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Lu Y, Ren C, Wu C. In-Hospital Mortality Prediction Model for Critically Ill Older Adult Patients Transferred from the Emergency Department to the Intensive Care Unit. Risk Manag Healthc Policy 2023; 16:2555-2563. [PMID: 38024492 PMCID: PMC10676667 DOI: 10.2147/rmhp.s442138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Studies on the prognosis of critically ill older adult patients admitted to the emergency department (ED) but requiring immediate admission to the intensive care unit (ICU) remain limited. This study aimed to develop an in-hospital mortality prediction model for critically ill older adult patients transferred from the ED to the ICU. Patients and Methods The training cohort was taken from the Medical Information Mart for Intensive Care IV (version 2.2) database, and the external validation cohort was taken from the Affiliated Dongyang Hospital of Wenzhou Medical University. In the training cohort, class balance was addressed using Random Over Sampling Examples (ROSE). Univariate and multivariate Cox regression analyses were performed to identify independent risk factors. These were then integrated into the predictive nomogram. In the validation cohort, the predictive performance of the nomogram was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, calibration curve, clinical utility decision curve analysis (DCA), and clinical impact curve (CIC). Results In the ROSE-balanced training cohort, univariate and multivariate Cox regression analysis identified that age, sex, Glasgow coma scale score, malignant cancer, sepsis, use of mechanical ventilation, use of vasoactive agents, white blood cells, potassium, and creatinine were independent predictors of in-hospital mortality in critically ill older adult patients, and were included in the nomogram. The nomogram showed good predictive performance in the ROSE-balanced training cohort (AUC [95% confidence interval]: 0.792 [0.783-0.801]) and validation cohort (AUC [95% confidence interval]: 0.780 [0.727-0.834]). The calibration curves were well-fitted. DCA and CIC demonstrated that the nomogram has good clinical application value. Conclusion This study developed a predictive model for early prediction of in-hospital mortality in critically ill older adult patients transferred from the ED to the ICU, which was validated by external data and has good predictive performance.
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Affiliation(s)
- Yan Lu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaoxiang Ren
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaolong Wu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
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Engebretsen S, Bogstrand ST, Jacobsen D, Rimstad R. Quality of care, resource use and patient outcome by use of emergency response team compared with standard care for critically ill medical patients in the emergency department: a retrospective single-centre cohort study from Norway. BMJ Open 2021; 11:e047264. [PMID: 34385247 PMCID: PMC8362729 DOI: 10.1136/bmjopen-2020-047264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aimed to investigate quality of care, resource use and patient outcome in management by an emergency response team versus standard care for critically ill medical patients in the emergency department (ED). The emergency response team was multidisciplinary and had eight members, with a registrar in internal medicine as team leader. DESIGN Register-based retrospective cohort study. SETTING Tertiary hospital in Norway. PARTICIPANTS The study included 1120 patients with National Early Warning Score 2 (NEWS2) 5-10 points from 2015 and 2016. Patients missing ≥3 NEWS2 part scores, <18 years and with orders 'Not for ICU' or 'Not for resuscitation' were excluded. OUTCOME MEASURES Quality of care: pain assessment documented, analgesics given within 20 min, complete set of vital signs documented and antibiotics within 60 min if sepsis. Resource use: >3 diagnostic interventions, critical care in the ED and ED length of stay (LOS) <180 min. Patient outcome: intensive care unit (ICU) admission, ICU LOS <66 hours, hospital LOS <194 hours and mortality. RESULTS The median age was 66 years, 53.5% were male, 44.3% were admitted to the ICU and the mortality rate was 10.6%. Altogether 691 patients received team management and 429 standard care. Team management had a positive association with 'complete set of vital signs documented' (OR 1.720, CI 1.254 to 2.360), 'analgesics given within 20 minutes' (OR 3.268, CI 1.375 to 7.767) and 'antibiotics within 60 minutes if sepsis' (OR 7.880, CI 3.322 to 18.691), but a negative association with ' pain assessment documented' (OR 0.068, CI 0.037 to 0.128). Team management was also associated with 'critical care in the ED' (OR 9.900, CI 7.127 to 13.751), 'ED LOS <180 min' (OR 2.944, CI 2.070 to 4.187), 'ICU admission' (OR 2.763, CI 1.962 to 3.891) and 'mortality' (OR 1.882, CI 1.142 to 3.102). CONCLUSIONS Team management showed positive results for quality of care and resource use. The results for later outcomes such as mortality, ICU LOS and hospital LOS were more ambiguous.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Rune Rimstad
- Joint Medical Services, Norwegian Armed Forces, Sessvollmoen, Norway
- Department of Corporate Governance, South-Eastern Norway Regional Health Authority, Hamar, Norway
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Engebretsen S, Bogstrand ST, Jacobsen D, Rimstad R. Characteristics, management and outcome of critically ill general medical patients in the Emergency Department: An observational study. Int Emerg Nurs 2020; 54:100939. [PMID: 33302239 DOI: 10.1016/j.ienj.2020.100939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/23/2020] [Accepted: 10/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Critically ill general medical patients are an increasing group in the Emergency Department (ED). This register-based cohort study aimed to examine these patients' characteristics, ED management and outcome, and investigate factors associated with ICU admission. METHODS The study comprised all adult medical triage 1 patients treated by a specialized multidisciplinary team in 2015 and 2016. Univariate and multivariate analysis were used. RESULTS 1294 patients were included. Mean age was 59 years, 56% (n = 725) were male, mean National Early Warning Score 2 (NEWS2) was 7, intensive care unit (ICU) admission was 56.8% (n = 735) and mortality rate was 16.8% (n = 217). Median ED length of stay (LOS) was 1.6 h, 1.2 h if admitted to ICU. The most frequent discharge diagnosis was acute poisoning (24.0%, n = 308). Younger age, male gender, arriving at nighttime weekdays, higher NEWS2 at arrival, critical care interventions or medications in the ED was associated with ICU admission. CONCLUSION More than half of the patients were admitted to ICU, and the mortality rate was 16.8%. A large proportion was diagnosed with acute poisoning. Younger age, higher NEWS and critical care in ED were associated with ICU admission. The short ED LOS suggests that management by a multidisciplinary team is beneficial.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway.
