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Veldhuis LI, Kuit M, Karim L, Ridderikhof ML, Nanayakkara PW, Ludikhuize J. Optimal timing for the Modified Early Warning Score for prediction of short-term critical illness in the acute care chain: a prospective observational study. Emerg Med J 2024; 41:363-367. [PMID: 38670792 PMCID: PMC11137464 DOI: 10.1136/emermed-2022-212733] [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: 07/25/2022] [Accepted: 03/14/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION The Modified Early Warning Score (MEWS) is an effective tool to identify patients in the acute care chain who are likely to deteriorate. Although it is increasingly being implemented in the ED, the optimal moment to use the MEWS is unknown. This study aimed to determine at what moment in the acute care chain MEWS has the highest accuracy in predicting critical illness. METHODS Adult patients brought by ambulance to the ED at both locations of the Amsterdam UMC, a level 1 trauma centre, were prospectively included between 11 March and 28 October 2021. MEWS was calculated using vital parameters measured prehospital, at ED presentation, 1 hour and 3 hours thereafter, imputing for missing temperature and/or consciousness, as these values were expected not to deviate. Critical illness was defined as requiring intensive care unit admission, myocardial infarction or death within 72 hours after ED presentation. Accuracy in predicting critical illness was assessed using the area under the receiver operating characteristics curve (AUROC). RESULTS Of the 790 included patients, critical illness occurred in 90 (11.4%). MEWS based on vital parameters at ED presentation had the highest performance in predicting critical illness with an AUROC of 0.73 (95% CI 0.67 to 0.79) but did not significantly differ compared with other moments. Patients with an increasing MEWS over time are significantly more likely to become critical ill compared with patients with an improving MEWS. CONCLUSION The performance of MEWS is moderate in predicting critical illness using vital parameters measured surrounding ED admission. However, an increase of MEWS during ED admission is correlated with the development of critical illness. Therefore, early recognition of deteriorating patients at the ED may be achieved by frequent MEWS calculation. Further studies should investigate the effect of continuous monitoring of these patients at the ED.
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Affiliation(s)
- Lars Ingmar Veldhuis
- Emergency Department, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Merijn Kuit
- Emergency Department, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Liza Karim
- Emergency Department, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Prabath Wb Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Jeroen Ludikhuize
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Department of Intensive Care, Haga Hospital, Den Haag, The Netherlands
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Havermans RJM, de Jongh MAC, van der Veen AH, Edwards M, Lansink KWW. Recovery to normal vital functions and acid-base status after a severe trauma in Level I versus Level II Trauma Centres. Eur J Trauma Emerg Surg 2024; 50:513-522. [PMID: 38093136 DOI: 10.1007/s00068-023-02390-x] [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: 08/20/2023] [Accepted: 11/02/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE In the Netherlands, approximately 70% of severely injured patients (ISS ≥ 16) are transported directly to a Level I trauma center. This study compared the time needed to return to normal vital parameters and normal acid-base status in severely injured patients and some in-hospital processes in Level I versus Level II trauma centers. METHODS This retrospective cohort study included all adult severely injured patients or adult trauma patients admitted to the intensive care unit between 2015 and 2020 in a Dutch trauma region. The primary endpoint was time until normal vital parameters and acid-base status. Secondary endpoints were complication rate, hospital length of stay, emergency department length of stay, and time until a computed tomography (CT) scan. RESULTS A total of 2345 patients were included. Patients admitted to a Level I trauma center had a significantly higher rate of normalization of vital parameters over time (HR 1.51). There was no significant difference in normalization rate of the acid-base status over time (HR 1.10). In Level I trauma centers, time spent at the emergency department and time until the CT scan was significantly shorter (respectively, β - 38 min and β - 77 min), and the complication rate was significantly lower (OR 0.35). CONCLUSION Severely injured patients admitted to a Level I trauma center require less time to normalize their vital functions. Level I centers are better equipped, resulting in better in-hospital processes with shorter time at the emergency department and shorter time until a CT scan.
