Emergency admissions' diagnoses and risk of in-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission.

BACKGROUND: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined. AIM: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions. METHOD: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022. RESULTS: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3. CONCLUSION: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

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.

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.

Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review.

PURPOSE: This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses. METHODS: Design was based on the PRISMA criteria and a systematic search of 6 databases was performed. RESULTS: Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression. CONCLUSIONS: Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

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.

Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study.

INTRODUCTION: Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status. METHODS: Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression. RESULTS: 726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition. CONCLUSION: Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.

Respiratory rates observed over 15 seconds compared with rates measured using the RRate app. Practice-based evidence from an observational study of acutely ill adult medical patients during their hospital admission.

BACKGROUND: counting respiratory rate over 60 seconds can be impractical in a busy clinical setting. METHODS: 870 respiratory rates of 272 acutely ill medical patients estimated from observations over 15 seconds and those calculated by a computer algorithm were compared. RESULTS: The bias of 15 seconds of observations was 1.85 breaths per minute and 0.11 breaths per minute for the algorithm derived rate, which took 16.2 SD 8.1 seconds. The algorithm assigned 88% of respiratory rates their correct National Early Warning Score points, compared with 80% for rates from 15 seconds of observation. CONCLUSION: The respiratory rates of acutely ill patients are measured nearly as quickly and more reliably by a computer algorithm than by observations over 15 seconds.

Which patients should be monitored, how should they be monitored, and why should they be monitored?

Intensively monitoring severely ill patients is like placing a smoke alarm in a burning building: it makes no sense. Smoke alarms only makes sense if they are placed in buildings before a fire starts, or after a fire has been extinguished in order to make sure it does not start again. Therefore, logic suggests that it is more important to monitor sick patients with normal vital signs in order to detect any deterioration as early as possible, or AFTER a severe illness in order to ensure they do not relapse, and it is safe for them to be discharged from hospital and return home.

Fever increases heart rate and respiratory rate; a prospective observational study of acutely admitted medical patients.

BACKGROUND: The relationship between increase in body temperature, heart rate, and respiratory rate has only been studied in young, healthy subjects. AIM: To show the changes in heart and respiratory rate associated with fever in acutely admitted medical patients. DESIGN: A prospective observational cohort study. METHODS: Vital parameters from 4,493 patients were retrospectively extracted. Linear and multiple variable regression analysis was used to calculate the change in heart and temperature rate for every degree rise in temperature (i.e. ΔHR/°C and ΔRR/°C) in the entire study group and in those with low (<36.1°C), normal (36.1-38°C) and high (>38°C) body temperatures. RESULTS: The ΔHR/°C and ΔRR/°C was 7.2±0.4 beats per minute (bpm) and 1.4 ±0.1 (1.2 to 1.62) breaths per minute (bpm). Adjusting for age, oxygen saturation and mean blood pressure, the results were 6.4±0.4 (5.7 to 7.1) bpm and 1.2±0.1 (1.0 to 1.4) bpm. In low, normal and high body temperature the ΔHR/°C were 2.7±1.9, 6.9±1.9 and 7.4±0.9 bpm, respectively; for ΔRR/°C the values were -0.5±0.5, 1.5±0.5 and 2.3±0.3 bpm, respectively. CONCLUSIONS: We only found a modest association between fever and changes in heart rate and respiratory rate.

How well are heart rates measured by pulse oximeters and electronic sphygmomanometers? Practice-based evidence from an observational study of acutely ill medical patients during hospital admission.

BACKGROUND: heart rates generated by pulse oximeters and electronic sphygmomanometers in acutely ill patients may not be the same as those recorded by ECG. METHODS: heart rates recorded by an oximeter and an electronic sphygmomanometer were compared with electrocardiogram (ECG) heart rates measured on acutely ill medical patients. RESULTS: 1010 ECGs were performed on 217 patients while they were in the hospital. The bias between the oximeter and the ECG measured heart rate was -1.37 beats per minute (limits of agreement -22.6 to 19.9 beats per minute), and the bias between the sphygmomanometer and the ECG measured heart rate was -0.14 beats per minute (limits of agreement -22.2 to 21.9 beats per minute). Both devices failed to identify more than half the ECG recordings that awarded 3 NEWS points for heart rate. CONCLUSION: Heart rates of acutely ill patients are not reliably measured by pulse oximeter or electronic sphygmomanometers.

Young people's experiences of managing Type 1 diabetes at university: a national study of UK university students.

AIM: Little is known about the challenges of transitioning from school to university for young people with Type 1 diabetes. In a national survey, we investigated the impact of entering and attending university on diabetes self-care in students with Type 1 diabetes in all UK universities. METHODS: Some 1865 current UK university students aged 18-24 years with Type 1 diabetes, were invited to complete a structured questionnaire. The association between demographic variables and diabetes variables was assessed using logistic regression models. RESULTS: In total, 584 (31%) students from 64 hospitals and 37 university medical practices completed the questionnaire. Some 62% had maintained routine diabetes care with their home team, whereas 32% moved to the university provider. Since starting university, 63% reported harder diabetes management and 44% reported higher HbA1c levels than before university. At university, 52% had frequent hypoglycaemia, 9.6% reported one or more episodes of severe hypoglycaemia and 26% experienced diabetes-related hospital admissions. Female students and those who changed healthcare provider were approximately twice as likely to report poor glycaemic control, emergency hospital admissions and frequent hypoglycaemia. Females were more likely than males to report stress [odds ratio (OR) 4.78, 95% confidence interval (CI) 3.19-7.16], illness (OR 3.48, 95% CI 2.06-5.87) and weight management issues (OR 3.19, 95% CI 1.99-5.11) as barriers to self-care. Despite these difficulties, 91% of respondents never or rarely contacted university support services about their diabetes. CONCLUSION: The study quantifies the high level of risk experienced by students with Type 1 diabetes during the transition to university, in particular, female students and those moving to a new university healthcare provider.

