Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older.

The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.

Factores asociados con mortalidad a corto plazo en personas que viven en residencias atendidas en servicios de urgencias: resultados del estudio multicéntrico Caregency / Factors associated with short-term mortality after emergency department care of residents living in aged care homes: findings from the multicenter Caregency study

Objetivo: Evaluar la frecuencia y los factores asociados con la mortalidad a corto plazo de personas que viven en residencias tras ingreso en urgencias.Método: Análisis retrospectivo multicéntrico de una muestra aleatoria de admisiones de personas $ 65 años que viven en residencias en cinco servicios de urgencias de Cataluña, a lo largo de 2017. Se analizaron características sociodemográficas, el estado funcional y cognitivo previo, multimorbilidad, nivel de triaje de las urgencias, duración de la estancia en urgencias, hospitalización y mortalidad a corto plazo (en urgencias o en los 30 días posteriores al alta). Se utilizó un análisis de regresión multivariante para investigar los factores asociados con la mortalidad a corto plazo. Resultados: Se analizaron 2.444 admisiones en urgencias, con una edad media de 85,9 (DE 7,1) años, 67,7% mujeres. La mortalidad a corto plazo (15,5%) se asoció con una edad > 90 años (OR 1,50; IC 95%: 1,5-1,95), un índice de Charlson > 2 (OR 1,47; IC 95%: 1,14-1,90), y un grado de dependencia moderado (OR 1,50; IC 95%: 1,03-2,20) y grave (OR 2,56; IC 95%: 1,84-3,55). También se asoció con un mayor nivel de triaje de la urgencia, duración de la estancia en urgencias e ingreso en planta de hospitalización. Conclusiones: Los ancianos residentes con las características descritas podrían beneficiarse especialmente de intervenciones dirigidas a la prevención de traslados potencialmente innecesarios a urgencias y a la implementación de una atención integral geriátrica dentro de los servicios de urgencias, a fin de garantizar una buena calidad de los cuidados en fases finales de la vida. (AU)

Objectives: To evaluate short-term mortality in people transferred from aged care homes for treatment in a hospital emergency department (ED) and to analyze factors associated with mortality. Methods: Multicenter study of a random sample of retrospective data of patients treated in 5 EDs in Catalonia in 2017. The patients were over the age of 65 years and lived in residential care facilities. In addition to short-term mortality (in the ED or within 30 days of discharge), we analyzed sociodemographic characteristics, prior functional and cognitive status, multimorbidity, triage level on arrival, length of stay in the ED, and hospital admission. Odds ratios (ORs) for factors associated with short-term mortality were calculated by multivariate regression analysis. Results: A total of 2444 ED admissions were analyzed. The patients’ mean (SD) age was 85.9 (7.1) years, and 67.7% were women. Short-term mortality (in 15.5%) was associated with age >90 years (OR, 1.50; 95% CI, 1.5-1.95 years), a Charlson index >2 (OR, 1.47; 95% CI, 1.14-1.90), and dependency assessed as moderate (OR, 1.50; 95% CI, 1.03-2.20) or severe (OR, 2.56; 95% CI, 1.84-3.55). Other associated factors were a higher level of urgency on triage, duration of ED stay, and hospital admission. Conclusions: Aged residents with the characteristics associated with short-term mortality could benefit from interventions for potentially avoiding unnecessary transfers to an ED, and from the implementation of comprehensive geriatric care within the ED. This could be useful to support good quality of care at the end of life. (AU)

[3D/3D+ as a tool for rapid geriatric assessment and adequacy of the care resource at discharge from the Emergency Department]. / Las 3D/3D+ como herramienta de valoración geriátrica rápida y de adecuación del recurso asistencial al alta de los Servicios de Urgencias.

