Relationship of the clinical acuity & complexity to the outcome of an emergency medical admission.

BACKGROUND: An Illness Severity and Co-morbidity composite score can predict 30-day mortality outcome. METHODS: We computed a summary risk score (RS) for emergency medical admissions and used cluster analysis to define four subsets Results: Four cluster groups were defined. Cluster 1 - RS 7 points (IQR 5, 8) Cluster 2 - 9 (IQR 8, 11), Cluster 3 - 12 (IQR 11, 13) and Cluster 4 - 14 (IQR 13, 15). Clusters predicted 30-day in hospital mortality OR 1.86 (95%CI: 1.82, 1.92); respective rates 1.4% (95% CI: 1.3%, 1.6%), 3.4% (95% CI: 3.1%, 3.6%), 7.8% (95% CI: 7.5%, 8.1%) and 16.5% (95% CI: 15.7%, 17.2%). CONCLUSION: Cluster grouping of Risk Score was age related; strongest outcome determinant was Acute Illness Severity.

Hospital Readmissions - Independent Predictors of 30-day Readmissions derived from a 10 year Database.

Unplanned medical 30 day readmissions place a burden on the provision of acute hospital services and are increasingly used as quality indicators to assess quality of care in hospitals. Multivariable logistic regression of a 10 year database showed that four factors were most strongly associated with early readmission: Charlson comorbidity index >=1, respiratory disease as a principal diagnosis, liver disease and alcohol-related illness as an additional diagnosis, and the number of previous readmissions. Disease and patient-related factors beyond control of the hospital are the factors most strongly associated with 30 day readmission to hospital, suggesting that this may not be an appropriate quality indicator.

The Relationship between Resource Utilization, Clinical Risk and Hospital Costs for Emergency Medical Admissions.

There has been little study of the relationship between resource utilisation, clinical risks and hospital costs in acute medicine with the question remaining as to whether current funding models reflect patient acuity. We examined the relationship between resource use for investigations/allied professional and patient episode costs in all emergency medical admissions admitted to our institution during 2008-2013. Univariate estimates were compared with a multivariate model adjusted for major cost predictors. Interestingly, the model adjusted cost estimates changed considerably when compared with univariate analysis. We used both linear and non-linear (quantile regression) methods due to the highly skewed nature of hospital costs. The data suggested that hospital episode costs were predictable and driven by objective measures of clinical complexity. The use of expensive investigations and healthcare professional time was secondary to the clinical acuity. Thus, cost was heavily weighted towards higher complexity, and lower resource utilisation associated with lower risk patient groups. However, the non-linear nature of the costings would caution against simple predictor models and non-linear techniques such as quantile regression may, as we have demonstrated, prove superior in defining the underlying relationships.

The Relationship Between Social Deprivation and a Weekend Emergency Medical Admission.

BACKGROUND: Deprivation increases admission rates; the specific effect of deprivation with regard to weekend admissions is unknown. METHODS: We calculated annual weekend admission rates for each small area population unit and related these to quintiles of Deprivation Index from 2002-2014. Univariate and multivariable risk estimates were calculated using truncated Poisson regression. RESULTS: There were 30,794 weekend admissions in 16,665 patients. The admission rate was substantially higher for more deprived areas, 12.7 per 1000 (95%CI 9.4, 14.7) vs 4.6 per 1000 (95%CI 3.3, 5.8). More deprived patients admitted at the weekend had a significantly lower 30-day in-hospital mortality (10.3% vs 14.5%, p<0.001). CONCLUSION: Deprivation is a powerful determinant of weekend admissions, however these comprise a group of patients with better outcomes.

Serum potassium levels as an outcome determinant in acute medical admissions.

