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BACKGROUND: To assess differences between patients referred to emergency departments by a primary care physician (PCP) and those presenting directly and the impact of referral on the likelihood of admission. DESIGN OF STUDY: Retrospective cohort study. SETTING: EDs of two nonacademic general hospitals in a German metropolitan region. PARTICIPANTS: Random sample of 1500 patients out of 80,845 presentations during the year 2019. RESULTS: Age was 55.8 ± 22.9 years, and 51.4% was female. A total of 34.7% presented by emergency medical services (EMS), and 47.7% were walk-ins. One-hundred seventy-four (11.9%) patients were referred by PCPs. Referrals were older (62.4 ± 20.1 vs 55.0 ± 23.1 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) (3 (1-5) vs 2 (0-4); p < .001). Referrals received more ultrasound examinations independently from their admission status (27.6% vs 15.7%; p < .001) and more CT and laboratory investigations. There were no differences in sex, Manchester Triage System (MTS) category, or pain-scale values. Referrals presented by EMS less often (9.2% vs 38.5%; p < .001). Admission rates were 62.6% in referrals and 37.1% in non-referrals (p < .001). Referral (OR 3.976 95% CI: 2.595-6.091), parenteral medication in ED (OR 2.674 (1.976-3.619)), higher MTS category (1.725 (1.421-2.093)), transport by EMS (1.623 (1.212-2.172)), abnormal vital parameters (1.367 (0.953-1.960)), higher CCI (1.268 (1.196-1.344)), and trauma (1.268 (1.196-1.344)) were positively associated with admission in multivariable analysis, whereas ultrasound in ED (0.450 (0.308-0.658)) and being a nursing home resident (0.444 (0.270-0.728)) were negatively associated. CONCLUSION: Referred patients were more often admitted. They received more laboratory investigations, ultrasound examinations, and computed tomographies. Difficult decisions regarding the necessity of admission requiring typical resources of EDs may be a reason for PCP referrals.
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INTRODUCTION AND AIMS: We aimed to explore the impact of infection diagnosed upon admission and of other clinical baseline parameters on mortality of cirrhotic patients with emergency admissions. MATERIAL AND METHODS: We performed a prospective observational monocentric study in a tertiary care center. The association of clinical parameters and established scoring systems with short-term mortality up to 90 days was assessed by univariate and multivariable Cox regression analysis. Akaike's Information Criterion (AIC) was used for automated variable selection. Statistical interaction effects with infection were also taken into account. RESULTS: 218 patients were included. 71.2% were male, mean age was 61.1 ± 10.5 years. Mean MELD score was 16.2 ± 6.5, CLIF-consortium Acute on Chronic Liver Failure-score was 34 ± 11. At 28, 90 and 365 days, 9.6%, 26.0% and 40.6% of patients had died, respectively. In multivariable analysis, respiratory organ failure [Hazard Ratio (HR) = 0.15], albumin substitution (HR = 2.48), non-HCC-malignancy (HR = 4.93), CLIF-C-ACLF (HR = 1.10), HCC (HR = 3.70) and first episode of ascites (HR = 0.11) were significantly associated with 90-day mortality. Patients with infection had a significantly higher 90-day mortality (36.3 vs. 20.1%, p = 0.007). Cultures were positive in 32 patients with resistance to cephalosporins or quinolones in 10, to ampicillin/sulbactam in 14 and carbapenems in 6 patients. CONCLUSION: Infection is common in cirrhotic ED admissions and increases mortality. The proportion of resistant microorganisms is high. The predictive capacity of established scoring systems in this setting was low to moderate.
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Antibacterianos/uso terapéutico , Infecciones Bacterianas/terapia , Servicio de Urgencia en Hospital , Cirrosis Hepática/terapia , Admisión del Paciente , Anciano , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/microbiología , Infecciones Bacterianas/mortalidad , Técnicas de Apoyo para la Decisión , Farmacorresistencia Bacteriana , Femenino , Alemania , Estado de Salud , Humanos , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM: Mortality of cirrhotic patients after emergency care admission is high, and prognostic factors can help in prioritizing patients. The aim of our study was to assess the association between levels of cardiac troponin T (cTnT) and 1-year mortality in patients with liver cirrhosis without known cardiac disease, who were admitted to the emergency department (ED). METHODS: All patients with cirrhosis presented to the ED from October 2009 until August 2015 who had an initial cTnT value measured with the first lab panel were retrospectively analyzed with a follow-up of 365 days. RESULTS: Of a total of 237 cirrhotic ED patients, cTnT measurements were available for 87 (63% men, mean age 58.9 ± 11.0 years, and median Model for End-stage Liver Disease score was 15 [25th-75th percentile: 10-19]). Chronic Liver Failure Consortium acute-on-chronic liver failure (CLIF-C-ACLF) score was 33. Forty-three patients (49%) had cTnT values above the normal range (14 ng/L), of which 19 (22%) had values over 30 ng/L. Two patients were lost to follow-up. In multivariable analysis, both CLIF-C-ACLF (hazard ratio 1.072 per point increase; 95% confidence interval 1.029-1.117; P < 0.001) and cTnT (hazard ratio 1.014 per ng/L increase; 95% confidence interval 1.004-1.024; P = 0.008) emerged as independently associated with mortality. CONCLUSIONS: A large proportion of cirrhotic patients in the ED have elevated levels of cTnT even if there is no evidence of cardiac disease. Elevated cTnT is associated with increased mortality during 1 year after correcting for Model for End-stage Liver Disease and CLIF-C-ACLF scores.
