Clinical Profile and Predictors of Outcomes in Patients with Acute Abdomen Presenting in the Emergency Department: A Prospective Cohort Study from a Tertiary Care Centre

To assess the impact of delay in emergency department (ED) on outcome of critically ill patients admitted to the medical intensive care unit (MICU). Outcome was defined as hospital mortality and as health-related quality of life (HRQoL) at 6 months after intensive care assessed by the 15D measure. The 15D is a generic, 15-dimensional, standardized measure of HRQoL. We hypothesized that prolonged stay in the ED is related to worse outcome. A prospective follow-up cohort study in university hospital. All consecutive 1675 patients admitted to the MICU between July 2002 and June 2004. The 15D questionnaire was mailed to all patients alive at 6 months after admission. Of all MICU patients, 64% were admitted from ED. The mean length of stay in the ED was 6.2 h (95%CI 5.9-6.5 h). The hospital mortality rate was 24.4% (20.0% in the ED vs. 33.0% in the non-ED cohort, P < 0.001) and it was associated with higher age and degree of physiological derangement at admission. Neither the length of ED stay was associated with hospital mortality (P = 0.82) nor with HRQoL at 6 months after MICU admission (P = 0.34). Altogether, HRQoL at 6 months was significantly lower compared with the age- and sex-matched general population (P < 0.001). In a university hospital, the length of ED stay was not associated with the outcome of critically ill medical patients. However, we feel that the effect of ED treatment and delay on outcome and outcome prediction in the critically ill patients deserves further evaluation.

Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Serum Procalcitonin: An Independent Predictor of Clinical Outcome in Health Care-Associated Pneumonia

Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study.

Comparison of phenobarbital-adjunct versus benzodiazepine-only approach for alcohol withdrawal syndrome in the ED

Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3 This article is protected by copyright. All rights reserved.

BackgroundTo study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU).MethodsThis is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend.ResultsA total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications.ConclusionsThe introduction of HDU helps to reduce ICU utilization in obstetric population.

Delta shock index in the emergency department as a predictor of clinical outcomes in traumatic injury.

Objectives:Patient risk stratification is the cornerstone of COVID-19 disease management; that has impacted health systems globally. We evaluated the performance of the Brescia-COVID Respiratory Severity Scale (BCRSS), CALL (Co-morbid, age, Lymphocyte and Lactate dehydrogenase) Score, and World Health Organization (WHO) guidelines in Emergency department (ED) on arrival, as predictors of outcomes; Intensive care unit (ICU) admission and in-hospital mortality.Methods:A two-month retrospective chart review of 88 adult patients with confirmed COVID-19 pneumonia; requiring emergency management was conducted at ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan, (April 1 to May 31, 2020). The sensitivity, specificity, receiver operator characteristic curve (ROC) and area under the curve (AUC) for the scores were obtained to assess their predictive capability for outcomes.Results:The in-hospital mortality rate was 48.9 % with 59.1 % ICU admissions and with a mean age at presentation of 56 ± 13 years. Receiver operator curve for BCRSS depicted good predicting capability for in hospital mortality [AUC 0.81(95% CI 0.71-0.91)] and ICU admission [AUC 0.73(95%CI 0.62-0.83)] amongst all models of risk assessment.Conclusion:BCRSS depicted better prediction of in-hospital mortality and ICU admission. Prospective studies using this tool are needed to assess its utility in predicting high-risk patients and guide treatment escalation in LMIC’s.

Background and purposeDespite the increasing number of reports on the spectrum of neurological manifestations of COVID‐19 (neuro‐COVID), few studies have assessed short‐ and long‐term outcome of the disease.MethodsThis is a cohort study enrolling adult patients with neuro‐COVID seen in neurological consultation. Data were collected prospectively or retrospectively in the European Academy of Neurology NEuro‐covid ReGistrY ((ENERGY). The outcome at discharge was measured using the modified Rankin Scale and defined as ‘stable/improved’ if the modified Rankin Scale score was equal to or lower than the pre‐morbid score, ‘worse’ if the score was higher than the pre‐morbid score. Status at 6 months was also recorded. Demographic and clinical variables were assessed as predictors of outcome at discharge and 6 months.ResultsFrom July 2020 to March 2021, 971 patients from 19 countries were included. 810 (83.4%) were hospitalized. 432 (53.3%) were discharged with worse functional status. Older age, stupor/coma, stroke and intensive care unit (ICU) admission were predictors of worse outcome at discharge. 132 (16.3%) died in hospital. Older age, cancer, cardiovascular complications, refractory shock, stupor/coma and ICU admission were associated with death. 262 were followed for 6 months. Acute stroke or ataxia, ICU admission and degree of functional impairment at discharge were predictors of worse outcome. 65/221 hospitalized patients (29.4%) and 10/32 non‐hospitalized patients (24.4%) experienced persisting neurological symptoms/signs. 10/262 patients (3.8%) developed new neurological complaints during the 6 months of follow‐up.ConclusionsNeuro‐COVID is a severe disease associated with worse functional status at discharge, particularly in older subjects and those with comorbidities and acute complications of infection.

