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Chen JY, Hsieh CC, Lee JT, Lin CH, Kao CY. Patient stratification based on the risk of severe illness in emergency departments through collaborative machine learning models. Am J Emerg Med 2024; 82:142-152. [PMID: 38908339 DOI: 10.1016/j.ajem.2024.06.015] [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: 11/10/2023] [Revised: 04/18/2024] [Accepted: 06/07/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVES Emergency department (ED) overcrowding presents a global challenge that inhibits prompt care for critically ill patients. Traditional 5-level triage system that heavily rely on the judgment of the triage staff could fail to detect subtle symptoms in critical patients, thus leading to delayed treatment. Unlike previous rivalry-focused approaches, our study aimed to establish a collaborative machine learning (ML) model that renders risk scores for severe illness, which may assist the triage staff to provide a better patient stratification for timely critical cares. METHODS This retrospective study was conducted at a tertiary teaching hospital. Data were collected from January 2015 to October 2022. Demographic and clinical information were collected at triage. The study focused on severe illness as the outcome. We developed artificial neural network (ANN) models, with or without utilizing the Taiwan Triage and Acuity Scale (TTAS) score as one of the predictors. The model using the TTAS score is termed a machine-human collaborative model (ANN-MH), while the model without it is referred to as a machine-only model (ANN-MO). The predictive power of these models was assessed using the area under the receiver-operating-characteristic (AUROC) and the precision-recall curves (AUPRC); their sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score were compared. RESULTS The study analyzed 668,602 ED visits from 2015 to 2022. Among them, 278,724 visits from 2015 to 2018 were used for model training and validation, while 320,201 visits from 2019 to 2022 were for testing model performance. Approximately 2.6% of visits were by severely ill patients, whose TTAS scores ranged from 1 to 5. The ANN-MH model achieved a testing AUROC of 0.918 and AUPRC of 0.369, while for the ANN-MO model the AUROC and AUPRC were 0.909 and 0.339, respectively. Based on these metrics, the ANN-MH model outperformed the ANN-MO model, and both surpassed human triage classification. Subgroup analyses further highlighted the models' capability to identify higher-risk patients within the same triage level. CONCLUSIONS The traditional 5-level triage system often falls short, leading to under-triage of critical patients. Our models include a score-based differentiation within a triage level to offer advanced risk stratification, thereby promoting patient safety.
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Affiliation(s)
- Jui-Ying Chen
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Ting Lee
- School of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan.
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yao Kao
- Department of Electrical Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan
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Tsai CH, Hu YH. Application of Machine Learning Techniques to Development of Emergency Medical Rapid Triage Prediction Models in Acute Care. Comput Inform Nurs 2024; 42:35-43. [PMID: 38086831 DOI: 10.1097/cin.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Given the critical and complex features of medical emergencies, it is essential to develop models that enable prompt and suitable clinical decision-making based on considerable information. Emergency nurses are responsible for categorizing and prioritizing injuries and illnesses on the frontlines of the emergency room. This study aims to create an Emergency Medical Rapid Triage and Prediction Assistance model using electronic medical records and machine learning techniques. Patient information was retrieved from the emergency department of a large regional teaching hospital in Taiwan, and five supervised learning techniques were used to construct classification models for predicting critical outcomes. Of these models, the model using logistic regression had superior prediction performance, with an F1 score of 0.861 and an area under the receiver operating characteristic curve of 0.855. The Emergency Medical Rapid Triage and Prediction Assistance model demonstrated superior performance in predicting intensive care and hospitalization outcomes compared with the Taiwan Triage and Acuity Scale and three clinical early warning tools. The proposed model has the potential to assist emergency nurses in executing challenging triage assessments and emergency teams in treating critically ill patients promptly, leading to improved clinical care and efficient utilization of medical resources.