OBJECTIVE: Assess the 3D/3D+ rapid geriatric assessment tool for the early detection of frailty, its usefulness to identify the effects of the acute process on the functional, physical, cognitive and socioenvironmental dimensions, as well as the medications that may have triggered the patient's reason for visit. Finally, assess the usefulness of 3D/3D+ together with the clinical diagnosis to adequate care resource at discharge from the emergency department (ED). METHOD: Retrospective observational cohort study. Patients ≥75 years old, with clinical complexity visited at the ED were included. Basal frailty status was assessed using 3D (basal component), and the multidimensional impact of the acute process using 3D+ (current component). The main dependent variable was adequacy of the care resource at ED discharge. RESULTS: 278 patients were included, mean age 86 years (interquartile range: 83-90), 59.7% were women. According to the basal component (3D), 83.1% (95%CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) was altered in 60.1% (95%CI: 54.1-65.9). The adequacy of ED discharge was correct in 96.4% (95%CI: 93.0-98.0). One out of 4patients was admitted to a medicine ward. CONCLUSIONS: 3D/3D+ facilitates an optimal model of emergency care adapted to patients ≥ 75 years old treated in EDs. It stratifies the level of frailty (3D), detects the severity of patients' acute problems (3D+) and contributes to decision-making regarding the most appropriate care resource at ED discharge.

Las 3D/3D+ como herramienta de valoración geriátrica rápida y de adecuación del recurso asistencial al alta de los Servicios de Urgencias / 3D/3D+ as a tool for rapid geriatric assessment and adequacy of the care resource at discharge from the Emergency Department

Objetivo: Evaluar la herramienta de valoración geriátrica rápida 3D/3D+como cribado precoz de fragilidad; su utilidad para identificar la repercusión del proceso agudo en las dimensiones funcional, cognitiva, social y los posibles fármacos desencadenantes del motivo de consulta. Por último, la utilidad de las 3D/3D+junto al diagnóstico clínico para adecuar el recurso asistencial al alta del servicio de Urgencias hospitalario (SUH).Método: Estudio observacional de cohortes retrospectivo. Se incluyó a los pacientes de 75 o más años con complejidad clínica que fueron atendidos en el área médica del SUH. Se valoró el grado de fragilidad basal mediante las 3D (componente basal) y la repercusión multidimensional debida al proceso agudo mediante las 3D+(componente actual). La variable dependiente principal fue la adecuación del recurso asistencial al alta del SUH.Resultados: Se incluyó a 278 pacientes de edad media 86 años (rango intercuartil: 83-90) y 59,7% de mujeres. Según el componente basal (3D), el 83,1% (IC del 95%: 78,2-87,3) presentaba algún grado de fragilidad. El componente actual (3D+) estaba alterado en el 60,1% (IC del 95%: 54,1-65,9). La adecuación al alta del SUH fue correcta en un 96,4% (IC del 95%: 93,0-98,0). Uno de cada 4pacientes ingresó en hospitalización convencional.Conclusiones: Las 3D/3D+facilita un modelo óptimo de atención urgente adaptada a los pacientes de 75 o más años atendidos en los SUH. Estratifica el grado fragilidad (3D), detecta la gravedad debido al problema agudo por el que paciente consulta (3D+) y contribuye a la toma de decisiones sobre el recurso asistencial más apropiado al alta del SUH. (AU)

Objective: Assess the 3D/3D+ rapid geriatric assessment tool for the early detection of frailty, its usefulness to identify the effects of the acute process on the functional, physical, cognitive and socioenvironmental dimensions, as well as the medications that may have triggered the patient's reason for visit. Finally, assess the usefulness of 3D/3D+ together with the clinical diagnosis to adequate care resource at discharge from the emergency department (ED).Method: Retrospective observational cohort study. Patients ≥75 years old, with clinical complexity visited at the ED were included. Basal frailty status was assessed using 3D (basal component), and the multidimensional impact of the acute process using 3D+ (current component). The main dependent variable was adequacy of the care resource at ED discharge.Results: 278 patients were included, mean age 86 years (interquartile range: 83–90), 59.7% were women. According to the basal component (3D), 83.1% (95%CI: 78.2–87.3) presented some degree of frailty. The current component (3D+) was altered in 60.1% (95%CI: 54.1–65.9). The adequacy of ED discharge was correct in 96.4% (95%CI: 93.0–98.0). One out of 4patients was admitted to a medicine ward.Conclusions: 3D/3D+ facilitates an optimal model of emergency care adapted to patients ≥ 75 years old treated in EDs. It stratifies the level of frailty (3D), detects the severity of patients’ acute problems (3D+) and contributes to decision-making regarding the most appropriate care resource at ED discharge. (AU)

Factors associated with short-term mortality after emergency department care of residents living in aged care homes: findings from the multicenter Caregency study. / Factores asociados con mortalidad a corto plazo en personas que viven en residencias atendidas en servicios de urgencias: resultados del estudio multicéntrico Caregency.

