Derivation and Validation of Predictive Factors for Clinical Deterioration after Admission in Emergency Department Patients Presenting with Abnormal Vital Signs Without Shock.

Daniel J Henning,Nathan I Shapiro,Colby S Redfield,Colin J Huguenel,Richard E Wolfe,Leon D Sanchez,Danielle E Day,Kimie Oedorf,Jonathan C Roberts

doi:10.5811/westjem.2015.9.27348

Daniel J Henning, Nathan I Shapiro + Show 7 more

Open Access

https://doi.org/10.5811/westjem.2015.9.27348

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Abstract

IntroductionStrategies to identify high-risk emergency department (ED) patients often use markedly abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.MethodsWe performed a prospective observational study of patients with abnormal vital signs or lactate level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic blood pressure <90mm/Hg, or lactate ≥4mmole/L. We excluded patients with isolated atrial tachycardia, seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary outcome was deterioration, defined as development of acute renal failure (creatinine 2× baseline), non-elective intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after hospitalization were determined using logistic regression.ResultsOf 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission. Independent predictors of in-hospital deterioration were: lactate >4.0mmol/L (OR 5.1, 95% CI [2.1–12.2]), age ≥80 yrs (OR 1.9, CI [1.0–3.7]), bicarbonate <21mEq/L (OR 2.5, CI [1.3–4.9]), and initial HR≥130 (OR 3.1, CI [1.5–6.1]).ConclusionPatients exhibiting abnormal vital signs or elevated lactate levels without shock had significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered adverse outcomes with reasonable reliability.

Highlights

Strategies to identify high-risk emergency department (ED) patients often use markedly abnormal vital signs and serum lactate levels
Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were excluded, leaving 532 for analysis
Prior studies show that vital sign abnormalities, such as elevated respiratory rate, tachycardia, hypotension, and elevated shock index, as well as elevated lactate level identify a population of patients with a relatively higher risk of short-term adverse outcomes.[1,2,3]

Summary

Introduction

Predictive Factors for Clinical Deterioration After Admission stratify patients.[3,4] While patients with persistent hypotension and shock are clearly at increased risk for adverse outcomes,[2,5,6,7,8,9,10] risk stratification is more challenging in normotensive and fluid responsive patients.[2,8,11] data showing the rates of adverse outcomes among those patients exhibiting markedly abnormal vital signs without shock (persistent hypotension despite resuscitation or need for vasopressors) are lacking This risk has been assessed to a limited extent in infected patients with elevated lactate but no hypotension, who are shown to have a significant risk of adverse outcomes.[2,8,11] Yet diagnoses are often obscured during the ED evaluation,[12] making the application of risk stratification data difficult to apply when limited to a single diagnosis. Understanding the rates, types, and predictors of serious adverse outcomes in an undifferentiated ED population exhibiting abnormal vital signs without shock would inform triage decisions, and help practitioners anticipate those patients who may require more aggressive interventions or a higher level of care at disposition

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