Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study

Developing a consensus-based definition of out-of-hospital clinical deterioration: A Delphi study

BACKGROUND

Clinical deterioration is a time-critical medical emergency requiring rapid recognition and intervention. Deteriorating patients are seen across various healthcare settings, including the out-of-hospital (OOH) environment. OOH care is an evolving area of medicine where decisions are made regarding priority and timing of clinical interventions, ongoing management, and transport to appropriate care. To date, the literature lacks a standardised definition of OOH clinical deterioration.

OBJECTIVE

The objective of this study was to create a consensus-based definition of OOH clinical deterioration informed by emergency medicine health professionals.

METHODS

A Delphi study consisting three rounds was conducted electronically between June 2020 and January 2021. The expert panel consisted of 30 clinicians, including emergency physicians and paramedics.

RESULTS

A consensus-based definition of OOH clinical deterioration was identified as changes from a patient's baseline physiological status resulting in their condition worsening. These changes primarily take the form of measurable vital signs and assessable symptoms but should be evaluated in conjunction with the history of events and pertinent risk factors. Clinicians should be suspicious that a patient could deteriorate when changes occur in one or more of the following vital signs: respiratory rate, heart rate, blood pressure, Glasgow Coma Scale, oxygen saturation, electrocardiogram, and skin colour. Almost all participants (92%) indicated an early warning system would be helpful to assist timely recognition of deteriorating patients.

CONCLUSION

The creation of a consensus-based definition of OOH clinical deterioration can serve as a starting point for the development and validation of OOH-specific early warning systems. Moreover, a standardised definition allows meaningful comparisons to be made across health services and ensures consistency in future research. This study has shown recognition of OOH clinical deterioration to be a complex issue requiring further research. Improving our understanding of key factors contributing to deterioration can assist timely recognition and intervention, potentially reducing unnecessary morbidity and mortality.

Serial measurements of SIRS and SEP scores to identify unique phenotypes of sepsis

Using scoring systems in discreet microbiologic cohorts in a serial fashion to identify unique phenotypes of sepsis remains unknown. Single-center, retrospective study that screened adults who triggered the hospital's SIRS (systemic inflammatory response syndrome) based sepsis alert into culture positive (Cx +) and culture negative (Cx-) groups. Subgroups were based on the location where the SIRS alert fired. SIRS scores and a novel score called SEP were calculated at t = 0 and at 3, 6, 12, and 24 h before and after t = 0. Primary outcome was a difference in SIRS/SEP scores in Cx + or Cx- groups over time. Secondary outcomes were differences in total SIRS/SEP scores and the components constituting SIRS/SEP scores at various locations over time. The study contained 7955 patients who met inclusion criteria. Cx + and Cx- groups had increases in SIRS/SEP scores and at similar rates starting 6 hours before t = 0. Both culture groups had decreasing SIRS/SEP scores, at varying gradients compared to the change in SIRS/SEP scores seen prior to t = 0. This pattern in SIRS/SEP scores before and after t = 0 was consistent in all location subgroups. Statistically significant differences were seen in the overall SIRS/SEP scores for Cx + and Cx- groups at hours 6, 12, and 24 after t = 0, in the ED group at t = 24 h after t = 0, the floor group at t = 0 h, and in the step-down group at t = 3 h after t = 0 h. Microbiological cohorting and serial assessments may be an effective tool to identify homogenous phenotypes of sepsis.

Initiatives to detect and prevent death from perioperative deterioration

PURPOSE OF REVIEW

This study indicates that there are differences between hospitals in detection, as well as in adequate management of postsurgical complications, a phenomenon that is described as 'failure-to-rescue'.In this review, recent initiatives to reduce failure-to-rescue in the perioperative period are described.

RECENT FINDINGS

Use of cognitive aids, emergency manuals, family participation as well as remote monitoring systems are measures to reduce failure-to-rescue situations. Postoperative visit of an anaesthesiologist on the ward was not shown to improve outcome, but there is still room for improvement of postoperative care.

SUMMARY

Improving the complete emergency chain, including monitoring, recognition and response in the afferent limb, as well as diagnostic and treatment in the efferent limb, should lead to reduced failure-to-rescue situations in the perioperative period.