The relationship between serum potassium levels and mortality in acute medical admissions is uncertain. In particular, the relevance of minor abnormalities in potassium level or variations within the normal range remains to be determined. We performed a retrospective cohort study of all emergency medical admissions to St James's Hospital (Dublin, Ireland) between 2002 and 2012. We used a stepwise logistic regression model to predict in-hospital mortality, adjusting risk estimates for major predictor variables. There were 67,585 admissions in 37,828 patients over 11 years. After removing long-stay patients, 60,864 admissions in 35,168 patients were included in the study. Hypokalaemia was present in 14.5% and hyperkalaemia in 4.9%. In-hospital mortality was 3.9, 5.0, and 18.1% in the normokalaemic, hypokalaemic and hyperkalaemic groups respectively. Hypokalaemic patients had a univariate odds ratio (OR) of 1.29 for in-hospital mortality (95% confidence interval (CI) 1.16-1.43; p<0.001). Hyperkalaemic patients had a univariate OR for in-hospital mortality of 5.2 (95% CI 4.7-5.7; p<0.001). The ORs for an in-hospital death for potassium between 4.3 and 4.7 mmol/l, and 4.7 and 5.2 mmol/l, were 1.73 (95% CI 1.51-1.99) and 2.97 (95% CI 2.53-3.50) respectively. Hyperkalaemia and hypokalaemia are associated with increased mortality.

High-sensitivity troponin as an outcome predictor in acute medical admissions.

BACKGROUND: Troponin estimation is increasingly performed on emergency medical admissions. We report on a high-sensitivity troponin (hscTn) assay, introduced in January 2011, and its relevance to in-hospital mortality in such patients. AIM: To evaluate the impact of hscTn results on in-hospital mortality and the value of incorporating troponin into a predictive score of in-hospital mortality. METHODS: All patients admitted as general medical emergencies between January 2011 and October 2012 were studied. Patients admitted under other admitting services including cardiology were excluded. We examined outcomes using generalised estimating equations, an extension of generalised linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect. RESULTS: A total of 11 132 admission episodes were recorded. The in-hospital mortality for patients with predefined cut-offs was 1.9% when no troponin assay was requested, 5.1% when the troponin result was below the 25 ng/L 'normal' cut-off, 9.7% for a troponin result ≥25 and <50 ng/L, 14.5% for a troponin result ≥50 and <100 ng/L, 34.4% for a troponin result ≥100 and <1000 ng/L, and 58.3% for a troponin result >1000 ng/L. The OR for an in-hospital death for troponin-positive patients was 2.02 (95% CI 1.84 to 2.21); when adjusted for other mortality predictors including illness severity, the OR remained significant at 2.83 (95% CI 2.20 to 3.64). The incorporation of troponin into a multivariate logistic predictive algorithm resulted in an area under the receiver operating characteristic curve to predict an in-hospital death of 0.87 (95% CI 0.85 to 0.88). CONCLUSIONS: An increase in troponin carries prognostic information in acutely ill medical patients; the extent of the risk conferred justifies incorporation of this information into predictive algorithms for hospital mortality.

Reduced 30-day in-hospital but increased long-term mortality for weekend vs weekday acute medical admission.

BACKGROUND: Acute medical admission at the weekend has been reported to be associated with increased mortality. We aimed to assess 30-day in-hospital mortality and subsequent follow-up of all community deaths following discharge for acute medical admission to our institution over 21 years. METHODS: We employed a database of all acute medical admissions to our institution over 21 years (2002-2023). We compared 30-day in-hospital mortality by weekend (Saturday/Sunday) or weekday (Tuesday/Wednesday) admission. Outcome post-discharge was determined from the National Death Register to December 2021. Predictors of 30-day in-hospital and long-term mortality were analysed by logistic regression or Cox proportional hazards models. RESULTS: The study population consisted of 109,232 admissions in 57,059 patients. A weekend admission was associated with a reduced 30-day in-hospital mortality, odds ratio (OR) 0.70 (95%CI 0.65, 0.76). Major predictors of 30-day in-hospital mortality were acute illness severity score (AISS) OR 6.9 (95%CI 5.5, 8.6) and comorbidity score OR 2.4 (95%CI 1.2, 4.6). At a median follow-up of 5.9 years post-discharge, 19.0% had died. The strongest long-term predictor of mortality was admission AISS OR 6.7 (95%CI 4.6, 9.9). The overall survival half-life after hospital discharge was 16.6 years. Survival was significantly worse for weekend admissions at 20.8 years compared to weekday admissions at 13.3 years. CONCLUSION: Weekend admission of acute medical patients is associated with reduced 30-day in-hospital mortality but reduced long-term survival.

Red Cell Distribution Width as a Prognostic Indicator in Acute Medical Admissions.