OBJECTIVES: To evaluate short-term mortality in people transferred from aged care homes for treatment in a hospital emergency department (ED) and to analyze factors associated with mortality. MATERIAL AND METHODS: Multicenter study of a random sample of retrospective data of patients treated in 5 EDs in Catalonia in 2017. The patients were over the age of 65 years and lived in residential care facilities. In addition to short-term mortality (in the ED or within 30 days of discharge), we analyzed sociodemographic characteristics, prior functional and cognitive status, multimorbidity, triage level on arrival, length of stay in the ED, and hospital admission. Odds ratios (ORs) for factors associated with short-term mortality were calculated by multivariate regression analysis. RESULTS: A total of 2444 ED admissions were analyzed. The patients' mean (SD) age was 85.9 (7.1) years, and 67.7% .were women. Short-term mortality (in 15.5%) was associated with age >90 years (OR, 1.50; 95% CI, 1.5-1.95 years), a Charlson index >2 (OR, 1.47; 95% CI, 1.14-1.90), and dependency assessed as moderate (OR, 1.50; 95% CI, 1.03- 2.20) or severe (OR, 2.56; 95% CI, 1.84-3.55). Other associated factors were a higher level of urgency on triage, duration of ED stay, and hospital admission. CONCLUSION: Aged residents with the characteristics associated with short-term mortality could benefit from interventions for potentially avoiding unnecessary transfers to an ED, and from the implementation of comprehensive geriatric care within the ED. This could be useful to support good quality of care at the end of life.

OBJETIVO: Evaluar la frecuencia y los factores asociados con la mortalidad a corto plazo de personas que viven en residencias tras ingreso en urgencias. METODO: Análisis retrospectivo multicéntrico de una muestra aleatoria de admisiones de personas $ 65 años que viven en residencias en cinco servicios de urgencias de Cataluña, a lo largo de 2017. Se analizaron características sociodemográficas, el estado funcional y cognitivo previo, multimorbilidad, nivel de triaje de las urgencias, duración de la estancia en urgencias, hospitalización y mortalidad a corto plazo (en urgencias o en los 30 días posteriores al alta). Se utilizó un análisis de regresión multivariante para investigar los factores asociados con la mortalidad a corto plazo. RESULTADOS: Se analizaron 2.444 admisiones en urgencias, con una edad media de 85,9 (DE 7,1) años, 67,7% mujeres. La mortalidad a corto plazo (15,5%) se asoció con una edad > 90 años (OR 1,50; IC 95%: 1,5-1,95), un índice de Charlson > 2 (OR 1,47; IC 95%: 1,14-1,90), y un grado de dependencia moderado (OR 1,50; IC 95%: 1,03-2,20) y grave (OR 2,56; IC 95%: 1,84-3,55). También se asoció con un mayor nivel de triaje de la urgencia, duración de la estancia en urgencias e ingreso en planta de hospitalización. CONCLUSIONES: Los ancianos residentes con las características descritas podrían beneficiarse especialmente de intervenciones dirigidas a la prevención de traslados potencialmente innecesarios a urgencias y a la implementación de una atención integral geriátrica dentro de los servicios de urgencias, a fin de garantizar una buena calidad de los cuidados en fases finales de la vida.

XXXI Congreso de SEMES, Girona 2019: La fuerza del equipo / Thirty-first conference of SEMES - Girona 2019: The power of teamwork

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Importancia del anión GAP ante la falta de información clínica: descripción de un caso clínico de intoxicación oral grave por metanol / Importance of GAP anion in the absence of clinical information: Description of one clinical case of severe oral methanol poisoning

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Nasal flaring as a clinical sign of respiratory acidosis in patients with dyspnea.