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.

The way healthcare is funded is wrong: it should be linked to deaths as well as age, gender and social deprivation.

BACKGROUND: most spending on health occurs in the last few months of life. This study explored the number of deaths in England and their relationship to healthcare funding. METHODS: post hoc analysis Results: the number of deaths range from 3.3 to 15.1/1000/year, and the number of deaths per general practitioner from 5.2 to 27.3/year. Hospital deaths range from 12 to 52/1000 admissions. The correlation between the allocation index used for funding and deaths is not perfect and suggests that some regions may get up to17% less and others 14% more funding than is equitable. CONCLUSION: there is considerable variation in the prevalence of death throughout England. If healthcare funding considered the local number of deaths it would be more equitable.

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.

Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital.

BACKGROUND: little is known about the changes and trends of individual vital signs during the course of acute illness in hospital. METHODS: the weighted points of the VitalPAC Early Warning Score (ViEWS) were assigned to each vital sign value measured on 44,531 acutely ill medical patients while they were hospitalized in the Thunder Bay Regional Health Sciences Centre, Ontario, Canada. These ViEWS weighted vital signs were averaged for every 24 hour period for five days after admission and five days before death or discharge and then combined to obtain an approximation of the trajectory of each vital sign while in hospital. RESULTS: compared with the other vital signs, the ViEWS weighted points for respiratory rate increase the most in patients who died in hospital and decrease the most in survivors. Combining respiratory rate with the weighted points for any of the other vital signs reduced rather than increased their monitoring performance. CONCLUSION: trends in respiratory rate, measured by observation at the bedside and given a ViEWS weighting is the best predictor of clinical outcome; minor changes predicted clinical outcome several days in advance.

Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital.

BACKGROUND: Recently a very simple, easy to remember early warning score (EWS) dubbed TOTAL has been reported. The score was derived from 309 acutely ill medical patients admitted to a Malawian hospital and awards one point for Tachypnea >30 breaths per minute, one point for Oxygen saturation <90%, two points for a Temperature <35°C, one point for Altered mental status, and one point for Loss of independence as indicated by the inability to stand or walk without help. TOTAL has an area under the receiver operator characteristic curve (AUROC) for death within 72 hours of 78%. METHODS: We compared the performance of the TOTAL score in 849 medical patients attending a resource poor hospital in Uganda and 2935 patients admitted to a small rural hospital in Ireland. RESULTS: TOTAL's AUROC for death within 24 hours was the same in both hospital populations: 85.1% (95% CI 78.6 - 91.6%) for Kitovu Hospital patients and 84.7% (95% CI 77.1 - 92.2%) for Nenagh Hospital patients. CONCLUSION: The discrimination of TOTAL is exactly the same in elderly Irish patients as it is in young African patients. The score is easy to remember, easy to calculate, and works over a broad range of patients.

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.

ECG dispersion mapping predicts clinical deterioration, measured by increase in the Simple Clinical Score.

OBJECTIVE: ECG dispersion mapping (ECG-DM) is a novel technique that reports abnormal ECG microalternations. We report the ability of ECG-DM to predict clinical deterioration of acutely ill medical patients, as measured by an increase in the Simple Clinical Score (SCS) the day after admission to hospital. METHODS: 453 acutely ill medical patients (mean age 69.7 +/- 14.0 years) had the SCS recorded and ECGDM performed immediately after admission to hospital. RESULTS: 46 patients had an SCS increase 20.8 +/- 7.6 hours after admission. Abnormal micro-alternations during left ventricular re-polarization had the highest association with SCS increase (p=0.0005). Logistic regression showed that only nursing home residence and abnormal micro-alternations during re-polarization of the left ventricle were independent predictors of SCS increase with an odds ratio of 2.84 and 3.01, respectively. CONCLUSION: ECG-DM changes during left ventricular re-polarization are independent predictors of clinical deterioration the day after hospital admission.

Can the ECG be used to estimate age-related survival?

BACKGROUND: There are few reports of the relationship between electrocardiogram (ECG) findings and the age-related survival of acutely ill patients. AIM: This study compared the 1-year survival curves of patients attending two Danish emergency departments (EDs) with normal and abnormal ECGs. Patients were divided into age groups from 20 to 90 years of age, and an abnormal ECG was defined as low QRS voltage (i.e. lead I + II <1.4 mV) or QTc interval prolongation >434 ms. METHODS: A retrospective register-based observational study on 35 496 patients attending two Danish EDs, with 100% follow-up for 1 year. RESULTS: ECG abnormality increases linearly with age, and between 30 and 70 years of age. Patients aged 20-29 years with ECG abnormalities are more than four times more likely to die within a year than patients of the same age with a normal ECG. An individual with an abnormal ECG has the same risk of dying within a year as an individual with a normal ECG who is 10 years older. After 70 years of age this tight relationship ends, but for younger individuals with an abnormal ECG the increase in mortality is even higher. CONCLUSION: An ECG may be a simple practical estimate of age-related survival. For a patient under 70 years, an abnormal QRS voltage or a prolonged QTc interval may increase 1-year mortality to that of a patient ∼10 years older.