Causes of death among non-urgent patients in the emergency department who die within 30 days.

INTRODUCTION: Patients triaged as non-urgent in the emergency department constitute a diverse group with a low mortality rate assumed to be able to wait three hours for a physician. Little is known about the causes of death of non-urgent patients who die shortly after admission. We examined whether deaths among non-urgent patients were preventable. METHOD: Using data from the Copenhagen Triage Algorithm Study, we conducted a review of electronic medical records of all patients triaged as non-urgent who died within 30 days of presentation and constructed short summaries. These summaries were reviewed by two senior physicians who determined whether each death was expected or unexpected. The unexpected deaths were further assessed as unrelated or related to admission and if related as preventable or unpreventable. Any disagreements were settled by a third senior physician. RESULTS: Among the patients triaged as non-urgent, 335 of 14,655 (2%) died within 30 days. When comparing biomarkers and age, the non-urgent patients resembled the patients in other triage categories who died within 30 days. Most deaths were expected or not preventable (96%). The preventable deaths (n = 13, 4%) were among older patients with comorbidities. Causes of death were sudden cardiac arrest (n = 3), infection (n = 4), kidney failure (n = 1), electrolyte derangement (n = 1) and unknown (n = 4). CONCLUSION: Preventable deaths among non-urgent patients were rare and no overrepresentation was observed of specialties or diseases. FUNDING: Trygfonden. CLINICALTRIALS: gov:NCT02698319.

Abnormal routine blood tests as predictors of mortality in acutely admitted patients.

BACKGROUND: This study aimed to improve early risk stratification in the emergency department by creating a simple blood test score based on routine biomarkers and assess its predictive ability for 30-day mortality of acutely admitted patients. METHODS: This was a secondary analysis of data from the TRIAGE II study. It included unselected acutely admitted medical and surgical patients, who had albumin, C-reactive protein, creatinine, haemoglobin, leukocytes, potassium, sodium and thrombocytes levels analysed upon admission. Patients were classified according to the number of biomarker results outside the reference range into four risk groups termed "very low", "low", "intermediate", and "high" with 0-1, 2-3, 4-5 and 6-8 abnormal biomarker results, respectively. Logistic regression was used to calculate odds ratios for 30-day mortality and receiver operating characteristic was used to test the discriminative value. The primary analysis was done in patients triaged with ADAPT (Adaptive Process Triage). Subsequently, we analysed two other cohorts of acutely admitted patients. RESULTS: The TRIAGE II cohort included 17,058 eligible patients, 30-day mortality was 5.2%. The primary analysis included 7782 patients. Logistic regression adjusted for age and sex showed an OR of 24.1 (95% CI 14.9-41.0) between the very low- and the high-risk group. The area under the curve (AUC) was 0.79 (95% CI 0.76-0.81) for the blood test score in predicting 30-day mortality. The subsequent analyses confirmed the results. CONCLUSIONS: A blood test score based on number of routine biomarkers with an abnormal result was a predictor of 30-day mortality in acutely admitted patients.

Early Discharge from the Emergency Department Based on Soluble Urokinase Plasminogen Activator Receptor (suPAR) Levels: A TRIAGE III Substudy.

OBJECTIVE: Using biomarkers for early and accurate identification of patients at low risk of serious illness may improve the flow in the emergency department (ED) by classifying these patients as nonurgent or even suitable for discharge. A potential biomarker for this purpose is soluble urokinase plasminogen activator receptor (suPAR). We hypothesized that availability of suPAR might lead to a higher proportion of early discharges. DESIGN: A substudy of the interventional TRIAGE III trial, comparing patients with a valid suPAR measurement at admission to those without. The primary endpoint was the proportion of patients discharged alive from the ED within 24 hours. Secondary outcomes were length of hospital stay, readmissions, and mortality within 30 days. SETTING: EDs at two university hospitals in the Capital Region of Denmark. PARTICIPANTS: 16,801 acutely admitted patients were included. MEASUREMENTS AND MAIN RESULTS: The suPAR level was available in 7,905 patients (suPAR group), but not in 8,896 (control group). The proportion of patients who were discharged within 24 hours of admittance was significantly higher in the suPAR group compared to the control group (50.2% (3,966 patients) vs. 48.6% (4,317 patients), P = 0.04). Furthermore, the mean length of hospital stay in the suPAR group was significantly shorter compared to that in the control group (4.3 days (SD 7.4) vs. 4.6 days (SD 9.4), P = 0.04). In contrast, the readmission rate within 30 days was significantly higher in the suPAR group (10.6% (839 patients) vs. 8.8% (785 patients), P < 0.001). Among patients discharged within 24 hours, there was no significant difference in the readmission rate or mortality within 30 days. Readmission occurred in 8.5% (336 patients) vs. 7.7% (331 patients) (P = 0.18) and mortality in 1.3% (52 patients) vs. 1.8% (77 patients) (P = 0.08) for the suPAR group and control group, respectively. CONCLUSION: These post hoc analyses demonstrate that the availability of the prognostic biomarker suPAR was associated with a higher proportion of discharge within 24 hours and reduced length of stay, but more readmissions. In patients discharged within 24 hours, there was no difference in readmission or mortality. TRIAL REGISTRATION OF THE MAIN TRIAL: This trial is registered with NCT02643459.