CLINICAL PROFILE AND PREDICTORS OF OUTCOMES OF PATIENTS WITH MITRAL STENOSIS UNDERGOING PERCUTANEOUS TRANSSEPTAL MITRAL COMMISSUROTOMY

Early identification of sepsis and initiation of aggressive treatment saves lives. However, the diagnosis of sepsis may be delayed in patients without overt deterioration. Clinical screening tools and lactate levels may help identify sepsis patients at risk for adverse outcomes. The objective was to determine the diagnostic characteristics of a clinical screening tool in combination with measuring early bedside point-of-care (POC) lactate levels in emergency department (ED) patients with suspected sepsis. This was a prospective, observational study set at a suburban academic ED with an annual census of 90,000. A convenience sample of adult ED patients with suspected infection were screened with a sepsis screening tool for the presence of at least one of the following: temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or altered mental status. Patients meeting criteria had bedside POC lactate testing following triage, which was immediately reported to the treating physician if ≥2.0 mmol/L. Demographic and clinical information, including lactate levels, ED interventions, and final diagnosis, were recorded. Outcomes included presence or absence of sepsis using the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions and intensive care unit (ICU) admissions, use of vasopressors, and mortality. Diagnostic test characteristics were calculated using 2-by-2 tables with their 95% confidence intervals (CIs). The association between bedside lactate and ICU admissions, use of vasopressors, and mortality was determined using logistic regression. A total of 258 patients were screened for sepsis. Their mean (± standard deviation [SD]) age was 64 (±19) years; 46% were female, and 82% were white. Lactate levels were 2.0 mmol/L or greater in 80 (31%) patients. Patients were confirmed to meet sepsis criteria in 208 patients (81%). The diagnostic characteristics for sepsis of the combined clinical screening tool and bedside lactates were sensitivity 34% (95% CI = 28% to 41%), specificity 82% (95% CI = 69% to 90%), positive predictive value 89% (95% CI = 80% to 94%), and negative predictive value 23% (95% CI = 17% to 30%). Bedside lactate levels were associated with sepsis severity (p < 0.001), ICU admission (odds ratio [OR] = 2.01; 95% CI = 1.53 to 2.63), and need for vasopressors (OR = 1.54; 95% CI = 1.13 to 2.12). Use of a clinical screening tool in combination with early bedside POC lactates has moderate to good specificity but low sensitivity in adult ED patients with suspected sepsis. Elevated bedside lactate levels are associated with poor outcomes.

BackgroundAdrenomedullin is a vasoactive hormone with potentially prognostic and therapeutic value, which mainly has been investigated in intensive care unit (ICU) settings. The triaging in the emergency department (ED) of patients to the right level of care is crucial for patient outcome.ObjectivesThe primary aim of this study was to investigate the association of bioactive adrenomedullin (bio-ADM) with mortality among sepsis patients in the ED. Secondary aims were to investigate the association of bio-ADM with multiple organ failure (MOF), ICU admission and ED discharge.MethodsIn this prospective observational cohort study, adult sepsis patients in the ED (2013–2015) had blood samples collected for later batch analysis of bio-ADM. Odds ratios (OR) with 95% confidence interval (CI) for bio-ADM were calculated.ResultsBio-ADM in 594 sepsis patients was analyzed of whom 51 died within 28 days (8.6%), 34 developed severe MOF, 27 were ICU admitted and 67 were discharged from the ED. The median (interquartile range) bio-ADM was 36 (26–56) and 63 (42–132) pg/mL among survivors and non-survivors, respectively, 81 (56–156) pg/mL for patients with severe MOF and 77 (42–133) pg/mL for ICU admitted patients. Each log-2 increment of bio-ADM conferred an OR of 2.30 (95% CI 1.74–3.04) for mortality, the adjusted OR was 2.39 (95% CI 1.69–3.39). The area under the receiver operating characteristic curve of a prognostic mortality model based on demographics and biomarkers increased from 0.80 to 0.86 (p = 0.02) when bio-ADM was added. Increasing bio-ADM was associated with severe MOF, ICU admission and ED discharge with adjusted ORs of 3.30 (95% CI 2.13–5.11), 1.75 (95% CI 1.11–2.77) and 0.46 (95% CI 0.32–0.68), respectively.ConclusionBio-ADM in sepsis patients in the ED is associated with mortality, severe MOF, ICU admission and ED discharge, and may be of clinical importance for triage of sepsis patients in the ED.

Predictors of outcome in geriatric patients with urinary tract infections

AimTo test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome ‘mortality’ (hospital or 30 day) and secondary outcomes ‘intensive care unit (ICU) admission’ and ‘critical care in ED’ and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. MethodsRegister-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. Results1586 patients were included. NEWS2 showed poor prediction of ‘mortality’ (AUC 0.686, CI 0.633–0.739) and adequate prediction of ‘ICU admission’ (AUC 0.716, CI 0.690–0.742) and ‘critical care in ED’ (AUC 0.756, CI 0.732–0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with ‘mortality’ (OR 1.688, CI 1.052–2.708, p<0.05) and ‘critical care in ED’ (OR 3.267, CI 2.490–4.286, p<0.001). NEWS2 > 4 had the strongest association with ‘ICU admission’ (OR 2.339, CI 1.742–3.141, p<0.001). ConclusionFor identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.