Both acuity and long term prognosis are important Emergency Department metrics: comparison of mobility assessment with the Emergency Severity Index.

OBJECTIVE: To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes. DESIGN: Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI. RESULTS: Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality. CONCLUSION: SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.

A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study.

BACKGROUND: Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity patients should divert care and resources to more urgent cases. AIM: The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients' acuity. DESIGN: This is a prospective observational study of consecutive patients presenting to a Swiss academic ED. METHODS: Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%. RESULTS: The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score. CONCLUSION: Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.

Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients.

BACKGROUND AND OBJECTIVE: Symptoms may differ between frail and non-frail patients presenting to Emergency Departments (ED). However, the association between frailty status and type of presenting symptoms has not been investigated. We aimed to systematically analyse presenting symptoms in frail and non-frail older emergency patients and hypothesized that frailty may be associated with nonspecific complaints (NSC), such as generalised weakness. METHODS: Secondary analysis of a prospective, single centre, observational all-comer cohort study conducted in the ED of a Swiss tertiary care hospital. All presentations of patients aged 65 years and older were analysed. At triage, presenting symptoms and frailty were systematically assessed using a questionnaire. Patients with a Clinical Frailty Scale (CFS) > 4 were considered frail. Presenting symptoms, stratified by frailty status, were analysed. The association between frailty and generalised weakness was tested by logistic regression. RESULTS: Overall, 2'416 presentations of patients 65 years and older were analysed. Mean age was 78.9 (SD 8.4) years, 1'228 (50.8%) patients were female, and 885 (36.6%) patients were frail (CFS > 4). Generalised weakness, dyspnea, localised weakness, speech disorder, loss of consciousness and gait disturbance were recorded more often in frail patients, whereas chest pain was reported more often by non-frail patients. Generalised weakness was reported as presenting symptom in 166 (18.8%) frail patients and in 153 (10.0%) non-frail patients. Frailty was associated with generalised weakness after adjusting for age, gender and elevated National Early Warning Score 2 (NEWS) ≥ 3 (OR 1.19, CI 1.10-1.29, p < 0.001). CONCLUSION: Presenting symptoms differ in frail and non-frail patients. Frailty is associated with generalised weakness at ED presentation.

The prediction of early mortality by the ROX index of oxygenation and respiratory rate in diverse Canadian and Ugandan cohorts of unselected patient: a post-hoc retrospective analysis of 80,558 patient observations.

AIM: To investigate the association between in-hospital mortality and the ROX index of respiratory rate and oxygenation in diverse cohorts of unselected patient at different prediction windows. METHODS: A retrospective post-hoc analysis of data from a major regional referral Canadian hospital and a low-resource hospital in sub-Saharan Africa. RESULTS: Four patient cohorts were examined: Canadian medical, surgical and intensive care unit (ICU) patients, and all patients admitted to an African hospital. In all patients in-hospital mortality rose as ROX declined. Apart from ICU patients, ROX had a high discrimination for death within 72 hours. For non-ICU patients the negative predictive value of death within 72 hours for a ROX value <22 ranged from 0.994 to 1.000 Conclusion: In diverse cohorts of unselected patients, the ROX index has a high discrimination for death within 72 hours. However, the index has little or no prognostic value for patient admitted to ICU.

Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI).

INTRODUCTION: The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals. METHODS: A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training. RESULTS: Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine. CONCLUSION: The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine.

PURPOSE: Despite the rapidly expanding knowledge in the field of Geriatric Emergency Medicine in Europe, widespread implementation of change is still lacking. Many opportunities in everyday clinical care are missed to improve care for this susceptible and growing patient group. The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe. METHODS: A group of multi-disciplinary experts in the field of Geriatric Emergency Medicine in Europe was assembled. Using a modified Delphi procedure, a prioritized list of topics related to Geriatric Emergency Medicine was created. Next, a multi-disciplinary group of nurses, geriatricians and emergency physicians performed a review of recent guidelines and literature to create recommendations. These recommendations were voted upon by a group of experts and placed on visually attractive posters. The expert group identified the following eight subject areas to develop expert recommendations on: Comprehensive Geriatric Assessment in the Emergency Department (ED), age/frailty adjusted risk stratification, delirium and cognitive impairment, medication reviews in the ED for older adults, family involvement, ED environment, silver trauma, end of life care in the acute setting. RESULTS: Eight posters with expert clinical recommendations on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/ . CONCLUSION: Expert clinical recommendations for Geriatric Emergency Medicine may help to improve care for older patients in the Emergency Department and are ready for dissemination across Europe.

Mortality risk for different presenting complaints amongst older patients assessed with the Manchester triage system.

