Abstract
Background: Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event. We aimed to identify clinically relevant subphenotypes at high risk of IHCA in the emergency department (ED).Methods: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory markers, and IHCA status. Group-based trajectory modeling was performed.Results: There were 37,697 adult ED patients with a total of 1,507,121 data points across all vital-sign categories. Three to four trajectory groups per vital-sign category were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, recurring tachypnea, and low and fluctuating oxygen saturation. The IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have higher levels of C-reactive protein, lactic acid, cardiac troponin I, and D-dimer. Multivariable analysis revealed that hypothermia (adjusted odds ratio [aOR], 2.20; 95% confidence interval [95%CI], 1.35–3.57) and recurring tachypnea (aOR 2.44; 95%CI, 1.24–4.79) were independently associated with IHCA.Conclusions: We identified five novel vital-sign sub-phenotypes associated with a higher likelihood of IHCA, with distinct patterns in clinical course and laboratory markers. A better understanding of the pre-IHCA vital-sign trajectories may help with the early identification of deteriorating patients.
Highlights
In-hospital cardiac arrest (IHCA) is a major problem in the hospital and is associated with high morbidity and mortality worldwide [1]
After excluding patients aged less than 18 years or patients with out-of-hospital cardiac arrest, 325,502 adult visits were included in the analysis
Most patients arrived in the emergency department (ED) during the daytime or in the evening, and patients were evenly distributed across seasons
Summary
In-hospital cardiac arrest (IHCA) is a major problem in the hospital and is associated with high morbidity and mortality worldwide [1]. Previous studies have utilized a snapshot of vital-sign data to predict IHCA [5, 6]. Other studies have created summary measures for longitudinal vital-sign data [8], or have monitored early warning summary scores over time [9]. Information is somewhat lost in terms of the dynamic changes of each vital sign over time, which may be more intuitive and clinically useful in phenotyping and prognosticating patients with IHCA. To the best of our knowledge, no previous study has examined the latent trajectories of vital signs in patients with IHCA. Understanding the vital-sign change patterns prior to IHCA may gain lead time for appropriate interventions. Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event.
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