OBJECTIVE: To determine whether the presence of nasal flaring is a clinical sign of respiratory acidosis in patients attending emergency departments for acute dyspnea. METHODS: Single-center, prospective, observational study of patients aged over 15 requiring urgent attention for dyspnea, classified as level II or III according to the Andorran Triage Program and who underwent arterial blood gas test on arrival at the emergency department. The presence of nasal flaring was evaluated by two observers. Demographic and clinical variables, signs of respiratory difficulty, vital signs, arterial blood gases and clinical outcome (hospitalization and mortality) were recorded. Bivariate and multivariate analyses were performed using logistic regression models. RESULTS: The sample comprised 212 patients, mean age 78years (SD=12.8), of whom 49.5% were women. Acidosis was recorded in 21.2%. Factors significantly associated with the presence of acidosis in the bivariate analysis were the need for pre-hospital medical care, triage level II, signs of respiratory distress, presence of nasal flaring, poor oxygenation, hypercapnia, low bicarbonates and greater need for noninvasive ventilation. Nasal flaring had a positive likelihood ratio for acidosis of 4.6 (95% CI 2.9-7.4). In the multivariate analysis, triage level II (aOR 5.16; 95% CI: 1.91 to 13.98), the need for oxygen therapy (aOR 2.60; 95% CI: 1.13-5.96) and presence of nasal flaring (aOR 6.32; 95% CI: 2.78-14.41) were maintained as factors independently associated with acidosis. CONCLUSIONS: Nasal flaring is a clinical sign of severity in patients requiring urgent care for acute dyspnea, which has a strong association with acidosis and hypercapnia.

Aleteo nasal como factor pronóstico de mortalidad en el paciente con disnea grave / Nasal flaring as a predictor of mortality in patients with severe dyspnea

Objetivos: Determinar si la presencia de aleteo nasal es un factor de gravedad clínica y pronóstico de mortalidad hospitalaria en el paciente que consulta en urgencias por disnea. Método: Estudio prospectivo observacional un céntrico. Se incluyeron pacientes mayores de 15 años, que demandaron atención urgente por disnea, catalogados como niveles II y III por el Modelo Andorrano de Triaje (MAT). Se evaluó la presencia de aleteo nasal por dos observadores. Se recogieron variables demográficas, clínicas, signos de dificultad respiratoria, signos vitales, gasometría arterial y evolución clínica (ingreso hospitalario y mortalidad). Se realizaron análisis bivariantes y multivariantes con modelos de regresión logística. Resultados: Se incluyeron 246 pacientes, de edad media ± DE 77 (13) años (DE: 13,2) y un 52% de mujeres. Un19,5% presentaron aleteo nasal. Los pacientes con aleteo nasal tuvieron mayor gravedad en el triaje, más taquipnea, peor oxigenación, más acidosis y más hipercapnia. En el análisis bivariante los factores pronósticos de mortalidad hospitalaria fueron la edad (OR 1,05; IC95%: 1,01-1,10), la atención prehospitalaria por el servicio emergencias médicas (OR 3,97; IC95%: 1,39-11,39), el nivel de triaje II (OR 4,19; IC95%: 1,63-10,78), la presencia de signos de dificultad respiratoria como el aleteo nasal (OR 3,79; IC 95%: 1,65-8,69), la presencia de acidosis (OR 7,09; IC95%: 2,97-16,94) y la hipercapnia (OR 2,67; IC95%: 1,11-6,45). En el análisis multivariante, la edad, el nivel de triaje y el aleteonasal se mantuvieron como factores pronósticos independientes de mortalidad (AU)

Objective: To determine whether the presence of nasal flaring is a clinical sign of severity and a predictor of hospital mortality in emergency patients with dyspnea. Methods: Prospective, observational, single-center study. We enrolled patients older than 15 years of age who required attention for dyspnea categorized as level II or III emergencies according to the Andorran Medical Triage system. Two observers evaluated the presence of nasal flaring. We recorded demographic and clinical variables, including respiratory effort, vital signs, arterial blood gases, and clinical course (hospital admission and mortality). Bivariable analysis was performed and multivariable logistic regression models were constructed. Results: We enrolled 246 patients with a mean (SD) age of 77 (13) years; 52% were female. Nasal flaring was present in 19.5%. Patients with nasal flaring had triage levels indicating greater severity and they had more severe tachypnea, worse oxygenation, and greater acidosis and hypercapnia. Bivariable analysis detected that the following variables were associated with mortality: age (odds ratio [OR], 1.05; 95% CI, 1.01–1.10), prehospital care from the emergency medical service (OR, 3.97; 95% CI, 1.39–11.39), triage level II (OR, 4.19; 95% CI, 1.63–10.78), signs of respiratory effort such as nasal flaring (OR, 3.79; 95% CI, 1.65–8.69), presence of acidosis (OR, 7.09; 95% CI, 2.97–16.94), and hypercapnia (OR, 2.67; 95% CI, 1,11–6,45). The factors that remained independent predictors of mortality in the multivariable analysis were age, severity (triage level), and nasal flaring. Conclusions: In patients requiring emergency care for dyspnea, nasal flaring is a clinical sign of severity and a predictor of mortality (AU)

[Nasal flaring as a predictor of mortality in patients with severe dyspnea]. / Aleteo nasal como factor pronóstico de mortalidad en el paciente con disnea grave.