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Affiliation(s)
- Roos J M Havermans
- Department of Surgery, ETZ Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands.
| | - Mariska A C de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
| | | | - Michael Edwards
- Department of Trauma Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Koen W W Lansink
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
- Department of Trauma Surgery, ETZ Hospital, Tilburg, The Netherlands
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Zahid M, Khan AA, Ata F, Yousaf Z, Naushad VA, Purayil NK, Chandra P, Singh R, Kartha AB, Elzouki AYA, Al Mohanadi DHSH, Al-Mohammed AAAA. Medical Admission Prediction Score (MAPS); a simple tool to predict medical admissions in the emergency department. PLoS One 2023; 18:e0293140. [PMID: 37948401 PMCID: PMC10637671 DOI: 10.1371/journal.pone.0293140] [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] [Received: 05/28/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Overcrowding in the emergency departments (ED) is linked to adverse clinical outcomes, a negative impact on patient safety, patient satisfaction, and physician efficiency. We aimed to design a medical admission prediction scoring system based on readily available clinical data during ED presentation. METHODS In this retrospective cross-sectional study, data on ED presentations and medical admissions were extracted from the Emergency and Internal Medicine departments of a tertiary care facility in Qatar. Primary outcome was medical admission. RESULTS Of 320299 ED presentations, 218772 were males (68.3%). A total of 11847 (3.7%) medical admissions occurred. Most patients were Asians (53.7%), followed by Arabs (38.7%). Patients who got admitted were older than those who did not (p <0.001). Admitted patients were predominantly males (56.8%), had a higher number of comorbid conditions and a higher frequency of recent discharge (within the last 30 days) (p <0.001). Age > 60 years, female gender, discharge within the last 30 days, and worse vital signs at presentations were independently associated with higher odds of admission (p<0.001). These factors generated the scoring system with a cut-off of >17, area under the curve (AUC) 0.831 (95% CI 0.827-0.836), and a predictive accuracy of 83.3% (95% CI 83.2-83.4). The model had a sensitivity of 69.1% (95% CI 68.2-69.9), specificity was 83.9% (95% CI 83.7-84.0), positive predictive value (PPV) 14.2% (95% CI 13.8-14.4), negative predictive value (NPV) 98.6% (95% CI 98.5-98.7) and positive likelihood ratio (LR+) 4.28% (95% CI 4.27-4.28). CONCLUSION Medical admission prediction scoring system can be reliably applied to the regional population to predict medical admissions and may have better generalizability to other parts of the world owing to the diverse patient population in Qatar.
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Affiliation(s)
- Muhammad Zahid
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fateen Ata
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Medicine, Reading Hospital-Tower Health, West Reading, PA, United States of America
| | | | - Nishan K. Purayil
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Department of Medical Research, Medical Research Center, Academic Health System, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Department of Medical Research, Medical Research Center, Academic Health System, Hamad Medical Corporation, Doha, Qatar
| | - Anand Bhaskaran Kartha
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Abdelnaser Y. Awad Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Dabia Hamad S. H. Al Mohanadi
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Ahmed Ali A. A. Al-Mohammed
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
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Saba A, Nunes MDPT. Is Modified Early Warning Score associated with clinical outcomes of patients admitted to a university internal medicine ward? J Clin Nurs 2023; 32:1065-1075. [PMID: 35434871 DOI: 10.1111/jocn.16327] [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: 12/02/2021] [Revised: 02/12/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the MEWS association with the clinical outcomes (CO) of patients admitted to an internal medicine ward (IMW) at a Brazilian university hospital (UH). INTRODUCTION It is important to quickly identify patients with clinical deterioration, especially in wards. The health team must recognize and act before the situation becomes an adverse event. In Brazil, nurses' work to overcome performance myths and the application of standardized predictive scales for patients in wards is still limited. DESIGN An observational cohort study designed and developed by a registered nurse that followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. METHODS Data were collected from the IMW of a UH located in the city of São Paulo, Brazil (2017). An ROC curve was calculated to strengthen the use of a MEWS of < or ≥ 4 as a cutoff. CO of the two subgroups were compared. RESULTS Three hundred patients completed the study; their vital signs were recorded consecutively throughout hospitalization in the IMW. The highest MEWS value each day was considered for analysis. Scores < 4 were significantly associated with a higher probability of hospital discharge, a lower chance of transfer to the ICU, a lower total number of days of hospitalization, and a lower risk of death. Score ≥ 4 had worse CO (orotracheal intubation and cardiac monitoring), transfer to the ICU, and increased risk of death. CONCLUSION Scores < 4 were associated with positive outcomes, while scores ≥ 4 were associated with negative outcomes. MEWS can help prioritize interventions, increase certainty in decision-making, and improve patient safety, especially in a teaching IMW with medical teams undergoing professional development, thereby ensuring the central role of the nursing team in Brazil. RELEVANCE FOR CLINICAL PRACTICE MEWS aid nurses in identifying and managing patients, prioritizing interventions through assertive decision-making.
