1
|
Wasingya-Kasereka L, Nabatanzi P, Nakitende I, Nabiryo J, Namujwiga T, Kellett J. Two simple replacements for the Triage Early Warning Score to facilitate the South African Triage Scale in low resource settings. Afr J Emerg Med 2021; 11:53-59. [PMID: 33489734 PMCID: PMC7806646 DOI: 10.1016/j.afjem.2020.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/17/2020] [Accepted: 11/30/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The South African Triage Scale (SATS) requires the calculation of the Triage Early Warning Score (TEWS), which takes time and is prone to error. AIM to derive and validate triage scores from a clinical database collected in a low-resource hospital in sub-Saharan Africa over four years and compare them with the ability of TEWS to triage patients. METHODS A retrospective observational study carried out in Kitovu Hospital, Masaka, Uganda as part of an ongoing quality improvement project. Data collected on 4482 patients was divided into two equal cohorts: one for the derivation of scores by logistic regression and the other for their validation. RESULTS Two scores identified the largest number of patients with the lowest in-hospital mortality. A score based on oxygen saturation, mental status and mobility had a c statistic for discrimination of 0.83 (95% CI 0.079-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. Another score based on respiratory rate, mental status and mobility had a c statistic of 0.82 (95% CI 0.078-0.87) in the derivation, and 0.81 (95% CI 0.77-0.86) in the validation cohort. The oxygen saturation-based score of zero points identified 51% of patients in the derivation cohort who had in-hospital mortality rate of 0.5%, and 49% of patients in the validation cohort who had in-hospital mortality of 1.0%. A respiratory rate-based score of zero points identified 45% in the derivation cohort who had in-hospital mortality rate of 0.5%, and 44% of patients in the validation cohort who had in-hospital mortality of 0.8%. Both scores had comparable performance to TEWS. CONCLUSION Two easy to calculate scores have comparable performance to TEWS and, therefore, could replace it to facilitate the adoption of SATS in low-resource settings.
Collapse
Affiliation(s)
| | | | | | - Joan Nabiryo
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | | | - John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Kitovu Hospital Study Group
- Kitovu Hospital, Masaka, Uganda
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| |
Collapse
|
2
|
Wasingya-Kasereka L, Nakitende I, Nabiryo J, Namujwiga T, Kellett J. Presenting symptoms, diagnoses and in-hospital mortality in a low resource hospital environment. QJM 2021; 114:25-31. [PMID: 32415975 DOI: 10.1093/qjmed/hcaa169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/08/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The relationship between symptoms, signs and discharge diagnoses with in-hospital mortality is poorly defined in low-resource settings. AIM To explore the prevalence of presenting symptoms, signs and discharge diagnoses of medical patients admitted to a low-resource sub-Saharan hospital and their association with in-hospital mortality. METHODS In this prospective observational study, the presenting symptoms and signs of all medical patients admitted to a low-resource hospital in sub-Saharan Africa, their discharge diagnoses and in-hospital mortality were recorded. RESULTS Pain, gastro-intestinal complaints and feverishness were the commonest presenting symptoms, but none were associated with in-hospital mortality. Only headache was associated with decreased mortality, and no symptom was associated with increased in-hospital mortality. Malaria was the commonest diagnosis. Vital signs, mobility, mental alertness and mid-upper arm circumference (MUAC) had the strongest association with in-hospital mortality. Tuberculosis and cancer were the only diagnoses associated with in-hospital mortality after adjustment for these signs. CONCLUSION Vital signs, mobility, mental alertness and MUAC had the strongest association with in-hospital mortality. All these signs can easily be determined at the bedside at no additional cost and, after adjustment for them by logistic regression the only diagnoses that remain statistically associated with in-hospital mortality are tuberculosis and cancer.
