Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study.

BACKGROUND: Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established. METHODS: The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores. RESULTS: Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome. CONCLUSIONS: ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.

Evaluating dynamic patterns in mortality before and after reconfiguration of the Danish emergency healthcare system.

BACKGROUND: This study explored changes in short-term mortality during a national reconfiguration of emergency care starting in 2007. METHODS: Unplanned hospital contacts at emergency departments across Denmark from 2007 to 2016. The reconfiguration was a natural experiment, resulting in individual timelines for each hospital. The outcome was in-hospital and 30-day mortality. RESULTS: Individual patient-level data included 9,745,603 unplanned hospital contacts from 2007 to 2016 at 20 hospitals with emergency departments. We observed a sharp downwards shift in in-hospital mortality and 30-day mortality in three hospitals in relation to the reconfiguration. CONCLUSION: This nationwide study identified three hospitals where the reconfiguration was closely associated with reduced in-hospital and 30-day mortality. In contrast, no major effects were identified for the remaining hospitals.

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.

Mobile emergency department care to nursing home residents: a novel outreach service.

BACKGROUND: Every month, 6% of Danish nursing home residents are admitted to hospital. However, these admissions might have limited benefits and are associated with an increased risk of complications. We initiated a new mobile service comprising consultants performing emergency care in nursing homes. OBJECTIVE: Describe the new service, the recipients of this service, hospital admission patterns and 90-day mortality. DESIGN: A descriptive observational study. MODEL: When an ambulance is requested to a nursing home, the emergency medical dispatch centre simultaneously dispatches a consultant from the emergency department who will provide an emergency evaluation and decisions regarding treatment at the scene in collaboration with municipal acute care nurses. METHOD: We describe the characteristics of all nursing home contacts from 1st November 2020 to 31st December 2021. The outcome measures were hospital admissions and 90-day mortality. Data were extracted from the patients' electronic hospital records and prospectively registered data. RESULTS: We identified 638 contacts (495 individuals). The new service had a median of two (interquartile range: 2-3) new contacts per day. The most frequent diagnoses were related to infections, unspecific symptoms, falls, trauma and neurologic disease. Seven out of eight residents remained at home following treatment, 20% had an unplanned hospital admission within 30 days and 90-day mortality was 36.4%. CONCLUSION: Transitioning emergency care from hospitals to nursing homes could present an opportunity for providing optimised care to a vulnerable population and limiting unnecessary transfers and admissions to hospitals.

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.

Readmission is experienced as inevitable among older adults receiving homecare: A qualitative interview study.

BACKGROUND: Older adults receiving homecare have an increased risk of readmission. The transition from hospital to home can be experienced as unsafe, and older adults describe themselves as vulnerable during the post-discharge period. Thus, the objective was to explore the experiences of unplanned readmissions among older adults who receive homecare. METHODS: We conducted qualitative individual semi-structured interviews with older adults, 65 years or above, receiving homecare and being readmitted to an emergency department (ED) between August and October 2020. Data were analysed by systematic text condensation as described by Malterud. FINDINGS: We included 12 adults aged 67-95 years, seven were male, and eight lived alone. The analysis derived three themes: (1) Responsibility and security at home, (2) the role of family, friends and homecare and (3) the importance of trust. The older adults felt that the hospital strived for too-early discharge, as they still did not feel well. They worried about how to manage their daily life. Active involvement of their family increased their sense of security, but those living alone described feeling anxious being at home by themselves after discharge. Although older adults did not wish to go to the hospital, inadequate treatment at home and the feeling of responsibility for their illness made them feel insecure. They expressed that earlier negative experiences affected their trust in the system and their inclination to ask for help. CONCLUSIONS: The older adults were discharged from the hospital despite feeling ill. They described inadequate competencies from healthcare professionals in the home as a contributing factor to their readmission. The readmission increased a sense of security. Support from the family in the process was essential and provided a sense of security, whereas older adults living alone experienced feelings of insecurity in the home environment.

Centralization of emergency hospital care is not associated with increased in-hospital mortality; a population-based cohort study.