Availability of suPAR in emergency departments may improve risk stratification: a secondary analysis of the TRIAGE III trial.

INTRODUCTION: Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic and nonspecific biomarker associated with short-term mortality in emergency department (ED) patients. Therefore, the blood level of suPAR might be usable for identification of patients at high- and low risk, shortly after arrival at the ED. Here, we investigate the value of adding suPAR to triage and how this may impact on risk stratification regarding mortality. METHODS: The analyses were performed on the TRIAGE III cohort. Patients were triaged in four groups: Red, Orange, Yellow, and Green. Outcome was all-cause mortality within seven days. Discriminative abilities of triage and suPAR on mortality were assessed using the area under the curve (AUC) for receiver operating characteristics (ROC) curves. A suPAR cut-off value was generated using the Youden's index. Patients were subsequently reclassified one triage level up if the suPAR level was above this cut-off and one level down if the suPAR level was below that value. RESULTS: The study included 4420 patients with an available triage category and suPAR measurement. suPAR was significantly better in predicting mortality than triage; AUC (95% confidence interval): 0.85 (0.80-0.89) vs. 0.71 (0.64-0.78), P < 0.001. Combining suPAR and triage yielded an AUC of 0.87 (0.82-0-93). The Youden's cut-off of suPAR was 5.9 ng/mL and reclassified triage using this value resulted in a more accurate risk stratification regarding hospital admission and mortality. CONCLUSION: Addition of suPAR to triage potentially improves prediction of short-term mortality. Measurement of suPAR in relation to the triage process may allow a more accurate identification of ED patients at risk. TRIAL REGISTRATION: Clinicaltrials.gov , NCT02643459. Registered 31 December 2015. https://clinicaltrials.gov/ct2/show/NCT02643459?cond=NCT02643459&rank=1 .

The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study.

INTRODUCTION: Triage systems with limited room for clinical judgment are used by emergency departments (EDs) worldwide. The Copenhagen Triage Algorithm (CTA) is a simplified triage system with a clinical assessment. METHODS: The trial was a non-inferiority, two-center cluster-randomized crossover study where CTA was compared to a local adaptation of Adaptive Process Triage (ADAPT). CTA involves initial categorization based on vital signs with a final modification based on clinical assessment by an ED nurse. We used 30-day mortality with a non-inferiority margin at 0.5%. Predictive performance was compared using Receiver Operator Characteristics. RESULTS: We included 45,347 patient visits, 23,158 (51%) and 22,189 (49%) were triaged with CTA and ADAPT respectively with a 30-day mortality of 3.42% and 3.43% (P = 0.996) a difference of 0.01% (95% CI: -0.34 to 0.33), which met the non-inferiority criteria. Mortality at 48 hours was 0.62% vs. 0.71%, (P = 0.26) and 6.38% vs. 6.61%, (P = 0.32) at 90 days for CTA and ADAPT. CTA triaged at significantly lower urgency level (P<0.001) and was superior in predicting 30-day mortality, Area under the curve: 0.67 (95% CI 0.65-0.69) compared to 0.64 for ADAPT (95% CI 0.62-0.66) (P = 0.03). There were no significant differences in rate of admission to the intensive care unit, length of stay, waiting time nor rate of readmission within 30 or 90 days. CONCLUSION: A novel triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm by short term mortality, and superior in predicting 30-day mortality. TRIAL REGISTRATION: Clinicaltrials.gov NCT02698319.

Use of the prognostic biomarker suPAR in the emergency department improves risk stratification but has no effect on mortality: a cluster-randomized clinical trial (TRIAGE III).