The red cell distribution width (RDW) is the coefficient of variation of the mean corpuscular volume (MCV). We sought to evaluate RDW as a predictor of outcomes following acute medical admission. We studied 10 years of acute medical admissions (2002-2011) with subsequent follow-up to 2021. RDW was converted to a categorical variable, Q1 < 12.9 fl, Q2-Q4 ≥ 12.9 and <15.7 fL and Q5 ≥ 15.7 fL. The predictive value of RDW for 30-day in-hospital and long-term mortality was evaluated with logistic and Cox regression modelling. Adjusted odds ratios (aORs) were calculated and loss of life years estimated. There were 62,184 admissions in 35,140 patients. The 30-day in-hospital mortality (n = 3646) occurred in 5.9% of admissions. An additional 15,086 (42.9%) deaths occurred by December 2021. Admission RDW independently predicted 30-day in-hospital mortality aOR 1.93 (95%CI 1.79, 2.07). Admission RDW independently predicted long-term mortality aOR 1.04 (95%CI 1.02, 1.05). Median survival post-admission was 189 months. For those with admission RDW in Q5, observed survival half-life was 133 months-this represents a shortfall of 5.7 life years (33.9%). In conclusion, admission RDW independently predicts 30-day in-hospital and long-term mortality.

Prognostic value and clinical utility of NT-proBNP in acute emergency medical admissions.

BACKGROUND: NT-proB-type natriuretic peptide (NT-proBNP) is a frequently utilized test in congestive cardiac failure. There is little data on its utility in unselected emergency medical admissions. AIM: This study aims to investigate the clinical utility and prognostic value of NT-proBNP in emergency medical admissions and to determine whether such testing influenced downstream investigations and length of stay (LOS). METHODS: We report on NT-proBNP tests performed in emergency medical admissions in a 2005/2006 and subsequent 7-year (2014-2020) retrospective cohort. We assessed 30-day in-hospital mortality with a multivariable logistic regression model. The utilization of procedures/services was related to LOS with zero-truncated Poisson regression. RESULTS: There were 64,212 admissions in 36,252 patients. Patients with a NT-proBNP test were significantly older at 75.3 years vs. 63.0 years and had longer LOS -9.4 days vs. 4.9 days. They had higher acute illness severity and comorbidity scores. Thirty-day in-hospital mortality was higher in those with a NT-proBNP test (8.8%) vs. no request (3.2%). NT-proBNP test level was prognostic in univariate - OR 2.87 (2.61, 3.15), and multivariate analyses - OR 1.40 (1.26, 1.56). Higher NT-proBNP levels predicted higher 30-day in-hospital mortality. Multivariable thirty-day in-hospital mortality was 3.8% (3.6%, 3.9%) for those without a test, increasing to 4.9% (4.7%, 5.2%) for ≥ 250 ng/L and 5.8% (5.8%, 6.3%) for ≥ 3000 ng/L. LOS was linearly related to the total number of procedures/services performed. CONCLUSION: NT-proBNP is prognostic in emergency medical admissions. Downstream resource utilization differed following an NT-proBNP test; this may reflect different case complexity or the 'uncertainty' surrounding such admissions.

Hospital mortality and length of stay differences in emergency medical admissions related to 'on-call' specialty.

BACKGROUND: The outcomes of acute medical admissions have been shown to be influenced by a variety of factors including system, patient, societal, and physician-specific differences. AIM: To evaluate the influence of on-call specialty on outcomes in acute medical admissions. METHODS: All acute medical admissions to our institution from 2015 to 2020 were evaluated. Admissions were grouped based on admitting specialty. Thirty-day in-hospital mortality and length of stay (LOS) were evaluated. Data was analysed using multivariable logistic regression and truncated Poisson regression modelling. RESULTS: There were 50,347 admissions in 30,228 patients. The majority of admissions were under Acute Medicine (47.0%), and major medical subspecialties (36.1%); Elderly Care admitted 12.1%. Acute Medicine admissions were older at 72.9 years (IQR 57.0, 82.9) vs. 67.2 years (IQR 50.1, 80.2), had higher Acute Illness Severity (grades 4-6: 85.9% vs. 81.3%; p < 0.001), Charlson Index (> group 0; 61.5% vs. 54.6%; p < 0.001), and Comorbidity Score (40.7% vs. 36.7%; p < 0.001). Over time, there was a small (+ 8%) but significant increase in 30-day in-hospital mortality. Mortality rates for Acute Medicine, major medical specialties, and Elderly Care were not different at 5.1% (95% CI: 4.7, 5.5), 4.7% (95% CI: 4.3, 5.1), and 4.7% (95% CI: 3.9, 5.4), respectively. Elderly Care admissions had shorter LOS (7.8 days (95% CI: 7.6, 8.0)) compared with either Acute Medicine (8.7 days (95% CI: 8.6, 8.8)) or major medical specialties (8.7 days (95% CI: 8.6, 8.9)). CONCLUSION: No difference in mortality and minor differences in LOS were observed. The prior pattern of improved outcomes year on year for emergency medical admissions appears ended.

