Unselected Admissions Research Articles

The variable relationship between the National Early Warning Score on admission to hospital, the primary discharge diagnosis, and in-hospital mortality.

Patients with an elevated admission National Early Warning Score (NEWS) are more likely to die while in hospital. However, it is not known if this increased mortality risk is the same for all diagnoses. The aim of this study was to determine and compare the increased risk of in-hospital mortality associated with an elevated NEWS and different primary discharge diagnoses in unselected emergency admissions to a UK university teaching hospital. A non-interventional observational study of 122,321 consecutive, unselected, adult patients with complete data admitted as an emergency between 2014 and 2022. The overall in-hospital mortality was 4.3%. Eighty diagnostic groupings accounted for 85.8% of all admissions and 89.4% of all in-hospital deaths. Depending on diagnostic grouping, the risk of mortality associated with an admission NEWS ≥ 3 ranged from 2.3- to 100-fold. For example, the in-hospital mortality of COPD patients increased from 1.9% for those with admission NEWS < 3 to 35.6% for those with NEWS ≥ 3, for chest pain mortality increased from 0.1 to 3.9%, and for patients with an opiate overdose from 0.2 to 7.7%. Conversely, for admission NEWS < 3, aspiration pneumonia and intracranial hemorrhage had in-hospital mortalities of 13.7% and 12.1%, respectively. There is enormous variation in the mortality risk associated with an increased admission NEWS in different commonly encountered diagnoses. Therefore, the mortality risk of some 'low risk' conditions can be dramatically increased if their admission NEWS is elevated, whereas some 'high risk' conditions are still likely to die even if their admission NEWS is low.

17 The case for more specialist geriatric wards: redesigning health systems to meet the needs of older persons

Abstract Background The National Clinical Programme for Older Persons outlines that each hospital should have a dedicated Specialist Geriatric Ward (SGW) with appropriate staffing and access to Health and Social Care Professionals. As part of a quality improvement initiative to drive the development of a new SGW, we examined what proportion of older medical admissions had care needs that would be best served in a Specialist Geriatric Ward. Methods We completed a retrospective cohort study of unselected medical admissions over a two week period in a level four hospital. We established criteria that would deem a patient suitable for admission to a specialist geriatric ward and examined the journey of patients who were or were not admitted under the care of Geriatric Medicine. Results In total over the two week period there were 307 admissions, with 144 over the age of 75 years (47%). Over half of patients had more than one bed moves during their inpatient stay. 78% were frail. 109 (75%) of patients would have been eligible for care on a specialist geriatric ward. 20% of the over 75 year olds were admitted under the care of Geriatrics. 72% of the remaining patients admitted under general medical teams would have met the criteria for care on a specialist geriatric ward. 20% of this cohort had a review by the frailty at the front door team with 23% having an inpatient geriatric medicine consult. Conclusion A significant proportion of older adults being admitted have care needs that would benefit from coordinated care on a specialist geriatric ward. Patients receive input from geriatric medicine through a variety of avenues but there is a need for increased access to specialist geriatric inpatient wards. This would improve patient access to the Right Care, in the Right Place at the Right Time.

15 Hospital at home—a potential alternative option to acute hospital admission for older adults

Abstract Background Novel ways to respond to the acute care needs of older adults are needed. Hospital at Home (H@H) could be a viable alternative to emergency hospitalisation. We developed inclusion and exclusion criteria for selected medical conditions that could theoretically be treated in a hospital at home setting if supported by a geriatric medicine multidisciplinary team with a consultant, Advanced Nurse Practitioner (ANP), Physiotherapist (PT) and Cccupational Therapist (OT). Methods We completed a retrospective cohort study of unselected medical admissions over a two week period in a level four hospital. We developed illness specific criteria for stable patients that if met could allow a patient to be treated in a hospital at home environment. These conditions included community acquired pneumonia, congestive cardiac failure, COPD exacerbation and urinary tract infection. Results There were 307 medical admissions over the study period, with 144 over the age of 75 (47%). Mean age 83.2. 59 patients met our inclusion criteria for a potential H@H service (41%). All patients were clinically stable based on admission vital signs. The mean length of stay was shorter for patients eligible for H@H than patients who did not meet the criteria (9 days vs 14 days, p 0.01), and patients meeting the H@H criteria were more likely to be discharged home directly. They were less likely to have needed occupational therapy (32% vs 52%, p = 0.02) or medical social worker input (22% vs 42%). There was no difference in frailty category or readmission rates by whether or not a patient met the H@H criteria. Conclusion Over 40% of unselected medical take patients were of a low acuity that could have theoretically met our inclusion criteria for a supported hospital at home model. Strategies are needed to support expansion of this model of care.