Collapse
Affiliation(s)
| | - I Nakitende
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Nabiryo
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| |
Collapse
|
3
|
Nakitende I, Nabiryo J, Namujwiga T, Wasingya-Kasereka L, Kellett J. Do different patient populations need different early warning scores? The performance of nine different early warning scores used on acutely ill patients admitted to a low-resource hospital in sub-Saharan Africa. Clin Med (Lond) 2019; 20:67-73. [PMID: 31704729 DOI: 10.7861/clinmed.2019-0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Early warning scores (EWS) generated in a developed healthcare setting may not perform as well in low-resource settings in sub-Saharan Africa. METHOD The performance of EWS used in developed world was compared with those generated in low-resource settings in sub-Saharan Africa. RESULTS When tested on 1,266 acutely ill patients consecutively admitted to a low-resource Ugandan hospital there was no statistical difference in the performance of any of the EWS tested. The performance of all the scores appeared to be improved by the addition of mobility assessment. Although statistically insignificant, the National Early Warning Score with extra points added for impaired mobility had the highest discrimination and sensitivity. CONCLUSION There were only marginal and no statistical differences in the performance of EWS generated in low- and high-resource healthcare settings in a cohort of unselected acutely ill medical patients admitted to a low-resource hospital in sub-Saharan Africa.
Collapse
Affiliation(s)
| | | | | | | | - John Kellett
- Hospital of South West Jutland, Esbjerg, Denmark; on behalf of the Kitovu Hospital Study Group
| |
Collapse
|
4
|
Nakitende I, Namujwiga T, Kellett J, Opio M, Lumala A. Patient reported symptoms, body temperature and hospital mortality: an observational study in a low resource healthcare environment. QJM 2018; 111:691-697. [PMID: 29986087 DOI: 10.1093/qjmed/hcy147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fever is a common presenting complaint of patients, especially in sub-Saharan Africa. Although most medical authorities consider fever to be synonymous with an elevated body temperature the relationship of the complaint of fever made by patients to temperature has not been well defined. AIM This study examined the relationship of the complaint of fever to temperature on and after admission and in-hospital mortality. METHOD Observational study in a low-resource Ugandan mission hospital. RESULTS Out of 2122 alert patients admitted between 9 August 2016 and 5 January 2018, 349 (16.4%) complained of fever: these patients were no more likely to have an abnormal temperature or die in-hospital than those not complaining of fever. Of the 707 alert patients admitted after 1 July 2017, 422 were interviewed in detail about their symptoms: only rigors, feeling intermittently hot and cold, and anorexia were statistically related to the complaint of fever, and only rigors to an admission temperature >38°C. No symptom or sign was associated with a temperature ≤36°C: cold and clammy skin was the only finding associated with in-hospital death. On logistic regression the only independent predictors of mortality were: the National Early Warning Score, impaired mobility on presentation and cold and clammy skin. CONCLUSION In this study, the term fever used by patients and raised body temperature were not synonymous. Although fever and related symptoms reported by patients are common presenting complaints only the finding of cold and clammy skin was associated with in-hospital mortality.
Collapse
Affiliation(s)
- I Nakitende
- Department of Medicine, Enrolled Midwife, Kitovu Hospital, Masaka, Uganda
| | - T Namujwiga
- Department of Medicine, Enrolled Nurse, Kitovu Hospital, Masaka, Uganda
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Opio
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| | - A Lumala
- Department of Medicine, Kitovu Hospital, Masaka, Uganda
| |
Collapse
|
5
|
Opio MO, Namujwiga T, Nakitende I, Kellett J, Brabrand M. The prediction of in-hospital mortality by mid-upper arm circumference: a prospective observational study of the association between mid-upper arm circumference and the outcome of acutely ill medical patients admitted to a resource-poor hospital in sub-Saharan Africa. Clin Med (Lond) 2018; 18:123-127. [PMID: 29626015 PMCID: PMC6303455 DOI: 10.7861/clinmedicine.18-2-123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There are few reports of the association of nutritional status with in-hospital mortality of acutely ill medical patients in sub-Saharan Africa. This is a prospective observational study comparing the predictive value of mid-upper arm circumference (MUAC) of 899 acutely ill medical patients admitted to a resource-poor sub-Saharan hospital with mental alertness, mobility and vital signs. Mid-upper arm circumference ranged from 15 cm to 42 cm, and 12 (24%) of the 50 patients with a MUAC less than 20 cm died (OR 4.84, 95% CI 2.23-10.37). Of the 237 patients with a MUAC more than 28 cm only six (2.5%) died (OR 0.27, 95% CI 0.10-0.67). On logistic regression, the National Early Warning Score (NEWS), alertness, mobility and MUAC were independent predictors of in-hospital mortality. Mid-upper arm circumference is an independent predictor of the in-hospital mortality of acutely ill medical patients in a resource-poor hospital in sub-Saharan Africa.