The presence of a urinary catheter is an important predictor of in-hospital mortality in internal medicine patients.

RATIONALE AND OBJECTIVE: Mortality rates are used to assess the quality of hospital care after appropriate adjustment for case-mix. Urinary catheters are frequent in hospitalized adults and might be a marker of patient frailty and illness severity. However, we know of no attempts to estimate the predictive value of indwelling catheters for specific patient outcomes. The objective of the present study was to (a) identify the variables associated with the presence of a urinary catheter and (b) determine whether it predicts in-hospital mortality after adjustment for these variables. METHODS: The study population included all acutely admitted adult patients in 2020 (exploratory cohort) and January-October 2021 (validation cohort) to internal medicine, cardiology and intensive care departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. There were no exclusion criteria. The predictor variables were the presence of a urinary catheter on admission, age, gender, comorbidities and admission laboratory test results. We used bivariate and multivariate logistic regression to test the associations between the presence of a urinary catheter and mortality after adjustment for the remaining independent variables on admission. RESULTS: The presence of a urinary catheter was associated with other independent variables. In 2020, the odds of in-hospital mortality in patients with a urinary catheter before and after adjustment for the remaining predictors were 14.3 (11.6-17.7) and 6.05 (4.78-7.65), respectively. Adding the presence of a urinary catheter to the prediction logistic regression model increased its c-statistic from 0.887 (0.880-0.894) to 0.907 (0.901-0.913). The results of the validation cohort reduplicated those of the exploratory cohort. CONCLUSIONS: The presence of a urinary catheter on admission is an important and independent predictor of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

Emergency medical admissions and COVID-19: impact on 30-day mortality and hospital length of stay.

BACKGROUND: The COVID-19 pandemic has put considerable strain on healthcare systems. AIM: To investigate the effect of the COVID-19 pandemic on 30-day in-hospital mortality, length of stay (LOS) and resource utilization in acute medical care. METHODS: We compared emergency medical admissions to a single secondary care centre during 2020 to the preceding 18 years (2002-2019). We investigated 30-day in-hospital mortality with a multiple variable logistic regression model. Utilization of procedures/services was related to LOS with zero truncated Poisson regression. RESULTS: There were 132,715 admissions in 67,185 patients over the 19-year study. There was a linear reduction in 30-day in-hospital mortality over time; over the most recent 5 years (2016-2020), there was a relative risk reduction of 36%, from 7.9 to 4.3% with a number needed to treat of 27.7. Emergency medical admissions increased 18.8% to 10,452 in 2020 with COVID-19 admissions representing 3.5%. 18.6% of COVID-19 cases required ICU admission with a median stay of 10.1 days (IQR 3.8, 16.0). COVID-19 was a significant univariate predictor of 30-day in-hospital mortality, 18.5% (95%CI: 13.9, 23.1) vs. 3.0% (95%CI: 2.7, 3.4)-OR 7.3 (95%CI: 5.3, 10.1). ICU admission was the dominant outcome predictor-OR 12.4 (95%CI: 7.7, 20.1). COVID-19 mortality in the last third of 2020 improved-OR 0.64 (95%CI: 0.47, 0.86). Hospital LOS and resource utilization were increased. CONCLUSION: A diagnosis of COVID-19 was associated with significantly increased mortality and LOS but represented only 3.5% of admissions and did not attenuate the established temporal decline in overall in-hospital mortality.

Using the MDRD value as an outcome predictor in emergency medical admissions.