Emergency admissions’ diagnoses and risk of in-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission

Background: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined. Aim: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions. Method: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022. Results: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS &lt;3. Conclusion: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

1334 THE OXFORD COGNITIVE COMORBIDITY AND AGEING RESEARCH DATABASE (ORCHARD): DESCRIPTION OF A LARGE ACUTE CARE RESEARCH DATABASE

Abstract Background Guidelines recommend that all older hospital patients are screened for cognitive comorbidity (i.e. dementia, delirium) and frailty to inform care and target multidisciplinary team resources based mainly on evidence from studies in outpatient or specialty-specific settings. Unselected hospital-wide data are needed to inform guidance and service design and delivery, so we set up the Oxford Cognitive Comorbidity and Ageing Research Database (ORCHARD) using routinely-acquired electronic patient record (EPR) data. Methods ORCHARD includes pseudonymised EPR data on all patients &amp;gt;65 years with unplanned admission to one of four general hospitals in Oxfordshire, serving a population of 660,000. Data collected include cognitive screening (mandatory for &amp;gt;70 years) comprising dementia history, delirium diagnosis (Confusion Assessment Method—CAM), and 10-point Abbreviated Mental Test; together with nursing risk assessments, frailty, diagnoses, comorbidities (Charlson index), observations, illness acuity, laboratory tests and brain imaging. Outcomes include length of stay, delayed transfers of care, discharge destination, readmissions, death and dementia through linkage to electronic mental health records. Results ORCHARD (2017-2019) includes data from 90,303 consecutive, unselected hospital admissions across all specialties (n=60,535 [67%] inpatient versus n=29,768 [33%] day case; n=73,385 [81%] medical versus n=16,918 [19%] surgical or other). Admissions data were linked to 46,533 unique individuals (n=23,724 [52%] female) with a mean/SD age of 78.3/9.6, Index of Multiple Deprivation Decile of 7.5/2.3 and Charlson Comorbidity of 8.1/9.4 at first admission. Frailty was prevalent, with 15,423 (33%) scoring moderate and 2,471 (5%) high on the Hospital Frailty Risk Score. Complete cognitive screening data are available for 34,416 (67%) unique individuals ≥70 years with inpatient admission. Conclusion ORCHARD is a large and rich data resource that will enable studies on the burden and impact of cognitive and physical frailty in-hospital, with relevance to the design and delivery of clinical services, and understanding of healthcare resource use hospital-wide and by specialty.

Quick Sequential Organ Failure Assessment Score and the Modified Early Warning Score for Predicting Clinical Deterioration in General Ward Patients Regardless of Suspected Infection

BackgroundThe quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection.MethodsThe predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea.ResultsOf 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770–0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676–0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781–0.795 vs. AUC, 0.640; 95% CI, 0.625–0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760–0.773 vs. AUC, 0.716; 95% CI, 0.707–0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2.ConclusionMEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.

The effect of plasma potassium on hospital length of stay in unselected acute admissions

The effect of plasma potassium on hospital length of stay in unselected acute admissions

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

Background:Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations.Methods:The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group.Results:In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62–83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01–2.88 (14-day mortality). There also appeared to be a dose–response relationship.Conclusion:Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results.Plain Language Summary Regular Use of Immune Suppressing Drugs is Associated with Increased Risk of Death in Hospitalised Patients with COVID-19 Background: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. Methods: This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. Results: 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. Conclusion: We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.

Impact of a system-wide multicomponent intervention on administrative diagnostic coding for delirium and other cognitive frailty syndromes: observational prospective study

We determined the impact of a system-wide multicomponent intervention to improve recognition and documentation of cognitive frailty syndromes on hospital administrative coding for delirium. A multicomponent intervention including introduction of structured patient assessment including cognitive/delirium screen, regular audit/feedback and educational seminars was undertaken (2012-17). Sensitivity and specificity of administrative International Classification of Diseases, 10th revision (ICD-10) delirium codes for the gold standard of prospectively clinically diagnosed delirium were calculated in consecutive patients admitted to acute medicine over five 8-week cycles (2010-18). Among 1,281 consecutive unselected admissions to acute medicine overall (mean / standard deviation age = 70.0/19.2 years; n=615 (48.0%) male), 320 had clinical delirium diagnosis (n=220 delirium only; n=100 delirium on dementia). Sensitivity of delirium coding increased from 12.8% (95% confidence interval (CI) 5.6-26.7) in 2010 to 60.2% (95% CI 50.1-69.7; ptrend<0.0001) in 2018 while specificity remained at >99% throughout. A multicomponent intervention increased sensitivity of hospital administrative diagnostic coding for delirium almost six-fold without increasing the false positive diagnosis rate.

