Association of Vital Signs and Process Outcomes in Emergency Department Patients

Estimated glomerular filtration rate may be an independent predictor for clinical outcomes regardless of acute kidney injury complication in the emergency department

Study objective

Acute kidney injury (AKI), chronic kidney disease (CKD), and decreased estimated glomerular filtration rate (eGFR) are all associated with poor clinical outcomes among emergency department (ED) patients. This study aimed to evaluate the effect of different types of renal dysfunction and the degree of eGFR reduction on the clinical outcomes in a real-world ED setting.

Methods

Adult patients with an eGFR lower than 60 mL/min/1.73m² in our ED, from October 1, 2016, to December 31, 2016, were enrolled in this retrospective observational study. Besides AKI and CKD, patients with unknown baseline renal function before an ED visit were categorized in the undetermined renal dysfunction (URD) category.

Results

Among 1495 patients who had eGFR evaluation at ED, this study finally enrolled 441 patients; 22 patients (5.0%) had AKI only, 32 (7.3%) had AKI on CKD, 196 (44.4%) had CKD only, 27 (6.1%) had subclinical kidney injury (those who met neither criteria for AKI nor CKD), and 164 (37.2%) had URD. There was a significant association between eGFR and critical illness defined as the composite outcome of death or intensive care unit (ICU) need, hospitalization, ICU need, death, and renal replacement therapy need (odds ratio [95% confidence interval]: 1.72 [1.45–2.05], 1.36 [1.16–1.59], 1.66 [1.39–2.00], 1.73 [1.32–2.28], and 2.71 [1.73–4.24] for every 10 mL/min/1.73m² of reduction, respectively). Multivariate logistic regression analysis showed eGFR was an independent predictor of critical illness composite outcome (death or ICU need), hospitalization, and ICU need even after adjustment with AKI or URD.

Conclusions

Estimated GFR may be a sufficient predictor of clinical outcomes of ED patients regardless of AKI complication. Considerable ED patients were determined as URD, which might have a significant impact on the ED statistics regarding renal dysfunction.

Initial assessment in emergency departments by chief complaint and respiratory rate

BACKGROUND

Understanding heterogeneity of the respiratory rate (RR) as a risk stratification marker across chief complaints is important to reduce misinterpretation of the risk posed by outcome events and to build accurate risk stratification tools. This study was conducted to investigate the associations between RR and clinical outcomes according to the five most frequent chief complaints in an emergency department (ED): fever, shortness of breath, altered mental status, chest pain, and abdominal pain.

METHODS

This retrospective cohort study examined ED data of all adult patients who visited the ED of a tertiary medical center during April 2018-September 2019. The primary exposure was RR at the ED visit. Outcome measures were hospitalization and mechanical ventilation use. We used restrictive cubic spline and logistic regression models to assess the association of interest.

RESULTS

Of 16 956 eligible ED patients, 4926 (29%) required hospitalization; 448 (3%) required mechanical ventilation. Overall, U-shaped associations were found between RR and the risk of hospitalization (eg, using RR = 16 as the reference, the odds ratio [OR] of RR = 32, 6.57 [95% CI 5.87-7.37]) and between RR and the risk of mechanical ventilation. This U-shaped association was driven by patients' association with altered mental status (eg, OR of RR = 12, 2.63 [95% CI 1.25-5.53]). For patients who have fever or shortness of breath, the risk of hospitalization increased monotonously with increased RR.

CONCLUSIONS

U-shaped associations of RR with the risk of overall clinical outcomes were found. These associations varied across chief complaints.

Emergency department use by patients with end-stage renal disease in the United States

Background

We sought to describe the national characteristics of ED visits by patients with end-stage renal disease (ESRD) in the United States in order to improve the emergency treatment and screening of ESRD patients.

Methods

We analyzed data from 2014 to 2016 ED visits provided by the National Hospital Ambulatory Medical Care Survey. We sampled adult (age ≥ 18 years) ED patients with ESRD. By proportion or means of weighted sample variables, we quantified annual ED visits by patients with ESRD. We investigated demographics, ED resource utilization, clinical characteristics, and disposition of patients with ESRD and compared these to those of patients without ESRD. Logistic regression models were used to estimate the association between these characteristics and ESRD ED visits.

Results

Approximately 722,692 (7.78%) out of 92,899,685 annual ED visits represented ESRD patients. Males were more likely to be ESRD patients than females (aOR: 1.34; 95% CI: 1.09–1.66). Compare to whites, non-Hispanic Blacks were 2.55 times more likely to have ESRD (aOR: 2.55; 95% CI: 1.97–3.30), and Hispanics were 2.68 times more likely to have ESRD (95% CI: 1.95–3.69). ED patients with ESRD were more likely to be admitted to the hospital (aOR: 2.70; 95% CI: 2.13–3.41) and intensive care unit (ICU) (aOR: 2.21; 95% CI: 1.45–3.38) than patients without ESRD. ED patients with ESRD were more likely to receive blood tests and get radiology tests.

Conclusion

We described the unique demographic, socioeconomic, and clinical characteristics of ED patients with ESRD, using the most comprehensive, nationally representative study to date. These patients’ higher hospital and ICU admission rates indicate that patients with ESRD require a higher level of emergency care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00420-8.