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Affiliation(s)
- Cheng-Han Tsai
- Author Affiliations: Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, and Department of Emergency Medicine, Chiayi Branch, Taichung Veteran's General Hospital (Tsai); and Department of Information Management and Asian Institute for Impact Measurement and Management, National Central University, Taoyuan City (Hu), Taiwan
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Choi A, Choi SY, Chung K, Chung HS, Song T, Choi B, Kim JH. Development of a machine learning-based clinical decision support system to predict clinical deterioration in patients visiting the emergency department. Sci Rep 2023; 13:8561. [PMID: 37237057 DOI: 10.1038/s41598-023-35617-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/21/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to develop a machine learning-based clinical decision support system for emergency departments based on the decision-making framework of physicians. We extracted 27 fixed and 93 observation features using data on vital signs, mental status, laboratory results, and electrocardiograms during emergency department stay. Outcomes included intubation, admission to the intensive care unit, inotrope or vasopressor administration, and in-hospital cardiac arrest. eXtreme gradient boosting algorithm was used to learn and predict each outcome. Specificity, sensitivity, precision, F1 score, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve were assessed. We analyzed 303,345 patients with 4,787,121 input data, resampled into 24,148,958 1 h-units. The models displayed a discriminative ability to predict outcomes (AUROC > 0.9), and the model with lagging 6 and leading 0 displayed the highest value. The AUROC curve of in-hospital cardiac arrest had the smallest change, with increased lagging for all outcomes. With inotropic use, intubation, and intensive care unit admission, the range of AUROC curve change with the leading 6 was the highest according to different amounts of previous information (lagging). In this study, a human-centered approach to emulate the clinical decision-making process of emergency physicians has been adopted to enhance the use of the system. Machine learning-based clinical decision support systems customized according to clinical situations can help improve the quality of care.
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Affiliation(s)
- Arom Choi
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - So Yeon Choi
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyungsoo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Taeyoung Song
- LG Electronics, 128 Yeoui-daero, Yeongdeungpo-gu, Seoul, 07336, Republic of Korea
| | - Byunghun Choi
- LG Electronics, 128 Yeoui-daero, Yeongdeungpo-gu, Seoul, 07336, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Institute for Innovation in Digital Healthcare, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Ackermann K, Baker J, Green M, Fullick M, Varinli H, Westbrook J, Li L. Computerized Clinical Decision Support Systems for the Early Detection of Sepsis Among Adult Inpatients: Scoping Review. J Med Internet Res 2022; 24:e31083. [PMID: 35195528 PMCID: PMC8908200 DOI: 10.2196/31083] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/23/2021] [Accepted: 10/29/2021] [Indexed: 12/21/2022] Open
Abstract
Background Sepsis is a significant cause of morbidity and mortality worldwide. Early detection of sepsis followed promptly by treatment initiation improves patient outcomes and saves lives. Hospitals are increasingly using computerized clinical decision support (CCDS) systems for the rapid identification of adult patients with sepsis. Objective This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of adult inpatients with sepsis. Methods The protocol for this scoping review was previously published. A total of 10 electronic databases (MEDLINE, Embase, CINAHL, the Cochrane database, LILACS [Latin American and Caribbean Health Sciences Literature], Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and PQDT [ProQuest Dissertations and Theses]) were comprehensively searched using terms for sepsis, CCDS, and detection to identify relevant studies. Title, abstract, and full-text screening were performed by 2 independent reviewers using predefined eligibility criteria. Data charting was performed by 1 reviewer with a second reviewer checking a random sample of studies. Any disagreements were discussed with input from a third reviewer. In this review, we present the results for adult inpatients, including studies that do not specify patient age. Results A search of the electronic databases retrieved 12,139 studies following duplicate removal. We identified 124 studies for inclusion after title, abstract, full-text screening, and hand searching were complete. Nearly all studies (121/124, 97.6%) were published after 2009. Half of the studies were journal articles (65/124, 52.4%), and the remainder were conference abstracts (54/124, 43.5%) and theses (5/124, 4%). Most studies used a single cohort (54/124, 43.5%) or before-after (42/124, 33.9%) approach. Across all 124 included studies, patient outcomes were the most frequently reported outcomes (107/124, 86.3%), followed by sepsis treatment and management (75/124, 60.5%), CCDS usability (14/124, 11.3%), and cost outcomes (9/124, 