BACKGROUND: We describe changes in the distance travelled, the utilization of emergency services, and the inhospital mortality before and after the centralization of hospital emergency services in Denmark. METHODS: All unplanned non-psychiatric hospital contacts from adults (aged ≥18 years) in 2008 and 2016 are included. Analyses are age-standardized and conducted at a municipality level. The municipalities are divided into groups according to the presence of emergency hospital services. RESULTS: Municipalities where hospitals with emergency services have been closed differed by having the most significant increase in distance travelled from 2008 to 2016. All groups experienced a reduction in overall in-hospital mortality. The reduction in mortality was not present for acute myocardial infarct contacts from municipalities where hospitals with emergency services have been closed. CONCLUSION: Our data do not suggest that hospital closures, and thereby increased travel distance, have contributed significantly as a barrier to emergency-care access and changes to in-hospital mortality.

The COVID-19 pandemic has not affected the mortality for patients admitted with pneumonia in Denmark.

During the COVID-19 pandemic, several hospital systems observed a reduction in patients with respiratory complaints. Using the Danish national registers, we conducted an observational study on disease severity and 30-day all-cause mortality for acutely admitted pneumonia patients before (3/19-3/20) and during (3/20-2/21) the pandemic. We calculated mortality rate ratios and Cox regression analyses. We identified 54,405 patients and during the pandemic, patients were older, more likely to be male, had more co-morbidity and a lower albumin on admission. Crude mortality was higher during the pandemic (8.4 vs. 6.9%). Adjusted hazard ratio for 30-day all-cause mortality was 1.07 (95%CI 1.01-1.14). We showed a small but significant, increase in mortality risk for patients admitted to hospital during the COVID-19 pandemic in Denmark.

Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis.

OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism. DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used. ELIGIBILITY CRITERIA AND DATA ANALYSIS: Eligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I2 was used to assess the study heterogeneity. MAIN OUTCOME MEASURES: The primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism. RESULTS: 6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell's sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)). CONCLUSION: Several ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging. PROSPERO REGISTRATION NUMBER: CRD42020184313.

The Impact of Age on Predictive Performance of National Early Warning Score at Arrival to Emergency Departments: Development and External Validation.

STUDY OBJECTIVE: To investigate how age affects the predictive performance of the National Early Warning Score (NEWS) at arrival to the emergency department (ED) regarding inhospital mortality and intensive care admission. METHODS: International multicenter retrospective cohorts from 2 Danish and 3 Dutch ED. Development cohort: 14,809 Danish patients aged ≥18 years with at least systolic blood pressure or pulse measured from the Danish Multicenter Cohort. External validation cohort: 50,448 Dutch patients aged ≥18 years with all vital signs measured from the Netherlands Emergency Department Evaluation Database (NEED). Multivariable logistic regression was used for model building. Performance was evaluated overall and within age categories: 18 to 64 years, 65 to 80 years, and more than 80 years. RESULTS: In the Danish Multicenter Cohort, a total of 2.5% died inhospital, and 2.8% were admitted to the ICU, compared with 2.8% and 1.6%, respectively, in the NEED. Age did not add information for the prediction of intensive care admission but was the strongest predictor for inhospital mortality. For NEWS alone, severe underestimation of risk was observed for persons above 80 while overall Area Under Receiver Operating Characteristic (AUROC) was 0.82 (confidence interval [CI] 0.80 to 0.84) in the Danish Multicenter Cohort versus 0.75 (CI 0.75 to 0.77) in the NEED. When combining NEWS with age, underestimation of risks was eliminated for persons above 80, and overall AUROC increased significantly to 0.86 (CI 0.85 to 0.88) in the Danish Multicenter Cohort versus 0.82 (CI 0.81 to 0.83) in the NEED. CONCLUSION: Combining NEWS with age improved the prediction performance regarding inhospital mortality, mostly for persons aged above 80, and can potentially improve decision policies at arrival to EDs.

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.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients.

Background: Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit. Methods: Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa. Results: Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%. Conclusion: In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Low diagnostic yield of ST elevation myocardial infarction amplitude criteria in chest pain patients at the emergency department.