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Affiliation(s)
- Amanda Saba
- School of Medicine, University of São Paulo (SP), São Paulo, Brazil
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Lam RPK, Chan CK, Tse ML, Lau EHY, Dai Z, Tsui MSH, Rainer TH. Derivation and internal validation of a clinical prediction score to predict major effect or death in acute metamfetamine toxicity. Clin Toxicol (Phila) 2023; 61:146-152. [PMID: 36795061 DOI: 10.1080/15563650.2022.2164297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Metamfetamine use can cause serious complications or death. We aimed to derive and internally validate a clinical prediction score to predict major effect or death in acute metamfetamine toxicity. METHODS We performed secondary analysis of 1,225 consecutive cases reported from all local public emergency departments to the Hong Kong Poison Information Centre between 1 January 2010 and 31 December 2019. We split the entire dataset chronologically into derivation (first 70% of cases) and validation (the remaining 30% of cases) cohorts. Univariate analysis was conducted, followed by multivariable logistic regression in the derivation cohort to identify independent predictors of major effect or death. We developed a clinical prediction score based on the regression coefficients of the independent predictors in the regression model and compared its discriminatory performance with five existing early warning scores in the validation cohort. RESULTS The MASCOT (Male, Age, Shock, Consciousness, Oxygen, Tachycardia) score was derived based on the six independent predictors: male gender (1 point), age (≥35 years, 1 point), shock (mean arterial pressure <65 mmHg, 3 points), consciousness (Glasgow Coma Scale <13, 2 points), need for supplemental oxygen (1 point), and tachycardia (pulse rate >120 beats/min, 1 point). The score ranges from 0-9, with a higher score indicating higher risk. The area under the receiver operating characteristic curve of the MASCOT score was 0.87 (95% CI 0.81-0.93) in the derivation cohort and 0.91 (95% CI 0.81-1.00) in the validation cohort, with a discriminatory performance comparable with existing scores. CONCLUSIONS The MASCOT score enables quick risk stratification in acute metamfetamine toxicity. Further external validation is warranted before wider adoption.
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Affiliation(s)
- Rex Pui Kin Lam
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chi Keung Chan
- Hong Kong Poison Information Centre, Hospital Authority, Hong Kong Special Administrative Region, China
| | - Man Li Tse
- Hong Kong Poison Information Centre, Hospital Authority, Hong Kong Special Administrative Region, China
| | - Eric Ho Yin Lau
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zonglin Dai
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Matthew Sik Hon Tsui
- Accident and Emergency Department, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Timothy Hudson Rainer
- Department of Emergency Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Palmer JH, James S, Wadsworth D, Gordon CJ, Craft J. How registered nurses are measuring respiratory rates in adult acute care health settings: An integrative review. J Clin Nurs 2022. [PMID: 36097417 DOI: 10.1111/jocn.16522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/06/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This integrative review aimed to draw conclusions from evidence on how registered nurses are measuring respiratory rates for acute care patients. BACKGROUND Despite the growing research supporting respiratory rate as an early indicator for clinical deterioration, respiratory rate has consistently been the least frequently measured and accurately documented vital sign. DESIGN An integrative review. METHODS A systematic literature search was conducted in June 2022 in four databases: CINAHL, PubMed, Medline and Scopus. Quality appraisal was undertaken using the Joanna Briggs Institute's Checklist. PRISMA guidelines were followed to ensure explicit reporting and reported in the PRISMA checklist. RESULTS Overall, 9915 records were identified, and 19 met the inclusion criteria. Of these 19 articles, seven themes emerged: estimation and digit preference, lack of understanding and knowledge, not valuing the clinical significance of respiratory rate, oxygen saturation substitute, interobserver agreement, subjective concern and count duration. A high prevalence of bias, estimation and incorrect technique was evident. A total of 15 articles reported specifically on how registered nurses are measuring respiratory rates on general medical and surgical wards. CONCLUSIONS Despite its importance, this integrative review has determined that respiratory rates are not being assessed correctly by nursing staff in the acute care environment. Evidence of using estimation, value bias or quick count and multiply techniques are emerging themes which urgently require further research. No patient or public contribution.