7.3%). For sepsis identification, the systemic inflammatory response syndrome criteria were the most commonly used, alone (50/124, 40.3%), combined with organ dysfunction (28/124, 22.6%), or combined with other criteria (23/124, 18.5%). Over half of the CCDS systems (68/124, 54.8%) were implemented alongside other sepsis-related interventions. Conclusions The current body of literature investigating the implementation of CCDS systems for the early detection of adult inpatients with sepsis is extremely diverse. There is substantial variability in study design, CCDS criteria and characteristics, and outcomes measured across the identified literature. Future research on CCDS system usability, cost, and impact on sepsis morbidity is needed. International Registered Report Identifier (IRRID) RR2-10.2196/24899
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Affiliation(s)
- Khalia Ackermann
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Jannah Baker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | | | - Mary Fullick
- Clinical Excellence Commission, Sydney, Australia
| | | | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
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Fernandes M, Vieira SM, Leite F, Palos C, Finkelstein S, Sousa JM. Clinical Decision Support Systems for Triage in the Emergency Department using Intelligent Systems: a Review. Artif Intell Med 2020; 102:101762. [DOI: 10.1016/j.artmed.2019.101762] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/29/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022]
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Miller A, Gallegly JD, Orsak G, Huff SD, Peters JA, Murry J, Ndetan H, Singh KP. Potential predictors of hospital length of stay and hospital charges among patients with all-terrain vehicle injuries in rural Northeast Texas. J Inj Violence Res 2019; 12:55-62. [PMID: 31822649 PMCID: PMC7001608 DOI: 10.5249/jivr.v12i1.1219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022] Open
Abstract
Background: All-Terrain Vehicles (ATVs) have become popular for recreation use in recent years. Texas has had more ATV related fatalities than any other state in the nation, with rural Northeast Texas having even higher rates of injuries. There is limited data examining the relationship between ATV injuries and the length of hospital stay, as well as hospital costs. This paper examines both issues in children as well as adults. Methods: The regional trauma registry was analyzed for all ATV related injuries between January 2011- October 2016. Injury Severity Score, Glasgow Coma Scale and if they are seen at a Level I Trauma center are predictive for both hospital length of stay and charges. Results: Length of Stay was predicted positively by Injury Severity Score, Emergency Department Respi-ration Rate and facility at which patients were treated and negatively by Glasgow Coma Scale. Hospital charges were predicted positively by age, Injury Severity Score, facility of treatment, means of transportation, and Emergency Department pulse and negatively by Glasgow Coma Scale. Conclusions: The study found that vital signs can be useful in predicting length of stay and hospital charges. This study not only confirms the findings of other studies regarding what predictors can be used, but expands the research into rural traumatic injuries. It is hoped that this data can help contribute to the development of algorithms to predict which patients will be most likely to require resource intensive treatment.
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Affiliation(s)
- Anastasia Miller
- Department of Health Care Administration, Texas Woman's University, USA.
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Hodgson NR, Poterack KA, Mi L, Traub SJ. Association of Vital Signs and Process Outcomes in Emergency Department Patients. West J Emerg Med 2019; 20:433-437. [PMID: 31123542 PMCID: PMC6526877 DOI: 10.5811/westjem.2019.1.41498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/14/2019] [Accepted: 01/29/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients. Methods We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality. Results Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours. Conclusion In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting.
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Affiliation(s)
- Nicole R Hodgson
- Mayo Clinic Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Karl A Poterack
- Mayo Clinic Hospital, Department of Anesthesiology, Phoenix, Arizona
| | - Lanyu Mi
- Mayo Clinic Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Stephen J Traub
- Mayo Clinic Hospital, Department of Emergency Medicine, Phoenix, Arizona
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Quinten VM, van Meurs M, Olgers TJ, Vonk JM, Ligtenberg JJM, ter Maaten JC. Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study. Scand J Trauma Resusc Emerg Med 2018; 26:57. [PMID: 30005671 PMCID: PMC6045840 DOI: 10.1186/s13049-018-0525-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND More than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate. METHODS We performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated. RESULTS In total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration. CONCLUSIONS Repeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission.