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Servicios Médicos de Urgencia , Cirrosis Hepática/mortalidad , Admisión del Paciente/estadística & datos numéricos , Troponina T/sangre , Anciano , Biomarcadores/sangre , Femenino , Humanos , Cirrosis Hepática/diagnóstico , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de TiempoRESUMEN
This study evaluates whether immature platelets (IPF) determined in the post anesthesia care unit (PACU) can predict major adverse cardiovascular events (MACE) or other thromboembolic events after intermediate and high-risk surgery. IPF are increased in patients with acute coronary syndrome and recently gained interest as novel biomarker for risk stratification. In this prospective observational trial 732 patients undergoing intermediate or high-risk non-cardiac surgery were enrolled (NCT02097602). IPF was measured preoperatively and postoperatively in the PACU. Primary outcome was a composite endpoint defined as MACE, deep vein thrombosis or pulmonary embolism during hospital stay (modMACE). A cut off for IPF identifying a threshold between a low and high risk for modMACE was calculated by log-rank optimization. A multivariate Cox regression was calculated in a forward stepwise manner to assess the relation between this IPF cut off and modMACE as well as other established risk factors (inclusion if p<0.05). Preoperatively, there were no differences in IPF between patients with and without modMACE (3.1 % [2.2 % - 4.7 %](median [interquartile range]) vs. 2.8 % [1.9 % - 4.3 %]. Patients with modMACE (28 of 730 patients; 3.8 %) had higher IPF values in the PACU compared to patients without modMACE (3.6 % [2.6-6 %] vs. 2.9 % [2-4.4 %]; p=0.011). The optimal cut off of IPF > 5.4 % was associated with an increased risk for modMACE after adjustment for covariates (hazard ratio: 2.528; 95 % confidence interval: 1.156 to 5.528, p=0.02). In conclusion, IPF is an independent predictor of modMACE after surgery and might improve risk stratification of surgical patients.
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Plaquetas , Enfermedades Cardiovasculares/sangre , Procedimientos Quirúrgicos Operativos/efectos adversos , Anciano , Periodo de Recuperación de la Anestesia , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/etiología , Distribución de Chi-Cuadrado , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Embolia Pulmonar/sangre , Embolia Pulmonar/etiología , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Trombosis de la Vena/sangre , Trombosis de la Vena/etiologíaRESUMEN
Previous studies have focused on postoperative anaesthetic visit as a tool for measuring postoperative recovery or patient's satisfaction. Whether it could also improve timely recognition of complications has not been studied yet. Aim of our study was to assess pathological findings in physical examination requiring further intervention during postoperative visit and to explore whether a self-administered version of the Quality of Recovery (QoR)-9 score, compared to a detailed medical history, can act as a screening tool for identification of patients who show a low risk to develop postoperative complications. This observational study included 918 patients recovering from various types of non-cardiac surgery and anaesthesia. The postoperative visit implied three steps: measuring the QoR-9 score, a structured medical history and a physical examination. QoR-9-score showed a comparable negative predictive value (0.93 vs. 0.92) and a higher sensitivity of finding at least one pathological examination than a detailed medical history (0.92 vs. 0.81 respectively). At least one postoperative pathological examination finding was observed in 23.7% of the patients. Our approach presents a strategy on screening postoperative patients in order to identify patients whose examination and consequent treatment should be intensified. In further studies the question could be addressed whether the postoperative visit may help to reduce complications and mortality after surgery.
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Periodo de Recuperación de la Anestesia , Anestesia/efectos adversos , Morbilidad , Autoinforme , Adulto , Anciano , Anestesia/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
Low donor rates in Germany cause a trade-off between equity in the distribution of chances for survival and efficiency in dead-donor liver transplantation. Public attitudes concerning the principles that should govern organ allocation are of interest. We performed a questionnaire-based study among patients and medical staff. 1826 of 2200 questionnaires were returned. 79.2%, 67.1%, and 24.4% patients wanted to accept liver transplantation for themselves if expected 1-year survival was 80%, 50%, and 20%, respectively. 57.7% affirmed 'averting immediate risk of death (urgency) is a more important criterion for organ allocation than expected long-term success' (P = 0.002 against indifference). The majority of medical staff took the opposite decision. 20.7%, 8.8%, and 21.2% of patients chose 50%, 33%, and 10% as lowest acceptable 5-year survival, respectively. 49.3% accepted a survival of <10%. Variables associated with preferring urgency over efficiency as criterion for allocation were age (OR 1.009; 95% CI: 1.000-1.017; female gender (OR 1.331; 95%CI 0.992-1.784); higher education (OR 0.881; 95%CI 0.801-0.969); and refusal of transplantation for oneself (OR 1.719; 95%CI 1.272-2.324). Most patients supported urgency-based liver allocation. Patients and medical staff would accept lower survival rates than the transplant community.