BACKGROUND: Both physiological- and laboratory-derived variables, alone or in combination, have been used to predict mortality among acute medical admissions. Using the Modification of Diet in Renal Disease (MDRD) not as an estimate of glomerular filtration rate but as an outcome predictor for hospital mortality, we examined the relationship between the MDRD value and in-hospital death during an emergency medical admission. METHODS: An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2008, using the hospital in-patient enquiry system, linked to the patient administration system and laboratory datasets. Hospital mortality (any in-patient death within 30 days) was obtained from a database of deaths occurring during the same period under physicians participating in the 'on-call' roster. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for MDRD value. RESULTS: Univariate analysis identified those with MDRD value of <60 as possessing increased mortality risk. Their 30-day mortality rate was 21.63 versus 4.35% for patients without an abnormal value (P < 0.0001) with an OR of 6.07 (95% CI's 5.49, 6.73: P < 0.001). After adjustment for 12 other outcome predictors including comorbidity, the OR was 4.63 (4.08, 5.25: P < 0.0001). Using the Kidney Disease Outcomes Quality Initiative (KDOQI) class, the respective mortality rates by 30 days increased with a lower MDRD value, from 2.8% in KDOQI Class 1 to 48.6% in KDOQI Class 5. Outcome prediction of in-hospital death, at 5 and 30 days with the MDRD, yielded areas under the receiver operator curves of 0.84 (0.83, 0.84) and 0.77 (0.77, 0.78). CONCLUSIONS: Many factors predict survival following an emergency medical admission. The MDRD value offers a novel readily available and reliable estimate of mortality risk.

Emergency medical readmission: long-term trends and impact on mortality.

There is increasing emphasis on prevention of emergency medical readmissions. The broad pattern of acute medical readmissions was studied over a seven-year period and the impact of any readmission on 30-day mortality was recorded. Significant predictors of outcome, including co-morbidity and illness severity score, were entered into a multivariate regression model, adjusting the univariate estimates of the readmission status on mortality. In total, 23,114 consecutive acute medical patients were admitted between 2002-8; the overall readmission rate was 27%. Readmission independently predicted an increased 30-day mortality; the odds ratio, was 1.12 (95% confidence interval (CI) 1.09 to 1.14). This fell to 1.05 (95% CI 1.02 to 1.08) when adjusted for outcome predictors including acute illness severity. The trend for readmissions was to progressively increase over time; the median times between consecutive admissions formed an exponential time series. Efforts to reduce or avoid readmissions may depend on an ability to modify the underlying chronic disease.

Non-Specific Clinical Presentations are Not Prognostic and do not Anticipate Hospital Length of Stay or Resource Utilization.

AIM: To investigate whether a specific (SP) or non-specific (NSP) clinical presentation, predicts prognosis and in-hospital resource utilization in emergency medical admissions. METHODS: We studied admissions over 5 years (2015-2019) and classified the symptom presentation as SP or NSP. The predictive capacity of the NSP category was related to 30-day in-hospital mortality with a multivariable logistic regression model. Utilization of procedures/services was related to hospital length of stay (LOS) with zero truncated Poisson regression. RESULTS: There were 39,776 admissions in 23,995 patients. A NSP occurred in 18.2% of our top 20 clinical presentations; the top five being shortness of breath (12.8%), 'unwell' (7.1%), collapse (4.1%), abdominal pain (3.6%) and headache (2.7%). Baseline demographic characteristics were similar and unrelated to type of presentation; the model adjusted mortality by SP 4.0% (95% CI: 3.8%, 4.2%) or NSP 3.9% (95% CI: 3.5%, 4.4%) was identical. LOS was a dependant quantitative function of procedures/services undertaken; for the top two presentations of shortness of breath (SP) or unwell (NSP) there was no relationship between a SP or NSP presentation and hospital utilization of procedures/services or LOS. CONCLUSION: Our data suggest no utility for a categorisation of presentations as specific or non-specific in terms of provision of prognostic information nor as an indicator of the pattern of hospital investigation or LOS.

Is there excessive troponin testing in clinical practice? Evidence from emergency medical admissions.