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Affiliation(s)
- Jennifer H Palmer
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia.,Critical Care and Support Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
| | - Daniel Wadsworth
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia.,Sunshine Coast Health Institute, Birtinya, Queensland, Australia
| | - Christopher J Gordon
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,CIRUS Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Judy Craft
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Caboolture, Queensland, Australia
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Schinkel M, Bergsma L, Veldhuis LI, Ridderikhof ML, Holleman F. Comparing complaint-based triage scales and early warning scores for emergency department triage. Emerg Med J 2022; 39:691-696. [PMID: 35418407 PMCID: PMC9411919 DOI: 10.1136/emermed-2021-211544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 03/25/2022] [Indexed: 12/28/2022]
Abstract
Background Emergency triage systems are used globally to prioritise care based on patients’ needs. These systems are commonly based on patient complaints, while the need for timely interventions on regular hospital wards is usually assessed with early warning scores (EWS). We aim to directly compare the ability of currently used triage scales and EWS scores to recognise patients in need of urgent care in the ED. Methods We performed a retrospective, single-centre study on all patients who presented to the ED of a Dutch Level 1 trauma centre, between 1 September 2018 and 24 June 2020 and for whom a Netherlands Triage System (NTS) score as well as a Modified Early Warning Score (MEWS) was recorded. The performance of these scores was assessed using surrogate markers for true urgency and presented using bar charts, cross tables and a paired area under the curve (AUC). Results We identified 12 317 unique patient visits where NTS and MEWS scores were documented during triage. A paired comparison of the AUC of these scores showed that the MEWS score had a significantly better AUC than the NTS for predicting the need for hospital admission (0.65 vs 0.60; p<0.001) or 30-day all-cause mortality (0.70 vs 0.60; p<0.001). Furthermore, when non-urgent MEWS scores co-occur with urgent NTS scores, the MEWS score seems to more accurately capture the urgency level that is warranted. Conclusions The results of this study suggest that EWSs could potentially be used to replace the current emergency triage systems.
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Affiliation(s)
- Michiel Schinkel
- Center for Experimental and Molecular Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Lyfke Bergsma
- Internal Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | | | | | - Frits Holleman
- Internal Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
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T P M, T S D, Ramesh AC, K N V, Mahadevaiah T. Evaluation of the Overall Accuracy of the Combined Early Warning Scoring Systems in the Prediction of In-Hospital Mortality. Cureus 2022; 14:e24486. [PMID: 35651391 PMCID: PMC9135612 DOI: 10.7759/cureus.24486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Deterioration of clinical condition of in-hospital patients further leads to intensive care unit (ICU) transfer or death which can be reduced by the use of prediction tools. The early warning scoring (EWS) system is a prediction tool used in monitoring medical patients in hospitals, hospital staying length, and inpatient mortality. The present study evaluated four different EWS systems for the prediction of patient survival. Method The present prospective observational study has analyzed 217 patients visiting the emergency department from November 2016 to November 2018, followed by demographic and clinical data collection. Modified Early Warning Score (MEWS), Triage Early Warning Score (TEWS), Leed's Early Warning Score (LEWS), and patient-at-risk scores (PARS) were assigned based upon body temperature, consciousness level, heart rate, blood pressure, respiratory rate, mobility, etc. Data was analyzed with the help of R 4.0.4 (R Foundation, Vienna, Austria) and Microsoft Excel (Microsoft, Redmond, Washington). Results Out of these 217 patients, 205 got shifted to a ward, and 12 died, amongst which the majority belonged to the 31-40 age group. Among patients admitted to ICU had a MEWS greater than 3, TEWS within the range 0 to 2 and 3 to 5, LEWS greater than 7, and PARS greater than 5 on the initial days of admission. The patients who died and those who were shifted to the ward showed significant differences in EWS. A significant association was observed between all the EWS and patient outcomes (p<0.001). Conclusion MEWS, TEWS, LEWS, and PARS were effective in the prediction of inpatient mortality as well as admission to the ICU. With the increase in the EWS, there was an increase in the duration of ICU stay and a decrease in chances of survival.
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Affiliation(s)
- Mishal T P
- Emergency Medicine, Mathikere Sampige (MS) Ramaiah Medical College, Bengaluru, IND
| | - Deepak T S
- Emergency Medicine, Mathikere Sampige (MS) Ramaiah Medical College, Bengaluru, IND
| | - Aruna C Ramesh
- Emergency Medicine, Mathikere Sampige (MS) Ramaiah Medical College, Bengaluru, IND
| | - Vikas K N
- Anesthesiology, Mathikere Sampige (MS) Ramaiah Medical College, Bengaluru, IND
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Rogan A, Lockett J, Peckler B, Robinson B, Raymond N. Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study. Emerg Med Australas 2021; 34:417-427. [PMID: 34889063 DOI: 10.1111/1742-6723.13911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis. METHODS This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi-structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio-recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software. RESULTS Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail. CONCLUSION ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies.