OBJECTIVES: To determine whether the presence of nasal flaring is a clinical sign of severity and a predictor of hospital mortality in emergency patients with dyspnea. MATERIAL AND METHODS: Prospective, observational, single-center study. We enrolled patients older than 15 years of age who required attention for dyspnea categorized as level II or III emergencies according to the Andorran Medical Triage system. Two observers evaluated the presence of nasal flaring. We recorded demographic and clinical variables, including respiratory effort, vital signs, arterial blood gases, and clinical course (hospital admission and mortality). Bivariable analysis was performed and multivariable logistic regression models were constructed. RESULTS: We enrolled 246 patients with a mean (SD) age of 77 (13) years; 52% were female. Nasal flaring was present in 19.5%. Patients with nasal flaring had triage levels indicating greater severity and they had more severe tachypnea, worse oxygenation, and greater acidosis and hypercapnia. Bivariable analysis detected that the following variables were associated with mortality: age (odds ratio [OR], 1.05; 95% CI, 1.01-1.10), prehospital care from the emergency medical service (OR, 3.97; 95% CI, 1.39-11.39), triage level II (OR, 4.19; 95% CI, 1.63-10.78), signs of respiratory effort such as nasal flaring (OR, 3.79; 95% CI, 1.65-8.69), presence of acidosis (OR, 7.09; 95% CI, 2.97-16.94), and hypercapnia (OR, 2.67; 95% CI, 1,11-6,45). The factors that remained independent predictors of mortality in the multivariable analysis were age, severity (triage level), and nasal flaring. CONCLUSION: In patients requiring emergency care for dyspnea, nasal flaring is a clinical sign of severity and a predictor of mortality.

OBJETIVO: Determinar si la presencia de aleteo nasal es un factor de gravedad clínica y pronóstico de mortalidad hospitalaria en el paciente que consulta en urgencias por disnea. METODO: Estudio prospectivo observacional unicéntrico. Se incluyeron pacientes mayores de 15 años, que demandaron atención urgente por disnea, catalogados como niveles II y III por el Modelo Andorrano de Triaje (MAT). Se evaluó la presencia de aleteo nasal por dos observadores. Se recogieron variables demográficas, clínicas, signos de dificultad respiratoria, signos vitales, gasometría arterial y evolución clínica (ingreso hospitalario y mortalidad). Se realizaron análisis bivariantes y multivariantes con modelos de regresión logística. RESULTADOS: Se incluyeron 246 pacientes, de edad media ± DE 77 (13) años (DE: 13,2) y un 52% de mujeres. Un 19,5% presentaron aleteo nasal. Los pacientes con aleteo nasal tuvieron mayor gravedad en el triaje, más taquipnea, peor oxigenación, más acidosis y más hipercapnia. En el análisis bivariante los factores pronósticos de mortalidad hospitalaria fueron la edad (OR 1,05; IC95%: 1,01-1,10), la atención prehospitalaria por el servicio emergencias médicas (OR 3,97; IC95%: 1,39-11,39), el nivel de triaje II (OR 4,19; IC95%: 1,63-10,78), la presencia de signos de dificultad respiratoria como el aleteo nasal (OR 3,79; IC 95%: 1,65-8,69), la presencia de acidosis (OR 7,09; IC95%: 2,97- 16,94) y la hipercapnia (OR 2,67; IC95%: 1,11-6,45). En el análisis multivariante, la edad, el nivel de triaje y el aleteo nasal se mantuvieron como factores pronósticos independientes de mortalidad. CONCLUSIONES: El aleteo nasal es un signo clínico de gravedad y predictor de mortalidad en los pacientes que demandan atención urgente por disnea.

Varón de 21 años con trismus, tromboflebitis séptica y nódulos pulmonares / A 21-year-old male with trismus, septic thrombophlebitis and lung nodules

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