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Critical Care
Published in: Critical Care 1/2011

Open Access 01-02-2011 | Research

Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department

Authors: Tobias M Merz, Reto Etter, Ludger Mende, Daniel Barthelmes, Jan Wiegand, Luca Martinolli, Jukka Takala

Published in: Critical Care | Issue 1/2011

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Abstract

Introduction

The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients.

Methods

This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality.

Results

Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax).

Conclusions

Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome.
Appendix
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Literature
1.
Jones AE, Fitch MT, Kline JA: Operational performance of validated physiologic scoring systems for predicting in-hospital mortality among critically ill emergency department patients. Crit Care Med. 2005, 33: 974-978. 10.1097/01.CCM.0000162495.03291.C2.PubMedCrossRef
2.
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G, Collins CH: Confidential inquiry into quality of care before admission to intensive care. BMJ. 1998, 316: 1853-1858.PubMedPubMedCentralCrossRef
3.
Hillman KM, Bristow PJ, Chey T, Daffurn K, Jacques T, Norman SL, Bishop GF, Simmons G: Antecedents to hospital deaths. Intern Med J. 2001, 31: 343-348. 10.1046/j.1445-5994.2001.00077.x.PubMedCrossRef
4.
Derlet RW, Richards JR: Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000, 35: 63-68. 10.1016/S0196-0644(00)70105-3.PubMedCrossRef
5.
Lynn SG, Kellermann AL: Critical decision making: managing the emergency department in an overcrowded hospital. Ann Emerg Med. 1991, 20: 287-292. 10.1016/S0196-0644(05)80942-4.PubMedCrossRef
6.
Subbe CP, Slater A, Menon D, Gemmell L: Validation of physiological scoring systems in the accident and emergency department. Emerg Med J. 2006, 23: 841-845. 10.1136/emj.2006.035816.PubMedPubMedCentralCrossRef
7.
Subbe CP, Kruger M, Rutherford P, Gemmel L: Validation of a modified Early Warning Score in medical admissions. QJM. 2001, 94: 521-526. 10.1093/qjmed/94.10.521.PubMedCrossRef
8.
Bertollo S, Rodenberg H: Correlation of the RTS (Revised Trauma Score) and RAPS (Rapid Acute Physiology Score) in rotor-wing prehospital care. Air Med J. 1994, 13: 91-95. 10.1016/S1067-991X(05)80299-8.PubMedCrossRef
9.
Rees JE, Mann C: Use of the patient at risk scores in the emergency department: a preliminary study. Emerg Med J. 2004, 21: 698-699. 10.1136/emj.2003.006197.PubMedPubMedCentralCrossRef
10.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005, 112: IV1-203.
11.
Advanced Trauma Life Support® for Doctors (ATLS®) Student Course Manual. 2002, Chicago American College of Surgeons Committee on Trauma, 8
12.
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV: Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002, 324: 387-390. 10.1136/bmj.324.7334.387.PubMedPubMedCentralCrossRef
13.
Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart GK, Opdam H, Silvester W, Doolan L, Gutteridge G: A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003, 179: 283-287.PubMed
14.
Lee A, Bishop G, Hillman KM, Daffurn K: The Medical Emergency Team. Anaesth Intensive Care. 1995, 23: 183-186.PubMed
15.
Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finfer S, Flabouris A: Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005, 365: 2091-2097. 10.1016/S0140-6736(05)66733-5.PubMedCrossRef
16.
Kenward G, Castle N, Hodgetts T, Shaikh L: Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004, 61: 257-263. 10.1016/j.resuscitation.2004.01.021.PubMedCrossRef
17.
Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, Silvester W, Doolan L, Gutteridge G: Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004, 32: 916-921. 10.1097/01.CCM.0000119428.02968.9E.PubMedCrossRef
18.
Pittard AJ: Out of our reach? Assessing the impact of introducing a critical care outreach service. Anaesthesia. 2003, 58: 882-885. 10.1046/j.1365-2044.2003.03331.x.PubMedCrossRef
19.
DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL: Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care. 2004, 13: 251-254. 10.1136/qshc.2003.006585.PubMedPubMedCentralCrossRef
20.
Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A: The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 1999, 54: 853-860. 10.1046/j.1365-2044.1999.00996.x.PubMedCrossRef
21.
Bristow PJ, Hillman KM, Chey T, Daffurn K, Jacques TC, Norman SL, Bishop GF, Simmons EG: Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000, 173: 236-240.PubMed
22.
Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, Cope J, Hart D, Kay D, Cowley K, Pateraki J: Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004, 30: 1398-1404. 10.1007/s00134-004-2268-7.PubMedCrossRef