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Affiliation(s)
- Alice Rogan
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Jessica Lockett
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brad Peckler
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brian Robinson
- School of Nursing and Midwifery, Victoria University of Wellington, Wellington, New Zealand
| | - Nigel Raymond
- Infection Service and General Medicine Department, Wellington Regional Hospital, Wellington, New Zealand
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Sabbatini AK, Robicsek A, Chiu ST, Gluckman TJ. Excess Mortality Among Patients Hospitalized During the COVID-19 Pandemic. J Hosp Med 2021; 16:596-602. [PMID: 34328844 DOI: 10.12788/jhm.3633] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The extent to which the COVID-19 pandemic has affected outcomes for patients with unplanned hospitalizations is unclear. OBJECTIVE To examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020 to December 31, 2020). DESIGN, SETTING, AND PARTICIPANTS Observational study of adults with unplanned hospitalizations at 51 hospitals across 6 Western states. EXPOSURES Unplanned hospitalizations occurring during the spring COVID-19 surge (March 4 to May 13, 2020; Period 1), an intervening period (May 14 to October 19, 2020; Period 2), and the fall COVID-19 surge (October 20 to December 31, 2020; Period 3) were compared with a pre-COVID-19 baseline period from January 1, 2019, to March 3, 2020. MAIN OUTCOMES AND MEASURES We examined daily hospital admissions and in-hospital mortality overall and in 30 conditions. RESULTS Unplanned hospitalizations declined steeply during Periods 1 and 3 (by 47.5% and 25% compared with baseline, respectively). Although volumes declined, adjusted in-hospital mortality rose from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2, and rose again to 3.4% in Period 3. Elevated mortality was seen for nearly all conditions studied during the pandemic surge periods. CONCLUSION Pandemic COVID-19 surges were associated with higher rates of in-hospital mortality among patients without COVID-19, suggesting disruptions in care patterns for patients with many common acute and chronic illnesses.
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Affiliation(s)
- Amber K Sabbatini
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Ari Robicsek
- Providence St. Joseph Health, Clinical Analytics, Renton, Washington
- Providence Research Network, Renton, Washington
| | - Shih-Ting Chiu
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Portland, Oregon
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Portland, Oregon
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Yu Z, Xu F, Chen D. Predictive value of Modified Early Warning Score (MEWS) and Revised Trauma Score (RTS) for the short-term prognosis of emergency trauma patients: a retrospective study. BMJ Open 2021; 11:e041882. [PMID: 33722865 PMCID: PMC7959230 DOI: 10.1136/bmjopen-2020-041882] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This study aimed to assess the predictive value of the Modified Early Warning Score (MEWS) and Revised Trauma Score (RTS) for emergency trauma patients who died within 24 hours. DESIGN A retrospective, single-centred study. SETTING This study was conducted at a tertiary hospital in Southern China. PARTICIPANTS A total of 1739 patients with acute trauma, aged 16 years or older who presented to the emergency department from 1 November 2016 to 30 November 2019, were included. INTERVENTIONS NONE None. OUTCOME 24-hour mortality was the primary outcome of trauma. RESULTS 1739 patients were divided into the survival group (1709 patients,98.27%), and the non-survival group (30 patients,1.73%). Crude OR and adjusted OR of MEWS were 1.99, 95% CI (1.73 to 2.29), and 2.00, 95% CI (1.74 to 2.31), p<0.001, respectively. Crude OR and adjusted OR of RTS were 0.62, 95% CI (0.55 to 0.69) and 0.61, 95% CI (0.55 to 0.68), p<0.001, respectively. The area under the curve of MEWS was significantly higher than that of RTS (p=0.005): 0.927, 95% CI (0.914 to 0.939) vs 0.799, 95% CI (0.779 to 0.817). CONCLUSIONS Both MEWS and RTS were independent predictors of the short-term prognosis in emergency trauma patients, MEWS had better predictive efficacy.
