Abstract
BackgroundWhile there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol.MethodsAll CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]).ResultsThe any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients.ConclusionOur simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.
Highlights
IntroductionThere are no comparable triggers for initiating resuscitation room management of critically ill nontrauma (CINT) patients, posing a challenge for their identification by emergency medical services (EMS) or triage nurses
While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED)
The 30-day mortality of CINT patients is around twice that of trauma patients [2], a recent survey showed that only ~ 50% of the participating German EDs use alert criteria to initiate interdisciplinary resuscitation room management of CINT patients, which are mostly limited to classic acute medical conditions triaged according to the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) scheme [5]
Summary
There are no comparable triggers for initiating resuscitation room management of critically ill nontrauma (CINT) patients, posing a challenge for their identification by emergency medical services (EMS) or triage nurses. The 30-day mortality of CINT patients is around twice that of trauma patients [2], a recent survey showed that only ~ 50% of the participating German EDs use alert criteria to initiate interdisciplinary resuscitation room management of CINT patients, which are mostly limited to classic acute medical conditions triaged according to the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) scheme [5]. The aim of this study was to specify and validate objective trigger factor cut-offs for initiating structured resuscitation management in non-intubated CINT patients. A total of 4 different datasets were used: a prospective derivation cohort, a retrospective validation cohort, and two external validation cohorts (Fig. 1)
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