BACKGROUND: Risk stratification of patients in the emergency department can be strengthened using prognostic biomarkers, but the impact on patient prognosis is unknown. The aim of the TRIAGE III trial was to investigate whether the introduction of the prognostic and nonspecific biomarker: soluble urokinase plasminogen activator receptor (suPAR) for risk stratification in the emergency department reduces mortality in acutely admitted patients. METHODS: The TRIAGE III trial was a cluster-randomized interventional trial conducted at emergency departments in the Capitol Region of Denmark. Eligible hospitals were required to have an emergency department with an intake of acute medical and surgical patients and no previous access to suPAR measurement. Three emergency departments were randomized; one withdrew shortly after the trial began. The inclusion period was from January through June of 2016 consisting of twelve cluster-periods of 3-weeks alternating between intervention and control and a subsequent follow-up of ten months. Patients were allocated to the intervention if they arrived in interventional periods, where suPAR measurement was routinely analysed at arrival. In the control periods suPAR measurement was not performed. The main outcome was all-cause mortality 10 months after arrival of the last patient in the inclusion period. Secondary outcomes included 30-day mortality. RESULTS: The trial enrolled a consecutive cohort of 16,801 acutely admitted patients; all were included in the analyses. The intervention group consisted of 6 cluster periods with 8900 patients and the control group consisted of 6 cluster periods with 7901 patients. After a median follow-up of 362 days, death occurred in 1241 patients (13.9%) in the intervention group and in 1126 patients (14.3%) in the control group. The weighted Cox model found a hazard ratio of 0.97 (95% confidence interval, 0.89 to 1.07; p = 0.57). Analysis of all subgroups and of 30-day all-cause mortality showed similar results. CONCLUSIONS: The TRIAGE III trial found no effect of introducing the nonspecific and prognostic biomarker suPAR in emergency departments on short- or long-term all-cause mortality among acutely admitted patients. Further research is required to evaluate how prognostic biomarkers can be implemented in routine clinical practice. TRIAL REGISTRATION: clinicaltrials.gov, NCT02643459 . Registered 31 December 2015.

Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study.

BACKGROUND: Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), the potential gain from a CT scan might outweigh the risk of radiation exposure. We hypothesized that an accelerated "multiple rule out" CT screening of moderate-to-high risk patients will detect many clinically unrecognized diagnoses that affect change in treatment. METHOD: Patients ≥ 40 years, triaged as high-risk or moderate-to-high risk according to vital signs, were eligible for inclusion. Patients were scanned with a combined ECG-gated and dual energy CT scan of cerebrum, thorax, and abdomen. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by an expert panel. RESULTS: A total of 100 patients were included in the study, (53% female, mean age 73 years [age range, 43-93]). The scan lead to change in treatment or additional examinations in 37 (37%) patients, of which 24 (24%) were diagnostically significant, change in acute treatment in 11 (11%) cases and previously unrecognized malignant tumors in 10 (10%) cases. The mean size specific radiation dose was 15.9 mSv (± 3.1 mSv). CONCLUSION: Screening with a multi-rule out CT scan of high-risk patients in an ED is feasible and result in discovery of clinically unrecognized diagnoses and malignant tumors, but at the cost of radiation exposure and downstream examinations. The clinical impact of these findings should be evaluated in a larger randomized cohort.

The Copenhagen Triage Algorithm: a randomized controlled trial.

BACKGROUND: Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. METHODS: The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. DISCUSSION: If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.

Introduction of a prognostic biomarker to strengthen risk stratification of acutely admitted patients: rationale and design of the TRIAGE III cluster randomized interventional trial.

BACKGROUND: Several biomarkers have shown to carry prognostic value beyond current triage algorithms and may aid in initial risk stratification of patients in the emergency department (ED). It has yet to be established if information provided by biomarkers can be used to prevent serious complications or deaths. Our aim is to determine whether measurement of the blood level of the biomarker soluble urokinase plasminogen activator receptor (suPAR) can enhance early risk stratification leading to reduced mortality, lower rate of complications, and improved patient flow in acutely admitted adult patients at the ED. The main hypothesis is that the availability of suPAR can reduce all-cause mortality, assessed at least 10 months after admission, by drawing attention towards patients with an unrecognized high risk, leading to improved diagnostics and treatment. METHODS: The study is designed as a cross-over cluster randomized interventional trial. SuPAR is measured within 2 h after admission and immediately reported to the treating physicians in the ED. All ED physicians are educated in the prognostic capabilities of suPAR prior to the inclusion period. The inclusion period began January 11(th) 2016 and ends June 6(th) 2016. The study aims to include 10.000 patients in both the interventional and control arm. The results will be presented in 2017. DISCUSSION: The present article aims to describe the design and rationale of the TRIAGE III study that will investigate whether the availability of prognostic information can improve outcome in acutely admitted patients. This might have an impact on health care organization and decision-making. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (ID NCT02643459 , November 13, 2015) and at the Danish Data Protection agency (ID HGH-2015-042 I-Suite no. 04087).

[Implementation of a national training assessment programme in anaesthesiology]. / Implementering af nationalt kompetenceprogram i anaestesiologi.