SUN-306 The Interaction Between Thiazide-Associated Hyponatremia and Acute Illness in Hospitalised Patients

Thiazide diuretics, widely used in the management of hypertension, are associated with a five times greater risk of hyponatremia (serum Na <135mmol/L) than in the general population. Hyponatremia in hospitalised patients warrants special consideration since it is associated with increased morbidity and mortality.The aim of this study was to describe the clinical characteristics and outcomes in acutely ill medical patients with thiazide-associated hyponatremia (TAH).We performed a retrospective, case control study examining all acute, unselected medical admissions, over a six week period, to The Royal London Hospital. Cases were defined as adults admitted to hospital with TAH (hyponatremia and a history of being prescribed thiazide diuretic pre-admission). Each case was matched by age, gender and degree of hyponatremia to a similar control - admitted with hyponatremia and no pre-admission exposure to thiazide (non-TAH). Clinical characteristics and treatment outcomes were compared between TAH and non-TAH cohorts.A total of 1,341 consecutive acute medical admissions (49.7% men) were evaluated. Hyponatremia was detected in 240 (17.9%) admissions. Median (±SD) length of stay was longer among patients with hyponatremia compared to normonatremic patients (5.0±12.4 versus 3.0±9.2 days; p=<0.0001). In-hospital mortality was higher in the hyponatremic group (8.8% versus 4.4% p=0.005). Twenty-two cases (11 men) of TAH accounted for 9.2% of patients with hyponatremia. Median age 64±14 years was similar to other patients with hyponatremia 68±20 years. The median admission serum sodium for TAH cases was 131.5 mmol/L (IQR 126.8 - 134) with a discharge serum sodium of 136.5 mmol/L (IQR 133.8 - 139.3). When compared to matched controls, patients with TAH had similar presenting symptoms - most commonly confusion, headache and dizziness. Length of stay among TAH cases was similar to controls; 5.5±5.1 versus 4.0±3.7 days; p=0.24. Mortality (10%) was the same in both groups. Thiazide was withdrawn during admission in 14 (64%) cases.In conclusion, acute, clinical outcomes for hospitalised patients with TAH are similar to those with comparable degrees of hyponatremia due to other causes.

Prevalence, indication and duration of proton pump inhibitor use in patients from unselected admissions

Proton pump inhibitors (PPIs) are inhibitors of gastric acid secretion and are among the most commonly prescribed drugs worldwide. Although they are effective for treatment and prevention of peptic ulcer disease and eradication of Helicobacter pylori , there is growing evidence of adverse effects

Gender Difference In Outcomes In Acute Medicine: Women Of Lower Socio-Economic Status Have Worse Outcomes

Background: There are data that suggest that women hospitalised for a variety of medical conditions may have worse outcomes than men; there is a paucity of literature on hospital mortality outcome by gender and Socio-Economic status (SES) for unselected admissions. Methods: Emergency medical admissions between 2002 and 2018 were examined. We assessed 30-day in-hospital mortality, by gender and SES, using logistic regression and margins statistics modelled outcomes against predictor variables. Results: There were 113,807 episodes in 58,126 patients over the period, with known SES status. There were multiple admissions per patient; only 45.4% had a single admission with the percentage of patients with 1, 2, or 3 at 18.8%, 10.4% and 6.5%, respectively. The average per patient 30-day in-hospital mortality was 11.1% (95%CI:10.6%, 11.6%) for males and 11.0% (95%CI:10.5%, 11.6%) females (p = 0.84). Males from higher, 12.2% (95%CI:10.6%, 13.8%), or lower SES small areas, 12.6% (95%CI: 12.1%, 13.1%), had equivalent 30-day mortality outcomes. Females from higher SES had significantly better outcomes compared with females from lower SES small areas- 9.4% (95% CI:8.0%, 10.8%) versus 12.7% (95%CI:12.2%,13.2%). Conclusion: 30-day in-hospital mortality adjusted for outcome predictors were similar for males and females; however, whereas the model-adjusted mortality for males was not different across SES, females of lower SES had significantly worse outcomes than those of higher SES.

Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis

ObjectiveTo examine the magnitude of the weekend effect, defined as differences in patient outcomes between weekend and weekday hospital admissions, and factors influencing it.DesignA systematic review incorporating Bayesian meta-analyses and...

Body Composition and Acquired Functional Impairment in Survivors of Pediatric Critical Illness.

