Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department

OBJECTIVES

Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr).

DESIGN

International multicenter cohort study.

SETTING

Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark.

PATIENTS

All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC).

MEASUREMENTS AND MAIN RESULTS

Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories.

CONCLUSIONS

The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.

THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY

BACKGROUND

Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress.

OBJECTIVE

To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years).

METHODS

A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]).

RESULTS

A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection.

CONCLUSION

No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.

The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study

BACKGROUND

The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h.

AIM

The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital.

METHODS

This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment.

RESULTS

The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P  < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%.

CONCLUSION

The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.

What matters and influence resuscitation preference? Development, field testing, and structural validation of items among older patients in the emergency department

BACKGROUND

Decisions about resuscitation preference is an essential part of patient-centered care but a prerequisite is having an idea about which questions to ask and understand how such questions may be clustered in dimensions. The European Resuscitation Council Guidelines 2021 encourages resuscitation shared decision making in emergency care treatment plans and needs and experiences of people approaching end-of-life have been characterized within the physical, psychological, social, and spiritual dimensions. We aimed to develop, test, and validate the dimensionality of items that may influence resuscitation preference in older Emergency Department (ED) patients.

METHODS

A 36-item questionnaire was designed based on qualitative interviews exploring what matters and what may influence resuscitation preference and existing literature. Items were organized in physical, psychological, social, and spiritual dimensions. Initial pilot-testing to assess content validity included ten older community-dwelling persons. Field-testing, confirmatory factor analysis and post-hoc bifactor analysis was performed on 269 older ED patients. Several model fit indexes and reliability coefficients (explained common variance (ECV) and omega values) were computed to evaluate structural validity, dimensionality, and model-based reliability.

RESULTS

Items were reduced from 36 to 26 in field testing. Items concerning religious beliefs from the spiritual dimension were misunderstood and deemed unimportant by older ED patients. Remaining items concerned physical functioning in daily living, coping, self-control in life, optimism, overall mood, quality of life and social participation in life. Confirmatory factor analysis displayed poor fit, whereas post-hoc bifactor analysis displayed satisfactory goodness of fit (χ² =562.335 (p<0.001); root mean square error of approximation=0.063 (90% CI [0.055;0.070])). The self-assessed independence may be the bifactor explaining what matters to older ED patients' resuscitation preference.

CONCLUSIONS

We developed a questionnaire and investigated the dimensionality of what matters and may influence resuscitation preference among older ED patients. We could not confirm a spiritual dimension. Also, in bifactor analysis the expected dimensions were overruled by an overall explanatory general factor suggesting independence to be of particular importance for clinicians practicing resuscitation discussions in EDs. Studies to investigate how independence may relate to patients' choice of resuscitation preference are needed.

Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs

BACKGROUND

Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs.

METHODS

Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping.

RESULTS

2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs.

CONCLUSION

Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.

The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older

Objective

To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI).

Methods

Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS.

Results

In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model.

Conclusion

The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.

[Assessment of older patients upon admission at the emergency department]

Older patients admitted to the emergency departments represent a heterogeneous group, some are frail with reduced reserve capacity and without ability to compensate to acute illness. They often present with nonspecific complaints and atypical presentation and are at-risk of complications and adverse events. These patients need a fast comprehensive interdisciplinary and multicomponent assessment and intervention to reduce the risk of further functional decline and to optimize their overall health status, independency and quality of life. This is the purpose of acute geriatrics.

Nationwide study on trends in unplanned hospital attendance and deaths during the 7 weeks after the onset of the COVID-19 pandemic in Denmark

BACKGROUND

The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued.

METHODS

We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs).

RESULTS

From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two.

CONCLUSION

The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns.