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Affiliation(s)
- Zhejun Yu
- Division of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Xu
- Division of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Du Chen
- Division of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
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Kao CC, Chen YC, Huang HH, Hsu TF, Yen DHT, Fan JS. Prognostic significance of emergency department modified early warning score trend in critical ill elderly patients. Am J Emerg Med 2021; 44:14-19. [PMID: 33571750 DOI: 10.1016/j.ajem.2021.01.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To explore the relationship between trends in emergency department modified early warning score (EDMEWS) and the prognosis of elderly patients admitted to the intensive care unit (ICU). METHODS Consecutive non-traumatic elderly ED patients (≥65 years old) admitted to the ICU between July 2018 and June 2019 were enrolled in this retrospective cohort study. The selected patients had at least 2 separate MEWS during their ED stay. Detailed patient information was retrieved initially from the ICU database of our hospital and then crosschecked with electronic medical recording system to confirm the completeness and correctness of the data. Patients who had do-not-resuscitate order and those with incomplete data of EDMEWS, acute physiology and chronic health evaluation (APACHE) II score, or survival information (7-day and 30-day mortality) were excluded. The trends in EDMEWS were determined using the regression line of multiple MEWS measured during ED stay, in which EDMEWS trend progression was defined as the slope of the regression line > zero. The relationship between EDMEWS trend and prognosis was assessed using univariate and multivariate analyses (multiple logistic regression analysis). RESULTS Of the 1423 selected patients, 499 (35.1%) had worsening 24-h APACHE II score, 110 (7.7%) died within 7 days, and 233 (16.4%) died within 30 days. Factors that were significantly associated with worsening 24-h APACHE II score, 7-day mortality, and 30-day mortality in univariate analysis were selected for inclusion into multiple logistic regression analyses. After adjusting for other covariates, EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality. CONCLUSIONS EDMEWS trend progression was significantly associated with 24-h APACHE II score progression, 7-day mortality, and 30-day mortality in elderly ED patients admitted to the ICU. EDMEWS is a simple and useful tool for precisely monitoring patients' ongoing condition and predicting prognosis.
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Affiliation(s)
- Chih-Chun Kao
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - The-Fu Hsu
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ju-Sing Fan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
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13
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Shaikh MA, Punshi A, Talreja ML, Rasheed T, Bader N, Zuberi BF. Comparison of within 7 Day All-Cause Mortality among HDU Patients with Modified Early Warning Score of ≥5 with those with Score of <5. Pak J Med Sci 2021; 37:515-519. [PMID: 33679942 PMCID: PMC7931294 DOI: 10.12669/pjms.37.2.2832] [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] [Indexed: 11/15/2022] Open
Abstract
Objective To compare 7-Day All-Cause Mortality among HDU Patients with Modified Early Warning Score of ≥5 with Those with Score of <5. Methods All patients of age more than 18 years, of either gender admitted in HDU of Medical Unit-II, CHK between September 2019 to February 2020 were included. MEWS was calculated for each patient at time of admission. Patients with MEWS score of ≥5 were allocated to Group-A and those with score of <5 were allocated to Group-B. Patients were followed for seven days and outcome status of alive, expired or discharged was noted. Results Total of 336 patients were selected out of which 168 patients was inducted in Group-A and 168 patients in Group-B. MEWS Score in patients who expired was significantly higher (Mdn=11) than in those who survived (Mdn=4), p <.001. 7-day mortality in Group-A was 62 (39.9%) while in Group-B was 40 (23.8%). ROC was plotted of MEWS Score for mortality, it showed significant area under curve of 68.4% (p <.001, 95% CI = .62 to .75). MEWS Score of 3.5 showed sensitivity of 89.2% and specificity of 65%. Conclusion Our results show that MEWS has a positive trend to predict mortality. MEWS score of 3.5 is suggested cut off based on ROC in our study.
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Affiliation(s)
- Majid Ahmed Shaikh
- Majid Ahmed Shaikh, FCPS, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Avinash Punshi
- Avinash Punshi, FCPS, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohan Lal Talreja
- Mohan Lal Talreja, MRCP, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Tazeen Rasheed
- Tazeen Rasheed, FCPS, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nimrah Bader
- Nimrah Bader, Department of Internal Medicine University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, FCPS, Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Mitchell OJL, Edelson DP, Abella BS. Predicting cardiac arrest in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:321-326. [PMID: 33000054 PMCID: PMC7493514 DOI: 10.1002/emp2.12015] [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: 11/20/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 12/03/2022] Open
Abstract
In-hospital cardiac arrest remains a leading cause of death: roughly 300,000 in-hospital cardiac arrests occur each year in the United States, ≈10% of which occur in the emergency department. ED-based cardiac arrest may represent a subset of in-hospital cardiac arrest with a higher proportion of reversible etiologies and a higher potential for neurologically intact survival. Patients presenting to the ED have become increasingly complex, have a high burden of critical illness, and face crowded departments with thinly stretched resources. As a result, patients in the ED are vulnerable to unrecognized clinical deterioration that may lead to ED-based cardiac arrest. Efforts to identify patients who may progress to ED-based cardiac arrest have traditionally been approached through identification of critically ill patients at triage and the identification of patients who unexpectedly deteriorate during their stay in the ED. Interventions to facilitate appropriate triage and resource allocation, as well as earlier identification of patients at risk of deterioration in the ED, could potentially allow for both prevention of cardiac arrest and optimization of outcomes from ED-based cardiac arrest. This review will discuss the epidemiology of ED-based cardiac arrest, as well as commonly used approaches to predict ED-based cardiac arrest and highlight areas that require further research to improve outcomes for this population.