To identify whether body mass and composition is associated with acquired functional impairment in PICU survivors. Retrospective dual-cohort study. Single multidisciplinary PICU. Two distinct PICU survivor cohorts: 432 unselected admissions from April 2015 to March 2016, and separately 92 patients with abdominal CT imaging at admission from January 2010 to December 2016. None. Admission body mass index and Functional Status Scale scores at admission, PICU discharge, and hospital discharge were obtained for all patients. Acquired functional impairment was defined as increase greater than or equal to 3 in Functional Status Scale from baseline. Patients were classified as having: "temporary acquired impairment" (acquired impairment at PICU discharge recovering by hospital discharge), "persistent acquired impairment" (acquired impairment at PICU discharge persisting to hospital discharge), and "no acquired impairment." CT scans were analyzed for skeletal muscle and fat area using National Institute of Health ImageJ software (Bethesda, MD). Multinomial logistic regression analyses were conducted to identify associations between body mass index, muscle and fat indices, and acquired functional impairment. High baseline body mass index was consistently predictive of persistent acquired impairment in both cohorts. In the second cohort, when body mass index was replaced with radiologic anthropometric measurements, greater skeletal muscle, and visceral adipose tissue indices were independently associated with persistent acquired impairment at hospital discharge (adjusted odds ratio, 1.29; 95% CI, 1.03-1.61; p = 0.024 and adjusted odds ratio, 1.13; 95% CI, 1.01-1.28; p = 0.042, respectively). However, this relationship was no longer significant in children with PICU stay greater than 2 days. In PICU survivors, baseline body mass and composition may play a role in the persistence of acquired functional impairment at hospital discharge. Characterization and quantification of skeletal muscle and fat deserves further study in larger cohorts of PICU children.

Intensity of medical care in internal medicine: impact on outcomes from a trend analysis over six years

In large acute medical wards treating heterogenous and complex patients, intensity of patient care should be graduated according to clinical severity. We conducted a retrospective observational study on all unselected admissions (8838) to the internal medicine ward of the Santa Chiara Hospital of Trento from 2012 to 2017. During 2012 and 2013, a standard organizational model (SMC) was in place, while an organizational model for intensity of medical care (IMC) was introduced in 2014. In SMC, patient admission was performed according to bed availability only. In IMC, patients were allocated to three different ward settings (high, medium and post-acute care) based on the stratification of clinical instability. The National Early Warning Score (NEWS) was used for the stratification, together with the clinical judgment. The implementation of the IMC model led to a decrease of mortality and urgent transfers for clinical deterioration to Intensive Care Unit and to an increase of admissions from Intensive Care Unit and from regional spoke hospitals. Redesigning delivery processes based on IMC can play a pivotal role in improving patient outcomes and bed management.

A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy.

BackgroundIn medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC).MethodsThe SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient’s admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model.ResultsWe managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01).ConclusionsRedesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances.

Independent validation of the ICU requirement score in a cohort of acutely poisoned adults

Objective: To independently validate the predictive value of the intensive care requirement score (IRS) in unselected poisoned patients.Design: Retrospective chart review.Patients and methods: Five hundred and seventeen out of 585 admissions for acute intoxications could be analyzed. Eleven were excluded for a condition already requiring intensive care unit (ICU) support at admission (e.g., preclinical intubation). A further 57 admissions were excluded due to missing data. The IRS was calculated using a point-scoring system including age, Glasgow Coma Scale, heart rate, type of intoxication, and preexisting conditions. It was then compared to a composite endpoint indicating an ICU requirement (death in hospital, vasopressors, need for ventilation). The endpoint and the point-scoring system were identical to the original publication of the score.Results and conclusion: Twenty-three out of 517 patients had a complicated clinical course as defined by meeting the endpoint definition. Twenty-one out of 23 complicated courses had a positive IRS (defined as greater or equal 6 points), as compared to 255/494 patients with an uncomplicated clinical course (p < .001, Fisher’s exact test). One patient (with a positive IRS) died. The negative predictive value of the IRS was 0.99 (95% CI: 0.97–1), the sensitivity was 0.91 and the specificity 0.48. In conclusion, the IRS is significantly linked to outcome. While a negative IRS virtually excludes the need for ICU care, a positive IRS has a positive predictive value too low to be used for risk stratification. The IRS could also be applied to unselected admissions of poisoned patients.

The derivation and validation of a simple model for predicting in-hospital mortality of acutely admitted patients to internal medicine wards.