OBJECTIVES: To evaluate the diagnostic yield of the ECG criteria for ST-elevation myocardial infarction in a large cohort of emergency department chest pain patients, and to determine whether extended ECG criteria or reciprocal ST depression can improve accuracy. Design: Observational, register-based diagnostic study on the accuracy of ECG criteria for ST-elevation myocardial infarction. Between Jan 2010 and Dec 2014 all patients aged ≥30 years with chest pain who had an ECG recorded within 4 h at two emergency departments in Sweden were included. Exclusion criteria were: ECG with poor technical quality; QRS duration ≥120 ms; ECG signs of left ventricular hypertrophy; or previous coronary artery bypass surgery. Conventional and extended ECG criteria were applied to all patients. The main outcome was acute myocardial infarction (AMI) and an occluded/near-occluded coronary artery at angiography. Results: Finally, 19932 patients were included. Conventional ECG criteria for ST elevation myocardial infarction were fulfilled in 502 patients, and extended criteria in 1249 patients. Sensitivity for conventional ECG criteria in diagnosing AMI with coronary occlusion/near-occlusion was 17%, specificity 98% and positive predictive value 12%. Corresponding data for extended ECG criteria were 30%, 94% and 8%. When reciprocal ST depression was added to the criteria, the positive predictive value rose to 24% for the conventional and 23% for the extended criteria. Conclusions: In unselected chest pain patients at the emergency department, the diagnostic yield of both conventional and extended ECG criteria for ST-elevation myocardial infarction is low. The PPV can be increased by also considering reciprocal ST depression.

Older adults who receive homecare are at increased risk of readmission and mortality following a short ED admission: a nationally register-based cohort study.

BACKGROUND: Older adults admitted to an emergency department (ED) who are dependent on homecare may be especially challenged with respect to readmission and mortality. This study aimed to assess whether receiving homecare prior admission was associated with readmission or mortality within 30 days of a short ED admission and to explore whether the amount of homecare received was associated with an increased risk of readmission or mortality. METHODS: This nationwide register-based cohort study included patients aged 65 or above who were admitted to an ED at any Danish hospital from 1 December 2016 to 30 November 2017 and discharged within 48 h. Data were extracted from national registers through Statistics Denmark. Homecare was categorized into groups; patients without homecare and three groups according to the amount of homecare received per week. Logistic regression analyses were used to explore the association between the four homecare groups and outcomes, readmissions and mortality. RESULTS: In total, 80,517 patients (51% female, median age 75 years) were included in the study. Overall, 64,886 patients without homecare, 15,631 (19%) patients received homecare (64% female, median age 83 years), of which 4938 patients received homecare ≤30 min, 4033 received > 30 min to ≤120 min and 6660 received > 120 min per week. The risk of readmission and mortality increased concurrently with the minutes of homecare received: Patients receiving homecare > 120 min per week had the highest odds ratios (ORs) for readmission within 30 days (OR 1.8 95% CI: 1.7-1.9) and mortality within 30 days (OR 4.5 95% CI: 4.1-4.9) compared with patients without homecare. CONCLUSION: Receiving homecare was associated with an increased risk of readmission and death following a short ED admission. Collaboration between the ED and primary health care sector in relation to rehabilitation and end-of-life care is essential to improve quality of care for older adults who receive homecare, particularly those receiving homecare > 2 h a week, because of their increased risk of readmission and mortality.

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.

Socioeconomic inequality in telephone triage on triage response, hospitalization and 30-day mortality.

We investigated socioeconomic inequality (measured by the indicators highest attained education level and household income) in telephone triage on triage response (face-to-face contact), hospitalization and 30-day mortality among Danish citizens calling the medical helpline 1813 between 23 January and 9 February 2017. The analysis included 6869 adult callers from a larger prospective cohort study and showed that callers with low socioeconomic status (SES) were less often triaged to a face-to-face contact and had higher 30-day mortality than callers with high SES.

Understanding what matters most to patients in acute care in seven countries, using the flash mob study design.