23.
Cretikos M, Parr M, Hillman K, Bishop G, Brown D, Daffurn K, Dinh H, Francis N, Heath T, Hill G, Murphy J, Sanchez D, Santiano N, Young L: Guidelines for the uniform reporting of data for Medical Emergency Teams. Resuscitation. 2006, 68: 11-25. 10.1016/j.resuscitation.2005.06.009.PubMedCrossRef
24.
Etter R, Ludwig R, Lersch F, Takala J, Merz TM: Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department. Crit Care Med. 2008, 36: 775-781. 10.1097/CCM.0B013E3181643C15.PubMedCrossRef
25.
Goransson KE, Ehrenberg A, Ehnfors M: Triage in emergency departments: national survey. J Clin Nurs. 2005, 14: 1067-1074. 10.1111/j.1365-2702.2005.01191.x.PubMedCrossRef
26.
Patel VL, Gutnik LA, Karlin DR, Pusic M: Calibrating urgency: triage decision-making in a pediatric emergency department. Adv Health Sci Educ Theory Pract. 2008, 13: 503-520. 10.1007/s10459-007-9062-6.PubMedCrossRef
27.
Gerdtz MF, Bucknall TK: Triage nurses' clinical decision making. An observational study of urgency assessment. J Adv Nurs. 2001, 35: 550-561. 10.1046/j.1365-2648.2001.01871.x.PubMedCrossRef
28.
Nardi G, Riccioni L, Cerchiari E, De Blasio E, Gristina G, Oransky M, Pallotta F, Ajmone-Cat C, Freni C, Trombetta S, Mega AM: [Impact of an integrated treatment approach of the severely injured patients (ISS =/> 16) on hospital mortality and quality of care]. Minerva Anestesiol. 2002, 68: 25-35.PubMed
29.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001, 345: 1368-1377. 10.1056/NEJMoa010307.PubMedCrossRef
30.
De Luca G, Suryapranata H, Ottervanger JP, Antman EM: Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004, 109: 1223-1225. 10.1161/01.CIR.0000121424.76486.20.PubMedCrossRef
31.
Duke G, Green J, Briedis J: Survival of critically ill medical patients is time-critical. Crit Care Resusc. 2004, 6: 261-267.PubMed
32.
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995, 333: 1581-1587. 10.1056/NEJM199512143332401.
33.
Goldhill DR, White SA, Sumner A: Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesthesia. 1999, 54: 529-534. 10.1046/j.1365-2044.1999.00837.x.PubMedCrossRef
34.
Hillman KM, Bristow PJ, Chey T, Daffurn K, Jacques T, Norman SL, Bishop GF, Simmons G: Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med. 2002, 28: 1629-1634. 10.1007/s00134-002-1496-y.PubMedCrossRef
35.
Groarke JD, Gallagher J, Stack J, Aftab A, Dwyer C, McGovern R, Courtney G: Use of an admission early warning score to predict patient morbidity and mortality and treatment success. Emerg Med J. 2008, 25: 803-806. 10.1136/emj.2007.051425.PubMedCrossRef
36.
Rhee KJ, Fisher CJ, Willitis NH: The Rapid Acute Physiology Score. Am J Emerg Med. 1987, 5: 278-282. 10.1016/0735-6757(87)90350-0.PubMedCrossRef
37.
Le Gall JR, Lemeshow S, Saulnier F: A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. Jama. 1993, 270: 2957-2963. 10.1001/jama.270.24.2957.PubMedCrossRef
38.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE: APACHE II: a severity of disease classification system. Crit Care Med. 1985, 13: 818-829. 10.1097/00003246-198510000-00009.PubMedCrossRef
39.
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG: The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996, 22: 707-710. 10.1007/BF01709751.PubMedCrossRef
40.
Buist M, Bernard S, Nguyen TV, Moore G, Anderson J: Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation. 2004, 62: 137-141. 10.1016/j.resuscitation.2004.03.005.PubMedCrossRef
41.
Nashef L, Brown S: Epilepsy and sudden death. Lancet. 1996, 348: 1324-1325. 10.1016/S0140-6736(05)65402-5.PubMedCrossRef
42.
Nguyen HB, Rivers EP, Havstad S, Knoblich B, Ressler JA, Muzzin AM, Tomlanovich MC: Critical care in the emergency department: A physiologic assessment and outcome evaluation. Acad Emerg Med. 2000, 7: 1354-1361. 10.1111/j.1553-2712.2000.tb00492.x.PubMedCrossRef
43.
Bion JF, Edlin SA, Ramsay G, McCabe S, Ledingham IM: Validation of a prognostic score in critically ill patients undergoing transport. Br Med J (Clin Res Ed). 1985, 291: 432-434. 10.1136/bmj.291.6493.432.CrossRef
44.
Dragsted L, Jorgensen J, Jensen NH, Bonsing E, Jacobsen E, Knaus WA, Qvist J: Interhospital comparisons of patient outcome from intensive care: importance of lead-time bias. Crit Care Med. 1989, 17: 418-422. 10.1097/00003246-198905000-00008.PubMedCrossRef
Metadata
Title
Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department
Authors
Tobias M Merz
Reto Etter
Ludger Mende
Daniel Barthelmes
Jan Wiegand
Luca Martinolli
Jukka Takala
Publication date
01-02-2011
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2011
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/cc9972

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