Collapse
Affiliation(s)
| | | | | | | | - Mikkel Brabrand
- Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - on behalf of the Kitovu Hospital Study Group
- Kitovu Hospital, Masaka, Uganda
- Kitovu Hospital, Masaka, Uganda
- Kitovu Hospital, Masaka, Uganda
- University of Southern Denmark, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Denmark
| |
Collapse
|
6
|
Opio MO, Mutiibwa G, Kellett J, Brabrand M. Does how the patient feels matter? A prospective observational study of the outcome of acutely ill medical patients who feel their condition has improved on their first re-assessment after admission to hospital. QJM 2017; 110:545-549. [PMID: 28402554 DOI: 10.1093/qjmed/hcx072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although asking how a patient feels is the first enquiry most clinicians make the value of the answer has never been examined in acutely ill patients. METHODS Prospective observational study that compared the predictive value of how well acutely ill medical patients felt after admission to a resource poor sub-Saharan hospital with their mental alertness, mobility and vital signs. RESULTS In total, 403 patients were studied. Patients who felt better when re-assessed 18.0 SD 9.1 h after admission to hospital were less likely to die in hospital (OR 0.18 95% CI 0.08-0.43, P = 0.00001) and more likely to be independent of others at discharge (OR 5.64 95% CI 3.04-10.47, P = 0.00001). Feeling better was an independent predictor of in-hospital death along with vital sign changes and gait stability, and an independent predictor of independence at discharge along with vital sign changes, gait stability and female gender. CONCLUSION In this patient cohort a subjective feeling of improvement at the first re-assessment after admission to hospital is a powerful independent predictor of reduced in-hospital mortality.
Collapse
Affiliation(s)
| | | | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| |
Collapse
|
7
|
Clynch N, Kellett J. Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. Int J Med Inform 2015; 84:221-8. [DOI: 10.1016/j.ijmedinf.2014.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 11/23/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
|
8
|
A four item scale based on gait for the immediate global assessment of acutely ill medical patients – one look is more than 1000 words. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
9
|
Clifford M, Ridley A, Gleeson M, Kellett J. The early mortality associated with agitation and sedation in acutely ill medical patients. Eur J Intern Med 2013; 24:e85. [PMID: 24051229 DOI: 10.1016/j.ejim.2013.08.707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 08/23/2013] [Accepted: 08/26/2013] [Indexed: 11/18/2022]
|
10
|
Subbe CP, Welch JR. Failure to rescue: using rapid response systems to improve care of the deteriorating patient in hospital. ACTA ACUST UNITED AC 2013. [DOI: 10.1177/1356262213486451] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
“Failure to rescue” is the inadequate or delayed response to clinical deterioration in hospitalized patients. Rapid response systems are a set of hospital-wide interventions that attempt to reduce failure to rescue by improving patient monitoring on general wards (the afferent component) and the reliability of the response to deterioration by a dedicated Critical Care Outreach Team, Rapid Response Team or Medical Emergency Team (the efferent component). The reliability of such systems depends on the faultless functioning of a “chain of survival” consisting of: (1) high-quality recording of vital signs; (2) the education and mind-set of staff at the bedside to recognize pathological patterns; (3) the reporting of abnormality to the efferent team; (4) a timely and appropriate response by the latter. Repeated feedback loops are crucial for an effective functioning of the chain.
Collapse
|