BACKGROUND: Truly patient-centred care needs to be aligned with what patients consider important, and is highly desirable in the first 24 h of an acute admission, as many decisions are made during this period. However, there is limited knowledge on what matters most to patients in this phase of their hospital stay. The objective of this study was to identify what mattered most to patients in acute care and to assess the patient perspective as to whether their treating doctors were aware of this. METHODS: This was a large-scale, qualitative, flash mob study, conducted simultaneously in sixty-six hospitals in seven countries, starting November 14th 2018, ending 50 h later. One thousand eight hundred fifty adults in the first 24 h of an acute medical admission were interviewed on what mattered most to them, why this mattered and whether they felt the treating doctor was aware of this. RESULTS: The most reported answers to "what matters most (and why)?" were 'getting better or being in good health' (why: to be with family/friends or pick-up life again), 'getting home' (why: more comfortable at home or to take care of someone) and 'having a diagnosis' (why: to feel less anxious or insecure). Of all patients, 51.9% felt the treating doctor did not know what mattered most to them. CONCLUSIONS: The priorities for acutely admitted patients were ostensibly disease- and care-oriented and thus in line with the hospitals' own priorities. However, answers to why these were important were diverse, more personal, and often related to psychological well-being and relations. A large group of patients felt their treating doctor did not know what mattered most to them. Explicitly asking patients what is important and why, could help healthcare professionals to get to know the person behind the patient, which is essential in delivering patient-centred care. TRIAL REGISTRATION: NTR (Netherlands Trial Register) NTR7538 .

Intended and unintended changes in length of stay following reconfiguration of emergency care departments.

BACKGROUND: The Danish health-care system has witnessed noticeable changes in the acute hospital care organization. The reconfiguration includes closing hospitals, centralizing acute care functions and investing in new buildings and equipment. OBJECTIVE: To examine the impact on the length of stay (LOS) and the proportion of overnight stays for hospitalized acute care patients. METHODS: This nationwide interrupted time series examined trend changes in LOS and overnight stay. Admissions were stratified based on admission time (weekdays/weekends and time of day), age and the level of co-morbidity. RESULTS: In 2007-2016, the global average LOS declined 2.9% per year (adjusted time ratio [CI (confidence interval) 95%] 0.971 [0.970-0.971]). The reconfiguration was overall not associated with change in trend of LOS (time ratio [CI 95%] 1.001 [1.000-1.002]). When admissions were stratified for either weekdays or weekends, the reconfiguration was associated with reduction of the underlying downward trend for weekdays (time ratio [CI 95%] 1.004 [1.003-1.005]) and increased downward trend for weekend admissions (time ratio [CI 95%] 0.996 [0.094-0.098]). Admissions at night were associated with a 0.7% trend change in LOS (time ratio [CI 95%] 0.993 [0.991-0.996]). The reconfiguration was not associated with trend changes for overnight stays. CONCLUSION: The nationwide reconfiguration of acute hospital care was overall not associated with change in trend for the registered LOS and no change in trend for overnight stays. However, the results varied according to hospitalization time, where admissions during weekends and nights after the reconfiguration were associated with shortened LOS.

Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department.

STUDY OBJECTIVE: We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale. METHODS: This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher. RESULTS: A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880). CONCLUSION: The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.

Cross-sectoral inter-rater reliability of the clinical frailty scale - a Danish translation and validation study.

BACKGROUND: Focus on frailty status has become increasingly important when determining care plans within and across health care sectors. A standardized frailty measure applicable for both primary and secondary health care sectors is needed to provide a common reference point. The aim of this study was to translate the Clinical Frailty Scale (CFS) into Danish (CFS-DK) and test inter-rater reliability for key health care professionals in the primary and secondary sectors using the CFS-DK. METHODS: The Clinical Frailty Scale was translated into Danish using the ISPOR principles for translation and cultural adaptation that included forward and back translation, review by the original developer, and cognitive debriefing. For the validation exercise, 40 participants were asked to rate 15 clinical case vignettes using the CFS-DK. The raters were distributed across several health care professions: primary care physicians (n = 10), community nurses (n = 10), hospital doctors from internal medicine (n = 10) and intensive care (n = 10). Inter-rater reliability was assessed using intraclass correlation coefficients (ICC), and sensitivity analysis was performed using multilevel random effects linear regression. RESULTS: The Clinical Frailty Scale was translated and culturally adapted into Danish and is presented in this paper in its final form. Inter-rater reliability in the four professional groups ranged from ICC 0.81 to 0.90. Sensitivity analysis showed no significant impact of professional group or length of clinical experience. The health care professionals considered the CFS-DK to be relevant for their own area of work and for cross-sectoral collaboration. CONCLUSION: The Clinical Frailty Scale was translated and culturally adapted into Danish. The inter-rater reliability was high in all four groups of health care professionals involved in cross-sectoral collaborations. However, the use of case vignettes may reduce the generalizability of the reliability findings to real-life settings. The CFS has the potential to serve as a common reference tool when treating and rehabilitating older patients.