AIM: To investigate whether excessive high-sensitivity cardiac troponin T (hscTnT) testing, in non-cardiac presentations, increases hospital length of stay (LOS) by driving down-stream investigations. METHODS: We report on all hscTnT tests in emergency medical admissions, performed over a 9-year period between 2011-2019. Troponin testing frequency in different risk cohorts was determined and related to 30-day in-hospital mortality with a multivariable logistic regression model adjusted for other outcome predictors. Downstream utilization of procedures/services was related to LOS with zero truncated Poisson regression. RESULTS: There were 66,475 admissions in 36,518 patients. hscTnT was tested in 24.4% of admissions, more frequently in the elderly (>70 years 33.4%, >80 years 35.9%), cardiovascular presentations (33.6%) and in those with high comorbidity (42.2%), and reduced in those with neurologic presentations (20%). A hscTnT request predicted increased 30-day in-hospital mortality OR 3.33 (95% CI: 3.06, 3.64). The univariate odds ratio (OR) of hscTnT test result was 1.45 (95% CI: 1.42, 1.49) and was semi-quantative with worsening outcomes as hscTnT increased. It remained predictive in the fully adjusted model OR 1.17 (95% CI: 1.09, 1.26). LOS was linearly related to the number of procedures/services performed. hscTnT testing did not increase LOS or number of procedures/services CONCLUSION: : A clinical request for hscTnT testing is prognostic and risk categorises. Subsequent resource utilization, if increased, appears an epiphenomenon related to risk categorisation, rather than being driven by inappropriate hscTnT testing.

Age and outcome in acute emergency medical admissions.

BACKGROUND: there is a lack of outcome information with respect to older health service users. The purpose of this study was to examine 30-day in-hospital mortality and its predictors in all elderly patients admitted as a medical emergency to our hospital. METHODS: all patients admitted between 2002 and 2008 were studied, linking anonymised clinical, administrative, laboratory and mortality data. Significant univariate predictors of outcome, including co-morbidity and illness severity score, were entered into a multivariate logistic regression model, adjusting the univariate estimates of the effect of age on in-hospital mortality. RESULTS: we admitted 23,114 consecutive acute medical admissions between 2002 and 2008; 30-day in-hospital mortality was 20.7% in the over 75 age category versus 4.5% in those younger. The unadjusted OR for a 30-day in-hospital mortality in the over 75 category of 5.21 (95% CI 4.73, 5.73) fell to 4.69 (95% CI 4.04, 5.44) when adjusted for outcome predictors excluding acute illness severity and 2.93 (95% CI 2.50, 3.42) when acute illness severity was added as a covariate. When the interaction between age and co-morbidity is examined, the odds ratio adjusts to 3.22 (95% CI 2.63, 3.6). CONCLUSION: acute illness severity is more important than co-morbidity in explaining the outcome in older patients admitted as medical emergencies. Service planning for acute elderly care should be based on effective disease management programmes but recognise the contribution of acute illness severity to outcome when conditions deteriorate.

Comparative influence of Acute Illness Severity and comorbidity on mortality.

BACKGROUND: The extent to which illness severity and comorbidity determine the outcome of an emergency medical admission is uncertain. We aim to quantitate the relative effect of these factors on mortality. METHODS: We evaluated all emergency medical admission to our institution between 2002 and 2018. We derived an Acute Illness Severity Score (AISS) and Comorbidity Score from admission data and International Classification of Diseases codings. We employed a multivariable logistic regression model to relate both to 30-day in-hospital mortality. RESULTS: There were 113,807 admissions in 58,126 patients. Both AISS, Odds Ratio (OR) 4.4 (95%CI 3.5, 5.5), and Comorbidity Score, OR 1.91 (95%CI 1.67, 2.18), independently predicted 30-day in-hospital mortality. The two highest AISS risk groups encompassed 46.5% of admissions with predicted mortality of 5.9% (95%CI 5.7%, 6.1%) and 14.4% (95%CI 13.9%, 14.8%) respectively. Comorbidity Score >=10 occurred in 17.9% of admissions with a predicted mortality of 13.3%. AISS and Comorbidity Score interacted to adversely influence mortality; the threshold effect for Comorbidity Score was reduced at high levels of AISS. CONCLUSION: High AISS and Comorbidity Scores were predictive of 30-day in-hospital mortality and relatively common in emergency medical admissions. There is a strong interaction between the two scores.