Limited information is available about clinical predictors of in-hospital mortality in acute unselected medical admissions. Such information could assist medical decision-making.To develop a clinical model for predicting in-hospital mortality in unselected acute medical admissions and to test the impact of secondary conditions on hospital mortality.This is an analysis of the medical records of patients admitted to internal medicine wards at one university-affiliated hospital. Data obtained from the years 2013 to 2014 were used as a derivation dataset for creating a prediction model, while data from 2015 was used as a validation dataset to test the performance of the model. For each admission, a set of clinical and epidemiological variables was obtained. The main diagnosis at hospitalization was recorded, and all additional or secondary conditions that coexisted at hospital admission or that developed during hospital stay were considered secondary conditions.The derivation and validation datasets included 7268 and 7843 patients, respectively. The in-hospital mortality rate averaged 7.2%. The following variables entered the final model; age, body mass index, mean arterial pressure on admission, prior admission within 3 months, background morbidity of heart failure and active malignancy, and chronic use of statins and antiplatelet agents. The c-statistic (ROC-AUC) of the prediction model was 80.5% without adjustment for main or secondary conditions, 84.5%, with adjustment for the main diagnosis, and 89.5% with adjustment for the main diagnosis and secondary conditions. The accuracy of the predictive model reached 81% on the validation dataset.A prediction model based on clinical data with adjustment for secondary conditions exhibited a high degree of prediction accuracy. We provide a proof of concept that there is an added value for incorporating secondary conditions while predicting probabilities of in-hospital mortality. Further improvement of the model performance and validation in other cohorts are needed to aid hospitalists in predicting health outcomes.

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records

SummaryBackgroundWeekend hospital admission is associated with increased mortality, but the contributions of varying illness severity and admission time to this weekend effect remain unexplored.MethodsWe analysed unselected emergency admissions to four Oxford University National Health Service hospitals in the UK from Jan 1, 2006, to Dec 31, 2014. The primary outcome was death within 30 days of admission (in or out of hospital), analysed using Cox models measuring time from admission. The primary exposure was day of the week of admission. We adjusted for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions. Models then considered the effect of adjusting for 15 common haematology and biochemistry test results or proxies for hospital workload.Findings257 596 individuals underwent 503 938 emergency admissions. 18 313 (4·7%) patients admitted as weekday energency admissions and 6070 (5·1%) patients admitted as weekend emergency admissions died within 30 days (p<0·0001). 9347 individuals underwent 9707 emergency admissions on public holidays. 559 (5·8%) died within 30 days (p<0·0001 vs weekday). 15 routine haematology and biochemistry test results were highly prognostic for mortality. In 271 465 (53·9%) admissions with complete data, adjustment for test results explained 33% (95% CI 21 to 70) of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% (lower 95% CI 34) on Sundays, and 87% (lower 95% CI 45) on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h (pinteraction=0·04). No hospital workload measure was independently associated with mortality (all p values >0·06).InterpretationAdjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.FundingNIHR Oxford Biomedical Research Centre.

Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of a susceptibility score based on factors identified externally in pooled data for use at entry to the acute care pathway.

Backgroundrecognition of prevalent delirium and prediction of incident delirium may be difficult at first assessment. We therefore aimed to validate a pragmatic delirium susceptibility (for any, prevalent and incident delirium) score for use in front-line clinical practice in a consecutive cohort of older acute medicine patients.Methodsconsecutive patients aged ≥65 years over two 8-week periods (2010–12) were screened prospectively for delirium using the Confusion Assessment Method (CAM), and delirium was diagnosed using the DSM IV criteria. The delirium susceptibility score was the sum of weighted risk factors derived using pooled data from UK-NICE guidelines: age >80 = 2, cognitive impairment (cognitive score below cut-off/dementia) = 2, severe illness (systemic inflammatory response syndrome) = 1, infection = 1, visual impairment = 1. Score reliability was determined by the area under the receiver operating curve (AUC).Resultsamong 308 consecutive patients aged ≥65 years (mean age/SD = 81/8 years, 164 (54%) female), AUC was 0.78 (95% CI 0.71–0.84) for any delirium; 0.71 (0.64–0.79), for prevalent delirium; 0.81 (0.70–0.92), for incident delirium; odds ratios (ORs) for risk score 5–7 versus <2 were 17.9 (5.4–60.0), P < 0.0001 for any delirium, 8.1 (2.2–29.7), P = 0.002 for prevalent delirium, and 25.0 (3.0–208.9) P = 0.003 for incident delirium, with corresponding relative risks of 5.4, 4.7 and 13. Higher risk scores were associated with frailty markers, increased care needs and poor outcomes.Conclusionsthe externally derived delirium susceptibility score reliably identified prevalent and incident delirium using clinical data routinely available at initial patient assessment and might therefore aid recognition of vulnerability in acute medical admissions early in the acute care pathway.