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.

Title: Understanding a Low Vitamin D State in the Context of COVID-19.

While a low vitamin D state has been associated with an increased risk of infection by SARS-CoV-2 in addition to an increased severity of COVID-19 disease, a causal role is not yet established. Here, we review the evidence relating to i) vitamin D and its role in SARS-CoV-2 infection and COVID-19 disease ii) the vitamin D status in the Irish adult population iii) the use of supplemental vitamin D to treat a deficient status and iv) the application of the Bradford-Hill causation criteria. We conclude that reverse causality probably makes a minimal contribution to the presence of low vitamin D states in the setting of COVID-19. Applying the Bradford-Hill criteria, however, the collective literature supports a causal association between low vitamin D status, SARS-CoV-2 infection, and severe COVID-19 (respiratory failure, requirement for ventilation and mortality). A biologically plausible rationale exists for these findings, given vitamin D's role in immune regulation. The thresholds which define low, deficient, and replete vitamin D states vary according to the disease studied, underscoring the complexities for determining the goals for supplementation. All are currently unknown in the setting of COVID-19. The design of vitamin D randomised controlled trials is notoriously problematic and these trials commonly fail for a number of behavioural and methodological reasons. In Ireland, as in most other countries, low vitamin D status is common in older adults, adults in institutions, and with obesity, dark skin, low UVB exposure, diabetes and low socio-economic status. Physiological vitamin D levels for optimal immune function are considerably higher than those that can be achieved from food and sunlight exposure alone in Ireland. A window exists in which a significant number of adults could benefit from vitamin D supplementation, not least because of recent data demonstrating an association between vitamin D status and COVID-19. During the COVID pandemic, we believe that supplementation with 20-25ug (800-1000 IU)/day or more may be required for adults with apparently normal immune systems to improve immunity against SARS-CoV-2. We expect that higher monitored doses of 37.5-50 ug (1,500-2,000)/day may be needed for vulnerable groups (e.g., those with obesity, darker skin, diabetes mellitus and older adults). Such doses are within the safe daily intakes cited by international advisory agencies.

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.

Investigating the Relationship between Vitamin D and Persistent Symptoms Following SARS-CoV-2 Infection.

The emergence of persistent symptoms following SARS-CoV-2 infection, known as long COVID, is providing a new challenge to healthcare systems. The cardinal features are fatigue and reduced exercise tolerance. Vitamin D is known to have pleotropic effects far beyond bone health and is associated with immune modulation and autoimmunity. We hypothesize that vitamin D levels are associated with persistent symptoms following COVID-19. Herein, we investigate the relationship between vitamin D and fatigue and reduced exercise tolerance, assessed by the Chalder Fatigue Score, six-minute walk test and modified Borg scale. Multivariable linear and logistic regression models were used to evaluate the relationships. A total of 149 patients were recruited at a median of 79 days after COVID-19 illness. The median vitamin D level was 62 nmol/L, with n = 36 (24%) having levels 30-49 nmol/L and n = 14 (9%) with levels <30 nmol/L. Fatigue was common, with n = 86 (58%) meeting the case definition. The median Borg score was 3, while the median distance covered for the walk test was 450 m. No relationship between vitamin D and the measures of ongoing ill-health assessed in the study was found following multivariable regression analysis. These results suggest that persistent fatigue and reduced exercise tolerance following COVID-19 are independent of vitamin D.

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.

Consultant duration of clinical practice as a cost determinant of an emergency medical admission.

BACKGROUND: Little data exists relating years of hospital consultant work experience, from time of consultant certification, and costs incurred for emergency medical patients under their care. We examined the total cost of emergency medical episodes in relation to certified consultant years experience using a database of emergency admissions. METHODS: All emergency admissions (19,295 patients) from January 2008 to December 2012 were studied. Consultants were categorized by total years of certified experience according to four experience categories (< 15, 15-20, > 20 to ≤ 25, and > 25 years). Costs per case calculations included all pay, non-pay, and diagnostic/support infra-structural costs. We used quantile regression analysis to examine the impact of predictor variables on total costs over the predictor distribution and logistic regression on outcomes and costs, adjusting for other major predictors of cost. RESULTS: Major predictors of costs were identified. Quantile regression cost parameter estimates of hospital episode costs decreased with experience; the unit change at the Q25 point of the years experience distribution was - 62 (95 % CI - 87, - 37), - 162 (95 % CI - 203, - 120) at the median, but decreased at the Q75 point to - 340 (95 % CI - 416, - 264). The odds ratio of a hospital episode cost being below the median for each category of consultant experience >15 years qualified were 0.75 (95 % CI 0.68, 0.83), 0.77 (95 % CI 0.70, 0.86), and 0.70 (95 % CI 0.64, 0.78): p < 0.001 for each experience category vs. <15 years qualified. CONCLUSIONS: There appear to be cost advantages to care delivered by certified consultants of >20 years in clinical practice.

Increasing wait times predict increasing mortality for emergency medical admissions.

BACKGROUND: The actual impact of emergency department (ED) 'wait' time on hospital mortality in patients admitted as a medical emergency has often been debated. We have evaluated the impact of such waits on 30-day mortality, for all medical patients over a 7-year period. METHODS: All patients admitted as medical emergencies by the ED between 2002 and 2008 were studied; we looked at the impact of time to medical referral and subsequent time to a ward bed on any inhospital death within 30 days. Significant univariate predictors of outcome, including Charlson's comorbidity and acute illness severity score, were entered into a multivariate regression model, adjusting the univariate estimates of the readmission status on mortality. RESULTS: We studied 23 114 consecutive acute medical admissions between 2002 and 2008. The triage category in the ED was highly predictive of subsequent 30-day mortality ranging from 4.8 (category 5) to 46.1% (category 1). After adjustment for all outcome predictors, including comorbidity and illness severity, both door-to-team and team-to-ward times were independent predictors of death within 30 days with respective odds ratios of 1.13 (95% confidence interval 1.07-1.18), and 1.07 (95% confidence interval 1.02-1.13). CONCLUSION: Delay to admission have been shown to be independently adversely related to mortality outcome. We recommend maximal target limits of 4 and 6 h for referrals and admissions, respectively, based on these mortality observations.

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.