INTRODUCTION: In 2004, outcome-based education and in-training assessment was introduced by a reform of postgraduate medical education in Denmark. An assessment programme covering the introductory year of anaesthesiology was constructed. The purpose of this study was to explore to which degree this programme was implemented in daily practice in the clinical departments and whether the recommended assessment protocol was followed. MATERIALS AND METHODS: A questionnaire was distributed to 26 departments and 38 trainees. RESULTS: The response rate for both groups exceeded 90%. Individual learning plans were prepared by (2/3) of the trainees according to both trainees and departments. The various methods in the assessment programme were implemented to a high degree. The use of structured clinical observations was reported by more than 70% of both groups. Global assessments were applied in more than 70% according to both groups. Fifty percent of the trainees and 70% of the departments reported that these were used in accordance with recommendations. The trainees profited from preparing the written assignments, but only half of them found that they were used in accordance with recommendations. In contrast, more than 90% of the departments reported that the assignments were implemented according to recommendations. Practical completion of in-training assessment was considered difficult by 67% of the departments and 30% of trainees. The workload was the primary difficulty reported. CONCLUSION: In conclusion, the in-training assessment programme of the introductory year of anaesthesia has been implemented to a high degree and the assessment protocol is used according to recommendations.

Influence of "liberal" versus "restrictive" intraoperative fluid administration on elimination of a postoperative fluid load.

BACKGROUND: Previously, the authors found "liberal" fluid administration (approximately 3 l Ringer's lactate [RL]) to improve early rehabilitation after laparoscopic cholecystectomy, suggesting functional hypovolemia to be present in patients receiving "restrictive" fluid administration (approximately 1 l RL). Because volume kinetic analysis after a volume load may distinguish between hypovolemic versus normovolemic states, the authors applied volume kinetic analysis after laparoscopic cholecystectomy to explain the difference in outcome between 3 and 1 l RL. METHODS: In a prospective, nonrandomized trial, the authors studied 20 patients undergoing laparoscopic cholecystectomy. Ten patients received 15 ml/kg RL (group 1) and 10 patients received 40 ml/kg RL (group 2) intraoperatively. All other aspects of perioperative management were standardized. A 12.5-ml/kg RL volume load was infused preoperatively and 4 h postoperatively. The distribution and elimination of the fluid load was estimated using volume kinetic analysis. RESULTS: Patient baseline demographics and intraoperative data did not differ between groups, except for intraoperative RL, having a median of 1,118 ml (range, 900-1,400 ml) in group 1 compared with a median of 2,960 ml (range, 2,000-3,960 ml) in group 2 (P<0.01). There were no significant preoperative versus postoperative differences in the size of the body fluid space expanded by infused fluid (V), whereas the clearance constant kr was higher postoperatively versus preoperatively (P=0.03). The preoperative versus postoperative changes in volume kinetics including V were not different between the two groups. CONCLUSIONS: Elimination of an intravenous fluid load was increased after laparoscopic cholecystectomy per se but not influenced by the amount of intraoperative fluid administration.

Vasoactive modulators during and after craniotomy: relation to postoperative hypertension.

Hypertension after craniotomy is frequent. To establish an association between vasoactive modulators and postoperative hypertension, we followed the arterial blood pressure and plasma concentrations of selected substances in patients undergoing craniotomy. Twelve consecutive patients scheduled for operation of a supratentorial brain tumor were anesthetized with thiopental, fentanyl, isoflurane, and pancuronium. None of the patients had a history of arterial hypertension or were hypertensive before the operation. Arterial blood pressure and heart rate measurements were obtained preoperatively, after incision, during closure, and four times in the 50-minute interval after stopping isoflurane. At the same time, plasma concentrations of norepinephrine, epinephrine, renin, aldosterone, atrial natriuretic peptide, endothelin, and cortisol were measured. Data are given as mean +/- SD (range). The postoperative concentrations of these substances were significantly higher than the baseline concentrations measured preoperatively. Six of the patients developed postoperative hypertension defined as a mean arterial pressure (MAP) > 20% more than the baseline MAP (group H), and six had normal blood pressure postoperatively (group N). The mean value of the maximal postoperative MAPs measured in groups H and N, respectively, was 118 +/- 16 mm Hg (range: 96-132) and 103 +/- 9 mm Hg (range: 92-115) (P =.01). Only renin levels were higher intraoperatively in group H when compared to group N. However, postoperative levels of catecholamines, aldosterone, renin, and endothelin levels were higher in group H patients. The results suggest that in addition to an increased discharge of the sympathetic system, activation of the renin-angiotensin aldosterone system may also play an important role in the development of postoperative hypertension after craniotomy.