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Non-invasive ventilation (NIV) is increasingly used to support very old (aged ≥85 years) patients with acute respiratory failure (ARF). This retrospective observational study evaluated the impact of NIV on the prognosis of very old patients who have been admitted to the intermediate care unit (IMC) of the Emergency Department of the University Hospital Policlinico-Vittorio Emanuele of Catania for ARF. METHODS All patients admitted to the IMC between January and December 2015 who received NIV as the treatment for respiratory failure were included in this study. Outcomes of patients aged ≥85 years were compared with lower ages. The expected intrahospital mortality was calculated through the Simplified Acute Physiology Score (SAPS) II and compared with the observed mortality. RESULTS The mean age was 87.9±2.9 years; the M:F ratio was approximately 1:3. The average SAPS II was 50.1±13.7. The NIV failure rate was 21.7%. The mortality in the very old group was not statistically different from the younger group (20% vs 25.6%; d=5.6%; 95% CI -8% to 19%; p=0.404). The observed mortality was significantly lower than the expected mortality in both the group ≥85 (20.0% vs 43.4%, difference=23.4%; 95% CI 5.6% to 41.1%, p=0.006) and the younger group (25.6% vs 38.5%, difference=12.9%; 95% CI -0.03% to 25.8%, p=0.046). In both age groups, patients treated with NIV for chronic obstructive pulmonary disease had lower mortalities than those treated for other illnesses, although this was statistically significant only in the younger group. CONCLUSION In very old patients, when used with correct indications, NIV was associated with mortality similar to younger patients. Patients receiving NIV had lower than expected mortality in all age groups.
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Affiliation(s)
- Gaetano Montoneri
- Emergency Medicine Unit, Azienda Ospedaliero - Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Paola Noto
- Emergency Medicine Unit, Azienda Ospedaliero - Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Francesca Maria Trovato
- Emergency Medicine Unit, Azienda Ospedaliero - Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy.,Department of Clinical and Experimental Medicine, Università degli Studi di Catania, Scuola di Medicina, Catania, Italy
| | - Giuseppe Mangano
- Emergency Medicine Unit, Azienda Ospedaliero - Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Lorenzo Malatino
- Department of Clinical and Experimental Medicine, Università degli Studi di Catania, Scuola di Medicina, Catania, Italy
| | - Giuseppe Carpinteri
- Emergency Medicine Unit, Azienda Ospedaliero - Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
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Characteristics and outcome of Emergency Department intubation in geriatric patients. Eur Geriatr Med 2018; 9:623-629. [PMID: 34654219 DOI: 10.1007/s41999-018-0085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The number of elderly patients admitted to the Emergency Department (ED) continues to grow due to the natural aging of the population. Consequently, tracheal intubation will be increasingly used in the oldest old. The objective of this retrospective study is to evaluate the characteristics and outcome of patients of 75 years and older undergoing an endotracheal intubation in the ED. METHODS In a single center, retrospective study we reviewed digital medical files of patients of 75 years and older in the period from 1/01/2008 to 31/12/2010, who were admitted to the ED of the Universitair Ziekenhuis Brussel in Brussels, Belgium and underwent endotracheal intubation. Survival served as primary outcome and survival without sequelae as secondary endpoint. RESULTS In the study period, 88 patients of 75 years and older were intubated in the ED. Sixty three (72%) patients died after intubation and 25 (28%) survived until discharge. All 23 patients (26%), who were intubated during cardiopulmonary resuscitation died. A survival rate of 48% was observed in patients, who were intubated for respiratory failure (28%), intracerebral hemorrhage or ischemic stroke (17%), cardiac failure (8%) or other reasons. Non-survivors were significant older, of male sex, had higher APACHE scores and more frequently used cholesterol lowering drugs. CONCLUSION Senior adults, aged 75 years or older and undergoing endotracheal intubation at the ED, have a high mortality rate. Younger age and female sex at admission were positively correlated with survival. Of those who left the hospital, one-third were able to return home without major sequelae.
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