The mortality of acutely ill medical patients for up to 60days after admission to a resource poor hospital in sub-Saharan Africa compared with patients of similar illness severity admitted to a Danish Regional Teaching Hospital--an exploratory observational study

A tale of two continents: The performance of six early warning scores in two emergency departments

Background:

Several early warning scores have been designed to optimize acute care by identifying patients at risk of deterioration.

Methods:

In this post hoc dual center study, we analyzed the performance of six clinical scores (the Goodacre score, Groarke, Worthing Physiological Score, Rapid Acute Physiology Score, Rapid Emergency Medicine Score, United Kingdom National Early Warning Score. The primary outcome is 30-day all-cause mortality after inclusion and data were obtained from previous studies performed at two different emergency departments on two continents (Denmark, Europe, and Hong Kong, Asia).

Results:

We included 2952 people; 1482 (50.2%) were male, mean age (standard deviation) was 65.7 (18.3) years, and 109 (3.7%) died within 30 days. Mortality rate increased steadily with increasing scores for all six scoring systems in Hong Kong while this was less obvious in Denmark. In all patients, Rapid Acute Physiology Score had the lowest discriminatory power while National Early Warning Score had the highest. National Early Warning Score performed best in Hong Kong while Worthing performed marginally better in Denmark.

Discussion:

Surprisingly, the performance of the scoring systems varied considerably, but were largely unaffected by location, and none of them performed close to what clinicians would normally require for predicting 30-day all-cause mortality

Conclusion:

All scores performed similarly across both centers, with poor prediction of 30-day all-cause mortality. Based on these findings, we believe that clinical scores must be supplemented by either biochemical values or global markers of physiological reserve to reflect reality and to be of true value.

Disposition Decision Support by Laboratory Based Outcome Prediction

Disposition is one of the main tasks in the emergency department. However, there is a lack of objective and reliable disposition criteria, and diagnosis-based risk prediction is not feasible at early time points. The aim was to derive a risk score (TRIAL) based on routinely collected baseline (TRIage level and Age) and Laboratory data—supporting disposition decisions by risk stratification based on mortality. We prospectively included consecutive patients presenting to the emergency department over 18 weeks. Data sets of routinely collected baseline (triage level and age) and laboratory data were used for multivariable logistic regression to develop the TRIAL risk score predicting mortality. Routine laboratory variables and disposition cut-offs were chosen beforehand by expert consensus. Risk stratification was based on low risk (<1%), intermediate risk (1–10%), and high risk (>10%) of in-hospital mortality. In total, 8687 data sets were analyzed. Variables identified to develop the TRIAL risk score were triage level (Emergency Severity Index), age, lactate dehydrogenase, creatinine, albumin, bilirubin, and leukocyte count. The area under the ROC curve for in-hospital mortality was 0.93. Stratification according to the TRIAL score showed that 67.5% of all patients were in the low-risk category. Mortality was 0.1% in low-risk, 3.5% in intermediate-risk, and 26.2% in high-risk patients. The TRIAL risk score based on routinely available baseline and laboratory data provides prognostic information for disposition decisions. TRIAL could be used to minimize admission in low-risk and to maximize observation in high-risk patients.

Hospitalization and post-discharge care in South Africa: A critical event in the continuum of care

OBJECTIVES

The purpose of this prospective cohort study is to characterize the event of acute hospitalization for people living with and without HIV and describe its impact on the care continuum. This study describes care-seeking behavior prior to an index hospitalization, inpatient HIV testing and diagnosis, discharge instructions, and follow-up care for patients for patients being discharged from a single hospital in South Africa.

METHODS

A convenience sample of adult patients was recruited from the medical wards of a tertiary care facility. Baseline information at the time of hospital admission, subsequent diagnoses, and discharge instructions were recorded. Participants were prospectively followed with phone calls for six months after hospital discharge. Descriptive analyses were performed.

RESULTS

A total of 293 participants were enrolled in the study. Just under half (46%) of the participants were known to be living with HIV at the time of hospital admission. Most participants (97%) were given a referral for follow-up care; often that appointment was scheduled within two weeks of discharge (64%). Only 36% of participants returned to care within the first month, 50% returned after at least one month had elapsed, and 14% of participants did not return for any follow up.

CONCLUSIONS

Large discrepancies were found between the type of post-discharge follow-up care recommended by providers and what patients were able to achieve. The period of time following hospital discharge represents a key transition in care. Additional research is needed to characterize patients' risk following hospitalization and to develop patient-centered interventions.