Translation of the updated clinical frailty scale 2.0 into Danish and implications for cross-sectoral reliability

The Clinical Frailty Scale, which provides a common language about frailty, was recently updated to version 2.0 to cater for its increased use in areas of medicine usually involved in the care and treatment of older patients. We have previously translated the Clinical Frailty Scale 1.2 into Danish and found inter-rater-reliability to be excellent for primary care physicians, community nurses, and hospital doctors often involved in cross-sectoral collaborations. In this correspondence we present the Danish translation and cultural adaption of the Clinical Frailty Scale 2.0. Our recent findings on cross-sectoral inter-rater reliability for the Clinical Frailty Scale 1.2 are likely also applicable for the Clinical Frailty Scale 2.0.

Clinical thermography at extreme temperatures

Every day, emergency departments and acute medical units all over the world receive and assess thousands of patients. Most are stable, but a few require immediate stabilization. To identify these, all patients are routinely triaged and have vital signs measured. Our group has shown that thermographic images of the face can be an alternative method for identifying patients at increased risk of 30-day mortality. In our previous studies, the thermographic images were taken after the patients had been inside for at least 30 minutes. However, to identify patients at risk, the images have to be available as quickly as triage, i.e. at the door when the patient arrives. Therefore, we have performed a small study, with the aim of illustrating the effect of such heat-gradients on thermal images of the face.

Trends of Opioid Utilisation in Denmark: A Nationwide Study

Background

Opioid use has more than doubled over recent decades, and Denmark occupies fifth place in the global ranking. These increases have been partly attributed to the ageing population.

Objective

Our objective was to assess the impact of age over time on utilisation of the most commonly used opioids in Denmark.

Methods

We retrieved nationwide sales data on opioid sales in Denmark from 1999 to 2017. We investigated utilisation trends in age groups for the four opioids with the highest use. We used three volume-based metrics (defined daily doses/1000/day, oral morphine equivalents/1000/day, and packages dispensed/year) and one person-based metric (users/1000/year).

Results

The four opioids selected according to users/1000/year were tramadol (46.1), codeine and combination products (12.4 for codeine, 3.7 for codeine and acetylsalicylic acid, and 4.2 for codeine and paracetamol), morphine (17.0), and oxycodone (12.1). Overall utilisation according to volume and person metrics increased for all except codeine and combination products. Tramadol doses or strength increased, albeit less with increasing age. Oxycodone doses or strength decreased for all age groups but were nearly unchanged for the age group ≥ 80 years.

Conclusion

Tramadol is the most utilised opioid in Denmark and was prescribed at increasing doses or strengths over the study period, particularly in the younger (< 80 years) age groups. Overall, oxycodone was prescribed at decreasing doses or strengths over time but remained unchanged for the age group ≥ 80 years. There is a need to address the pharmacological treatment of pain in terms of age, with tramadol and oxycodone being possible targets for regulatory efforts.

Electronic supplementary material

The online version of this article (10.1007/s40801-019-00163-w) contains supplementary material, which is available to authorized users.

Identification of a novel mutation in the factor VIII gene causing severe haemophilia A

Background

Deficiency in coagulation factor VIII encoded by F8 results in the X-linked recessive bleeding disorder haemophilia A (HEMA). Here we describe the identification of a novel variant in the factor VIII gene, F8, in an adult male patient with severe haemophilia A.

Case presentation

The patient was diagnosed in early childhood and subsequently co-infected with Hepatitis C and HIV acquired during early blood transfusion for haemophilia in the 1980ies. The identified F8 deletion, c.5411_5413delTCT, p.F1804del lies within a conserved part of the molecule, is predicted by bioinformatic software to be deleterious by the loss of Phenylalanine, and has not been previously described in any database.

Conclusion

This novel F8 deletion as a cause of haemophilia A did not result in generation of inhibitory antibodies to Factor VIII treatment and may have impact on (prenatal) diagnosis, genetic counselling, and treatment decisions in the affected family as well as in other families diagnosed with this F8 mutation. Finally, this novel mutation should be included in the panel of known genetic variants in F8 when searching for the genetic etiology in patients suspected of HEMA.

Electronic supplementary material

The online version of this article (10.1186/s12878-018-0113-4) contains supplementary material, which is available to authorized users.