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway; Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway; Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
| | - Rune Rimstad
- Medicine, Health, Patient Safety and Integration, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway.
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Engebretsen S, Bogstrand ST, Jacobsen D, Vitelli V, Rimstad R. NEWS2 versus a single-parameter system to identify critically ill medical patients in the emergency department. Resusc Plus 2020; 3:100020. [PMID: 34223303 PMCID: PMC8244393 DOI: 10.1016/j.resplu.2020.100020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 01/01/2023] Open
Abstract
AIM To test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome 'mortality' (hospital or 30 day) and secondary outcomes 'intensive care unit (ICU) admission' and 'critical care in ED' and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. METHODS Register-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. RESULTS 1586 patients were included. NEWS2 showed poor prediction of 'mortality' (AUC 0.686, CI 0.633-0.739) and adequate prediction of 'ICU admission' (AUC 0.716, CI 0.690-0.742) and 'critical care in ED' (AUC 0.756, CI 0.732-0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with 'mortality' (OR 1.688, CI 1.052-2.708, p<0.05) and 'critical care in ED' (OR 3.267, CI 2.490-4.286, p<0.001). NEWS2 > 4 had the strongest association with 'ICU admission' (OR 2.339, CI 1.742-3.141, p<0.001). CONCLUSION For identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Valeria Vitelli
- Oslo Center for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Postboks 1122 Blindern, 0317, Oslo, Norway
| | - Rune Rimstad
- Medicine, Health, Patient Safety and Integration, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
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Smith A, Parsons M, Renouf T, Boyd S, Rogers P. A mixed-methods evaluation of a multidisciplinary point of care ultrasound program. MEDICAL TEACHER 2019; 41:223-228. [PMID: 29688110 DOI: 10.1080/0142159x.2018.1461202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND Point of Care Ultrasound (PoCUS) is well established within emergency medicine, however, the availability of formal training for other clinical disciplines is limited. Memorial University has established a cost-efficient, multidisciplinary PoCUS training program focusing on training residents' discipline-specific ultrasound skills. This study evaluates the skills, knowledge, and attitudes of residents who participated in the program. METHODS Analysis was conducted using a mixed-methods, sequential exploratory approach. Initially, a focus group of seven first year residents was conducted to generate themes that were used to guide development of a survey administered to residents over a two-year period. RESULTS Thirty residents responded to the survey (response rate 63.8%) with 53.3% meeting the training requirements for focused assessment using sonography in trauma, 43.3% for pleural effusion, 40.0% for aortic aneurysms, and 40.0% for cardiac scans. Early pregnancy assessment was the skill of least interest with 46.6% not interested. Over half the residents (53.6%) agreed or strongly agreed that a multidisciplinary program met their needs while 21.4% disagreed. The focus group found the multidisciplinary approach adequate. CONCLUSIONS A single PoCUS curriculum has been shown to meet the needs and expectations of a majority of residents from multiple disciplines. It can enhance collaboration and bridge gaps between increasingly compartmentalized practices of medicine.
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Affiliation(s)
- Andrew Smith
- a Primary Healthcare Research Unit , Memorial University of Newfoundland , St. John's , NL , USA
| | - Michael Parsons
- b Discipline of Emergency Medicine , Memorial University of Newfoundland , St. John's , NL , USA
| | - Tia Renouf
- b Discipline of Emergency Medicine , Memorial University of Newfoundland , St. John's , NL , USA
| | - Sarah Boyd
- a Primary Healthcare Research Unit , Memorial University of Newfoundland , St. John's , NL , USA
| | - Peter Rogers
- b Discipline of Emergency Medicine , Memorial University of Newfoundland , St. John's , NL , USA
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