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Affiliation(s)
- Vincent M. Quinten
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pathology and Medical Biology, Medical Biology section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tycho J. Olgers
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Judith M. Vonk
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jack J. M. Ligtenberg
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Jan C. ter Maaten
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands
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Kim M, Watase T, Jablonowski KD, Gatewood MO, Henning DJ. A Sepsis-related Diagnosis Impacts Interventions and Predicts Outcomes for Emergency Patients with Severe Sepsis. West J Emerg Med 2017; 18:1098-1107. [PMID: 29085543 PMCID: PMC5654880 DOI: 10.5811/westjem.2017.7.34770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/28/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022] Open
Abstract
Introduction Many patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP). This study 1) compares emergency department (ED) interventions and in-hospital outcomes among patients with severe sepsis, based on the presence or absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hour sepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsis-related diagnosis. Methods We performed a retrospective cohort study using patients meeting criteria for severe sepsis at two urban, academic tertiary care centers from March 2015 through May 2015. We included all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis, including two or more systemic inflammatory response syndrome criteria and evidence of organ dysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patients transferred to or from another hospital and those <18 years old. Patients with an EP-assigned sepsis diagnosis created the “Physician Diagnosis” group; the remaining patients composed the “Consensus Criteria” group. The primary outcome was in-hospital mortality. Secondary outcomes included completed elements of the current three-hour sepsis bundle; non-elective intubation; vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to the ICU in < 24 hours. We compared proportions of each outcome between groups using the chi-square test, and we also performed a stratified analysis using chi square to assess the association between failure to complete the three-hour bundle and adverse outcomes in each group. Results Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients for analysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.” The “Physician Diagnosis” group had a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsis bundle (52.1% vs 20.2%, P < 0.01) compared with the “Consensus Criteria” group. An incomplete three-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressor use, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis. Conclusion “Physician Diagnosis” patients more frequently received sepsis-specific interventions and had a higher incidence of mortality. “Consensus Criteria” patients had infrequent adverse outcomes regardless of three-hour bundle compliance. EPs’ sepsis diagnoses reflect risk-stratification beyond the severe sepsis criteria.
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Affiliation(s)
- Mitchell Kim
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Taketo Watase
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Karl D Jablonowski
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Medley O Gatewood
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Daniel J Henning
- University of Washington, Division of Emergency Medicine, Seattle, Washington
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Oedorf K, Day DE, Lior Y, Novack V, Sanchez LD, Wolfe RE, Kirkegaard H, Shapiro NI, Henning DJ. Serum Lactate Predicts Adverse Outcomes in Emergency Department Patients With and Without Infection. West J Emerg Med 2016; 18:258-266. [PMID: 28210362 PMCID: PMC5305135 DOI: 10.5811/westjem.2016.10.31397] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/12/2016] [Accepted: 10/01/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Lactate levels are increasingly used to risk stratify emergency department (ED) patients with and without infection. Whether a serum lactate provides similar prognostic value across diseases is not fully elucidated. This study assesses the prognostic value of serum lactate in ED patients with and without infection to both report and compare relative predictive value across etiologies. METHODS We conducted a prospective, observational study of ED patients displaying abnormal vital signs (AVS) (heart rate ≥130 bpm, respiratory rate ≥24 bpm, shock index ≥1, and/or systolic blood pressure <90 mmHg). The primary outcome, deterioration, was a composite of acute renal failure, non-elective intubation, vasopressor administration or in-hospital mortality. RESULTS Of the 1,152 patients with AVS who were screened, 488 patients met the current study criteria: 34% deteriorated and 12.5% died. The deterioration rate was 88/342 (26%, 95% CI: 21 - 30%) for lactate < 2.5 mmol/L, 47/90 (52%, 42 - 63%) for lactate 2.5 - 4.0 mmol/L, and 33/46 (72%, 59 - 85%) for lactate >4.0mmol/L. Trended stratified lactate levels were associated with deterioration for both infected (p<0.01) and non-infected (p<0.01) patients. In the logistic regression models, lactate > 4mmol/L was an independent predictor of deterioration for patients with infection (OR 4.8, 95% CI: 1.7 - 14.1) and without infection (OR 4.4, 1.7 - 11.5). CONCLUSION Lactate levels can risk stratify patients with AVS who have increased risk of adverse outcomes regardless of infection status.
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Affiliation(s)
- Kimie Oedorf
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts; Aarhus University Hospital, Research Center for Emergency Medicine, Aarhus, Denmark
| | - Danielle E Day
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Yotam Lior
- Ben-Gurion University of the Negev, Clinical Research Center Soroka University Medical Center, and Faculty of Health Sciences, Beersheba, Israel
| | - Victor Novack
- Ben-Gurion University of the Negev, Clinical Research Center Soroka University Medical Center, and Faculty of Health Sciences, Beersheba, Israel
| | - Leon D Sanchez
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Richard E Wolfe
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Hans Kirkegaard
- Aarhus University Hospital, Research Center for Emergency Medicine, Aarhus, Denmark
| | - Nathan I Shapiro
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Daniel J Henning
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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