[Faecal impaction in elderly patients is a potential severe condition]

This case report presents an old hemiparetic male admitted to hospital from nursing home due to dark-coloured emesis. Transdermal buprenorphine 5 mcg/h had been instigated without laxatives in the preceding month. Upon arrival, an enlarged tense abdomen was found. A CT-scan dem-on-strated a 19 cm wide faecal colon impaction. Limited effect of enemas and endoscopic disimpaction resulted in surgery. The patient died shortly after discharge. The case stresses the prevention of constipation when using opioids; in particular in immobilized patients.

Sequential Vacc-4x and romidepsin during combination antiretroviral therapy (cART): Immune responses to Vacc-4x regions on p24 and changes in HIV reservoirs

OBJECTIVES

The REDUC clinical study Part B investigated Vacc-4x/rhuGM-CSF therapeutic vaccination prior to HIV latency reversal using romidepsin. The main finding was a statistically significant reduction from baseline in viral reservoir measurements. Here we evaluated HIV-specific functional T-cell responses following Vacc-4x/rhuGM-CSF immunotherapy in relation to virological outcomes on the HIV reservoir.

METHODS

This study, conducted in Aarhus, Denmark, enrolled participants (n = 20) with CD4>500 cells/mm³ on cART. Six Vacc-4x (1.2 mg) intradermal immunizations using rhuGM-CSF (60 μg) as adjuvant were followed by 3 weekly intravenous infusions of romidepsin (5 mg/m²). Immune responses were determined by IFN-γ ELISpot, T-cell proliferation to p24 15-mer peptides covering the Vacc-4x region, intracellular cytokine staining (ICS) to the entire HIV^Gag and viral inhibition.

RESULTS

The frequency of participants with CD8+ T-cell proliferation assay positivity was 8/16 (50%) at baseline, 11/15 (73%) post-vaccination, 6/14 (43%) during romidepsin, and 9/15 (60%)post-romidepsin. Participants with CD8+ T-cell proliferation assay positivity post-vaccination showed reductions in total HIV DNA post-vaccination (p = 0.006; q = 0.183), post-latency reversal (p = 0.005; q = 0.183), and CA-RNA reductions post-vaccination (p = 0.015; q = 0.254). Participants (40%) were defined as proliferation 'Responders' having ≥2-fold increase in assay positivity post-baseline. Robust ELISpot baseline responses were found in 87.5% participants. No significant changes were observed in the proportion of polyfunctional CD8+ T-cells to HIV^Gag by ICS. There was a trend towards increased viral inhibition from baseline to post-vaccination (p = 0.08).

CONCLUSIONS

In this 'shock and kill' approach supported by therapeutic vaccination, CD8+ T-cell proliferation represents a valuable means to monitor functional immune responses as part of the path towards functional HIV cure.

Innate DNA sensing is impaired in HIV patients and IFI16 expression correlates with chronic immune activation

The innate immune system has been recognized to play a role in the pathogenesis of HIV infection, both by stimulating protective activities and through a contribution to chronic immune activation, the development of immunodeficiency and progression to AIDS. A role for DNA sensors in HIV recognition has been suggested recently, and the aim of the present study was to describe the influence of HIV infection on expression and function of intracellular DNA sensing. Here we demonstrate impaired expression of interferon-stimulated genes in responses to DNA in peripheral blood monuclear cells from HIV-positive individuals, irrespective of whether patients receive anti-retroviral treatment. Furthermore, we show that expression levels of the DNA sensors interferon-inducible protein 16 (IFI16) and cyclic guanosine monophosphate-adenosine monophosphate synthase were increased in treatment-naive patients, and for IFI16 expression was correlated with high viral load and low CD4 cell count. Finally, our data demonstrate a correlation between IFI16 and CD38 expression, a marker of immune activation, in CD4(+) central and effector memory T cells, which may indicate that IFI16-mediated DNA sensing and signalling contributes to chronic immune activation. Altogether, the present study demonstrates abnormal expression and function of cytosolic DNA sensors in HIV patients, which may have implications for control of opportunistic infections, chronic immune activation and T cell death.