Presenting symptoms, diagnoses and in-hospital mortality in a low resource hospital environment.

BACKGROUND: The relationship between symptoms, signs and discharge diagnoses with in-hospital mortality is poorly defined in low-resource settings. AIM: To explore the prevalence of presenting symptoms, signs and discharge diagnoses of medical patients admitted to a low-resource sub-Saharan hospital and their association with in-hospital mortality. METHODS: In this prospective observational study, the presenting symptoms and signs of all medical patients admitted to a low-resource hospital in sub-Saharan Africa, their discharge diagnoses and in-hospital mortality were recorded. RESULTS: Pain, gastro-intestinal complaints and feverishness were the commonest presenting symptoms, but none were associated with in-hospital mortality. Only headache was associated with decreased mortality, and no symptom was associated with increased in-hospital mortality. Malaria was the commonest diagnosis. Vital signs, mobility, mental alertness and mid-upper arm circumference (MUAC) had the strongest association with in-hospital mortality. Tuberculosis and cancer were the only diagnoses associated with in-hospital mortality after adjustment for these signs. CONCLUSION: Vital signs, mobility, mental alertness and MUAC had the strongest association with in-hospital mortality. All these signs can easily be determined at the bedside at no additional cost and, after adjustment for them by logistic regression the only diagnoses that remain statistically associated with in-hospital mortality are tuberculosis and cancer.

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.

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.

Respiratory rates observed over 15 and 30 s compared with rates measured over 60 s: practice-based evidence from an observational study of acutely ill adult medical patients during hospital admission.

BACKGROUND: Respiratory rate is often measured over a period shorter than 1 min and then multiplied to produce a rate per minute. There are few reports of the performance of such estimates compared with rates measured over a full minute. AIM: Compare performance of respiratory rates calculated from 15 and 30 s of observations with measurements over 1 min. DESIGN: A prospective single center observational study. METHODS: The respiratory rates calculated from observations for 15 and 30 s were compared with simultaneous respiratory rates measured for a full minute on acutely ill medical patients during their admission to a resource poor hospital in sub-Saharan Africa using a novel respiratory rate tap counting software app. RESULTS: There were 770 respiratory rates recorded on 321 patients while they were in the hospital. The bias (limits of agreement) between the rate derived from 15 s of observations and the full minute was -1.22 breaths per minute (bpm) (-7.16 to 4.72 bpm), and between the rate derived from 30 s and the full minute was -0.46 bpm (-3.89 to 2.97 bpm). Rates observed over 1 min that scored 3 National Early Warning Score points were not identified by half the rates derived from 15 s and a quarter of the rates derived from 30 s. CONCLUSION: Practice-based evidence shows that abnormal respiratory rates are more reliably detected with measurements made over a full minute, and respiratory rate measurement 'short-cuts' often fail to identify sick patients.

Patient reported symptoms, body temperature and hospital mortality: an observational study in a low resource healthcare environment.

BACKGROUND: Fever is a common presenting complaint of patients, especially in sub-Saharan Africa. Although most medical authorities consider fever to be synonymous with an elevated body temperature the relationship of the complaint of fever made by patients to temperature has not been well defined. AIM: This study examined the relationship of the complaint of fever to temperature on and after admission and in-hospital mortality. METHOD: Observational study in a low-resource Ugandan mission hospital. RESULTS: Out of 2122 alert patients admitted between 9 August 2016 and 5 January 2018, 349 (16.4%) complained of fever: these patients were no more likely to have an abnormal temperature or die in-hospital than those not complaining of fever. Of the 707 alert patients admitted after 1 July 2017, 422 were interviewed in detail about their symptoms: only rigors, feeling intermittently hot and cold, and anorexia were statistically related to the complaint of fever, and only rigors to an admission temperature >38°C. No symptom or sign was associated with a temperature ≤36°C: cold and clammy skin was the only finding associated with in-hospital death. On logistic regression the only independent predictors of mortality were: the National Early Warning Score, impaired mobility on presentation and cold and clammy skin. CONCLUSION: In this study, the term fever used by patients and raised body temperature were not synonymous. Although fever and related symptoms reported by patients are common presenting complaints only the finding of cold and clammy skin was associated with in-hospital mortality.