PURPOSE: Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the presentational flowchart 'unwell adult' of the Manchester triage system (MTS) and (2) to assess the different mortality and admission rates among triage categories. METHODS: Retrospective cohort study including all consecutive patients aged 70 years and older who visited the ED of a tertiary care hospital in the Netherlands during a 1-year period. The primary outcome was 30-day mortality. Secondary outcomes were 7-day mortality, hospital admission and ED length of stay. RESULTS: 4255 patients were included in this study. Mean age was 78 years (IQR 73.9-83.4) and 2098 were male (49.3%). The MTS presentational flowchart 'unwell adult' was the most commonly used flowchart (n = 815, 19.3%). After the infrequent flowchart 'major trauma' (n = 9, 13.8%), 'unwell adult' had the highest 30-day mortality (n = 88, 10.8%). When compared to all other flowcharts, patients assigned as 'unwell adult' have significantly higher 30-day mortality rates (OR 1.89 (95%CI 1.46-2.46), p = < 0.001), also when adjusted for age, gender and triage priority (OR 1.75 (95%CI 1.32-2.31), p = < 0.001). Patients from the 'unwell adult' flowchart had the highest hospital admission rate (n = 540, 66.3%), and had among the longest ED length of stay. CONCLUSIONS: Older ED patients are most commonly assigned the presentational flowchart 'unwell adult' when using the MTS. Patients in this category have the highest non-trauma mortality and highest hospital admission rates when compared to other presenting complaints.

D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 - A Prospective Observational Study.

BACKGROUND: Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS: Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS: 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION: D-dimer levels are effective prognosticators in both patient groups.

Usability of a Web-based Software Tool for History Taking in the Emergency Department.

Medical history taking is an important step within the diagnostic process. This study aims to assess the quality and usability (effectiveness, satisfaction, efficiency) of a web-based medical history taking app in the emergency department. During three weeks, patients and junior physicians filled out study questionnaires about the app. Senior physicians rated the quality of medical histories taken by junior physicians and app. In 241 patients, the studied app showed excellent usability with patients not in need of immediate medical attention. Senior physicians rated medical histories as more complete when app was used by patients in comparison to conventional history taking alone (p<0.01). Current app could not substitute medical history taking by physicians, but could definitely rather be used to gather ancillary information.

Normal gait, albumin and d-dimer levels identify low risk emergency department patients: a prospective observational cohort study with 365-day 100% follow-up.

BACKGROUND: If survival could be reliably predicted many patients could be safely managed outside of hospital in an ambulatory care setting. AIM: Comparison of common laboratory findings, co-morbidities, mobility and vital signs as predictors of mortality of acutely ill emergency department (ED) attendees. DESIGN: Prospective observational study. METHODS: Secondary analysis of 1334 consenting acutely ill patients attending a Danish ED. RESULTS: 67 (5%) out of 1334 patients died within 100 days. After logistic regression seven predictors of 100 days mortality remained significant: an albumin level ≤34 gm/l, D-dimer level >0.51 mg/l, an Asadollahi score (based on admission laboratory data and age) ≥12, a platelet count <159 X 1000/ml, impaired mobility on presentation, a respiratory rate ≥30 bpm and a Charlson co-morbidity index ≥3. Only 5 of the 442 without any of these variables died within 365 days. Only one of the 517 patients with a stable independent gait and normal d-dimer and albumin levels died within 100 days, none died within 30 days of assessment and 12 died within 365 days. Of the remaining 817 patients 66 (8%) died within 100 days. CONCLUSION: These findings suggest that normal gait, albumin and d-dimer levels are the most parsimonious way of identifying low risk ED patients.

A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study.

OBJECTIVE: To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. DESIGN: In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. SETTING: The Hospital of South West Jutland. PATIENTS: All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. MAIN RESULTS: The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (≥0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02-0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. CONCLUSION: Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.

Higher In-Hospital Mortality in Patients with Nonspecific Complaints Presenting to the Emergency Department.

BACKGROUND: Nonspecific complaints (NSC) at the Emergency Department (ED) are not well researched yet. OBJECTIVE: To investigate the number of patients who could be classified as having NSC early after arrival in the ED using an algorithm. METHOD: Retrospective cohort study was conducted among all hemodynamically stable non-trauma adult patients with MTS category orange/yellow visiting the ED. Patients who had no specific complaints/signs, predefined on a list, were categorized as NSC. RESULTS: In total, 2419 patients, of whom 102 (4.2%) presented with NSC. Hospitalization was more prevalent (85.3% vs. 69.0%, p<0.001) and in-hospital mortality was higher in the NSC-group (11.8% vs. 3.5%, adjusted OR 2.0, 95% CI 1.0-3.9, p=0.04). CONCLUSION: Using an algorithm it is possible to identify NSC patients who have (worse) outcomes than those classified as SC.