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Affiliation(s)
- Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care Medicine and the Center for Resuscitation Science Hospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Dana P Edelson
- Department of Medicine University of Chicago Chicago Illinois
| | - Benjamin S Abella
- Department of Emergency Medicine and the Center for Resuscitation Science University of Pennsylvania School of Medicine Philadelphia Pennsylvania
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15
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Fang AHS, Lim WT, Balakrishnan T. Early warning score validation methodologies and performance metrics: a systematic review. BMC Med Inform Decis Mak 2020; 20:111. [PMID: 32552702 PMCID: PMC7301346 DOI: 10.1186/s12911-020-01144-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/03/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Early warning scores (EWS) have been developed as clinical prognostication tools to identify acutely deteriorating patients. In the past few years, there has been a proliferation of studies that describe the development and validation of novel machine learning-based EWS. Systematic reviews of published studies which focus on evaluating performance of both well-established and novel EWS have shown conflicting conclusions. A possible reason is the heterogeneity in validation methods applied. In this review, we aim to examine the methodologies and metrics used in studies which perform EWS validation. METHODS A systematic review of all eligible studies from the MEDLINE database and other sources, was performed. Studies were eligible if they performed validation on at least one EWS and reported associations between EWS scores and inpatient mortality, intensive care unit (ICU) transfers, or cardiac arrest (CA) of adults. Two reviewers independently did a full-text review and performed data abstraction by using standardized data-worksheet based on the TRIPOD (Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) checklist. Meta-analysis was not performed due to heterogeneity. RESULTS The key differences in validation methodologies identified were (1) validation dataset used, (2) outcomes of interest, (3) case definition, time of EWS use and aggregation methods, and (4) handling of missing values. In terms of case definition, among the 48 eligible studies, 34 used the patient episode case definition while 12 used the observation set case definition, and 2 did the validation using both case definitions. Of those that used the patient episode case definition, 18 studies validated the EWS at a single point of time, mostly using the first recorded observation. The review also found more than 10 different performance metrics reported among the studies. CONCLUSIONS Methodologies and performance metrics used in studies performing validation on EWS were heterogeneous hence making it difficult to interpret and compare EWS performance. Standardizing EWS validation methodology and reporting can potentially address this issue.
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Affiliation(s)
| | - Wan Tin Lim
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
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16
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Uwamahoro C, Aluisio AR, Chu E, Reibling E, Mutabazi Z, Karim N, Byiringiro JC, Levine AC, Guptill M. Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda. Afr J Emerg Med 2020; 10:17-22. [PMID: 32161707 PMCID: PMC7058878 DOI: 10.1016/j.afjem.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022] Open
Abstract
Background Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well-studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K. Methods UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality. Results 1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow = 3.61, p < .001 to Red (with alarm) = 7.80, p < .01). Likelihood for trauma patients, however, was not significantly increased (OR: Yellow = .84, p = .75 to Red (with alarm) = 1.50, p = .65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91). Conclusion The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda.
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Levin N, Horton D, Sanford M, Horne B, Saseendran M, Graves K, White M, Tonna JE. Failure of vital sign normalization is more strongly associated than single measures with mortality and outcomes. Am J Emerg Med 2019; 38:2516-2523. [PMID: 31864869 DOI: 10.1016/j.ajem.2019.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/05/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Modified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality. METHODS We conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis. RESULTS Our analysis included 8322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96-2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23-1.44; p < 0.001). Likewise, each point of worsened MEWS was associated with increased odds of ICU admission (Triage-to-Last: OR 2.12, 95% CI 1.92-2.33 and Triage-to-Max: OR 1.52, 95% CI 1.45-1.60, respectively). Among patients with suspected infection, similar associations are found. CONCLUSIONS Dynamic vital signs in the emergency department, as categorized by delta MEWS, and failure to normalize abnormalities, were associated with increased mortality, ICU admission, LOS, and the diagnosis of sepsis. Our results suggest that MEWS scores that do not normalize, from triage onward, are more strongly associated with outcome than any single score.
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Affiliation(s)
- Nicholas Levin
- Division of Emergency Medicine, University of Utah Health, United States of America
| | - Devin Horton
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Health, United States of America
| | - Matthew Sanford
- Value Engineering, University of Utah Health, United States of America
| | - Benjamin Horne
- Department of Surgery, Department of Biomedical Informatics, University of Utah Health, United States of America
| | - Mahima Saseendran
- System Quality Department, University of Utah Health, United States of America
| | - Kencee Graves
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Health, United States of America
| | | | - Joseph E Tonna
- Division of Emergency Medicine, University of Utah Health, United States of America; Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, United States of America.