Changes in vital signs post discharge as a potential target for intervention to avoid readmission.

Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≤ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate. Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.

End-of-life decisions in emergency patients: prevalence, outcome and physician effect.

BACKGROUND: End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation. AIM: We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions. DESIGN: Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources. METHODS: Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR. RESULTS: Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0). CONCLUSIONS: DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.

Should impaired mobility on presentation be a vital sign?

INTRODUCTION: Vital signs are routinely used to assess acutely ill patients, but they do not detect all patients at risk of death. This retrospective multicenter cohort study compares the prediction of death by impaired mobility with age, co-morbidities, and vital sign changes. METHODS: On first assessment, patients from a combined cohort of 9684 Danish and Irish patients and a separate cohort of 1010 Ugandan patients were stratified by impaired mobility on presentation (IMOP), vital sign changes assessed by the National Early Warning Score (NEWS), the Charlson Co-morbidity Index, and age. RESULTS: Fourteen percent of Danish and Irish patients had IMOP compared with 42% of Ugandan patients. The odds ratios of IMOP for 7-day mortality were similar for both cohorts (i.e. 11.8, 95% CI 5.8-24.0 for Ugandan patients versus 6.7, 95% CI 5.0-9.0 for Danish and Irish patients). Univariate analysis of Ugandan patients showed that none of the parameters tested (i.e. low blood pressure, pulse, elevated respiratory rate, hypothermia, low oxygen saturation, old age, and coma) had a statistically higher odds ratio for either 7-day mortality than IMOP. Multivariate logistic regression analysis of Danish and Irish patients also showed that none of these parameters or the Charlson Co-morbidity Index had a statistically higher odds ratio than IMOP for either 7-day or 30-day mortality. CONCLUSION: Immobility on presentation is a vital sign and predicts mortality for acutely ill patients independently of the traditional vital signs, age, and co-morbidities.

Exploring the value of routinely measured hematology parameters for identification of elderly patients at high risk of death at the Emergency Department.

Common risk stratification tools, e.g. for triage, fail in older patients. Some attempts have been undertaken to improve triage of older patients with nonspecific markers such as lactate with or without combination with vital signs or other aggregated lab scores.

Systematically assessed symptoms as outcome predictors in emergency patients.

INTRODUCTION: It is known that symptoms are predictive of mortality in "nonsurgical" emergency patients. It is unknown whether a prospective, systematic, and "unscreened" assessment of all symptoms is of any prognostic value. Therefore, we aimed to examine the association between symptoms and outcomes in an all-comer population. METHODS: Data were acquired during 6weeks at the ED of the University Hospital Basel, a tertiary hospital. Consecutive patients presenting to the ED were included. Symptoms at presentation were systematically assessed using a comprehensive questionnaire. RESULTS: A consecutive sample of 3960 emergency patients with a median age of 51years (51.7% male) was studied. The median number of symptoms was two. In the group of patients with the most prevalent symptoms, the median number of symptoms ranged between two and five. Overall, hospitalisation rate was 31.2%, referral to intensive care was 5.5%, in-hospital-mortality was 1.4%, and one-year mortality was 5.8%. In-hospital mortality ranged from 0% to 4.3%, and one-year mortality from 0% to 14.4% depending on the presenting symptoms. Dyspnoea and weakness were significant predictors of one-year mortality (14.4% and 9.2%, respectively). DISCUSSION: Most emergency patients indicated two or more symptoms. Systematically assessed symptoms at presentation can be used for prediction of outcomes. While dyspnoea is a known predictor, weakness has not been identified as predictor of mortality before. This knowledge could be used to improve risk stratification- thereby reducing the risk of adverse outcomes.

Intracerebral Bleeding and Massive Pericardial Effusion as Presenting Symptoms of Myxedema Crisis.

The endocrinological emergency of a fully blown myxedema crisis can present as a multicolored clinical picture. This can obscure the underlying pathology and easily lead to mistakes in clinical diagnosis, work-up, and treatment. We present a case of an unconscious 39-year-old patient with a medical history of weakness, lethargy, and findings of hyponatremia, intracerebral bleeding, and massive pericardial effusion. Finally, myxedema crisis was diagnosed as underlying cause. Replacement therapy of thyroid hormone and conservative management of the intracerebral bleeding resulted in patient's survival without significant neurological impairment. However, diagnostic pericardiocentesis resulted in life-threatening pericardial tamponade. It is of tremendous importance to diagnose myxoedema crisis early to avoid adverse health outcomes.