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Xie X, Huang W, Liu Q, Tan W, Pan L, Wang L, Zhang J, Wang Y, Zeng Y. Prognostic value of Modified Early Warning Score generated in a Chinese emergency department: a prospective cohort study. BMJ Open 2018; 8:e024120. [PMID: 30552276 PMCID: PMC6303659 DOI: 10.1136/bmjopen-2018-024120] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study aimed to validate the performance of the Modified Early Warning Score (MEWS) in a Chinese emergency department and to determine the best cut-off value for in-hospital mortality prediction. DESIGN A prospective, single-centred observational cohort study. SETTING This study was conducted at a tertiary hospital in South China. PARTICIPANTS A total of 383 patients aged 18 years or older who presented to the emergency department from 17 May 2017 through 27 September 2017, triaged as category 1, 2 or 3, were enrolled. OUTCOMES The primary outcome was a composite of in-hospital mortality and admission to the intensive care unit. The secondary outcome was using MEWS to predict hospitalised and discharged patients. RESULTS A total of 383 patients were included in this study. In-hospital mortality was 13.6% (52/383), and transfer to the intensive care unit was 21.7% (83/383). The area under the receiver operating characteristic curve of MEWS for in-hospital mortality prediction was 0.83 (95% CI 0.786 to 0.881). When predicting in-hospital mortality with the cut-off point defined as 3.5, 158 patients had MEWS >3.5, with a specificity of 66%, a sensitivity of 87%, an accuracy of 69%, a positive predictive value of 28% and a negative predictive value of 97%, respectively. CONCLUSION Our findings support the use of MEWS for in-hospital mortality prediction in patients who were triaged category 1, 2 or 3 in a Chinese emergency department. The cut-off value for in-hospital mortality prediction defined in this study was different from that seen in many other studies.
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Affiliation(s)
- Xiaohua Xie
- Department of Nursing, The Second People’s Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Wenlong Huang
- Department of Nursing, The People’s Hospital of Longhua, Shenzhen, China
| | - Qiongling Liu
- School of Nursing, Guangdong Medical University, Zhanjiang, China
| | - Wei Tan
- Emergency Department, The Second People’s Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Lu Pan
- Department of Intensive Care Unit, The Second People’s Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Lei Wang
- Reproductive Medicine Center, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jian Zhang
- School of Nursing, Guangzhou Medical University, Guangzhou, China
| | - Yunyun Wang
- School of Nursing, Anhui Medical University, Hefei, China
| | - Yingchun Zeng
- Research Institute of Gynecology and Obstetrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Singh I, Aithal S. Selecting best-suited "patient-related outcomes" in older people admitted to an acute geriatric or emergency frailty unit and applying quality improvement research to improve patient care. Patient Relat Outcome Meas 2018; 9:309-320. [PMID: 30288133 PMCID: PMC6163022 DOI: 10.2147/prom.s160519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The population is aging worldwide, and hospitals are admitting a higher proportion of acutely unwell older people. Population-specific factors such as multimorbidity and frailty in older people compounded by deficient expertise contribute to longer lengths of stay, higher readmission rates, and increased rates of institutionalization. A wide range of acute geriatric care models are currently providing acute care to frail older people and these have been shown to provide a cost-effective high-quality service. In this review, population-specific factors, service models, and a wide range of patient-related outcomes of "at risk" older people admitted to an acute geriatric care unit are explored. In addition, we also discuss data measurements and a quality improvement methodology to improve the delivery of care based on the patient outcome data. We hope, in addition to ensuring effectiveness and sustainability of our current services, this may also enhance academic research. Regular monitoring and evaluation of patient-related clinical outcomes not only improve the patient care and reduce the caregiver burden but also help in implementing quality initiatives to develop existing services.
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Affiliation(s)
- Inderpal Singh
- Department of Geriatric Medicine, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board, Ystrad Mynach, UK,
| | - Shridhar Aithal
- Department of Geriatric Medicine, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board, Ystrad Mynach, UK,
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20
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Singer AJ, Ng J, Thode HC, Spiegel R, Weingart S. Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection. Ann Emerg Med 2017; 69:475-479. [PMID: 28110990 DOI: 10.1016/j.annemergmed.2016.10.007] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/21/2016] [Accepted: 10/03/2016] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection. METHODS We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality. RESULTS We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively. CONCLUSION qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY.
| | - Jennifer Ng
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Rory Spiegel
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
| | - Scott Weingart
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY
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