Missed nursing care in emergency departments: A scoping review

BACKGROUND

Patient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.

AIM

The aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.

METHOD

A scoping review following the framework suggested by Arksey and O'Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.

RESULTS

In total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.

CONCLUSION

The findings from this scoping review indicate that patients' fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.

Predicting deterioration of patients with early sepsis at the emergency department using continuous heart rate variability analysis: a model-based approach

BACKGROUND

Sepsis is a life-threatening disease with an in-hospital mortality rate of approximately 20%. Physicians at the emergency department (ED) have to estimate the risk of deterioration in the coming hours or days and decide whether the patient should be admitted to the general ward, ICU or can be discharged. Current risk stratification tools are based on measurements of vital parameters at a single timepoint. Here, we performed a time, frequency, and trend analysis on continuous electrocardiograms (ECG) at the ED to try and predict deterioration of septic patients.

METHODS

Patients were connected to a mobile bedside monitor that continuously recorded ECG waveforms from triage at the ED up to 48 h. Patients were post-hoc stratified into three groups depending on the development of organ dysfunction: no organ dysfunction, stable organ dysfunction or progressive organ dysfunction (i.e., deterioration). Patients with de novo organ dysfunction and those admitted to the ICU or died were also stratified to the group of progressive organ dysfunction. Heart rate variability (HRV) features over time were compared between the three groups.

RESULTS

In total 171 unique ED visits with suspected sepsis were included between January 2017 and December 2018. HRV features were calculated over 5-min time windows and summarized into 3-h intervals for analysis. For each interval, the mean and slope of each feature was calculated. Of all analyzed features, the average of the NN-interval, ultra-low frequency, very low frequency, low frequency and total power were different between the groups at multiple points in time.

CONCLUSIONS

We showed that continuous ECG recordings can be automatically analyzed and used to extract HRV features associated with clinical deterioration in sepsis. The predictive accuracy of our current model based on HRV features derived from the ECG only shows the potential of HRV measurements at the ED. Unlike other risk stratification tools employing multiple vital parameters this does not require manual calculation of the score and can be used on continuous data over time. Trial registration The protocol of this study is published by Quinten et al., 2017.

Preparing New Graduate Nurses for Patient Rescue: An Experimental Quantitative Study

A patient deterioration educational program was offered to new graduate nurses. Pre and post self-confidence scores were compared, and competency performance was evaluated during a simulation. The results indicate that most of the participants successfully demonstrated simulation competencies, and there was a statistically significant improvement in self-confidence scores. Based on these findings, education on identifying and managing patient deterioration that includes a simulation experience may be beneficial.

Challenges to recognising patients at risk of out-of-hospital clinical deterioration

BACKGROUND

The acute derangement of physiological function is a time-critical medical emergency requiring prompt recognition. As autonomous practitioners in resource scarce, high-risk environments, clinical deterioration can impose complex and increased clinical demands on paramedics. Early recognition is imperative to facilitating proactive responses to mitigate adverse effects. This study aimed to determine if clinicians can meet consensus regarding meaningful clinical factors for recognising to out-of-hospital (OOH) clinical deterioration risk.

METHODS

A three-round electronic Delphi study was conducted between June 2020 and January 2021. The expert panel was composed of 30 clinicians, including paramedics and emergency physicians. Participants were presented with eight clinically diverse case vignettes addressing various clinical factors related to OOH clinical deterioration.

RESULTS

Participants identified various challenges related to the recognition of OOH clinical deterioration. Although participants were able to meet consensus on most clinical factors related to deterioration, consensus was not achieved where cases had a combination of factors including: medical aetiology, subtle vital sign changes, non-specific complaints, age-extreme patients, and presence of co-morbidities.

CONCLUSIONS

This study demonstrated that clinicians face various challenges to recognising clinical deterioration in the OOH setting. Better understanding these challenging patient cohorts could assist to increase awareness and improve early recognition of OOH clinical deterioration.

Using Vital Signs to Place Acutely Ill Patients Quickly and Easily into Clinically Helpful Pathophysiologic Categories: Derivation and Validation of Eight Pathophysiologic Categories in Two Distinct Patient Populations of Acutely Ill Patients

BACKGROUND

Early warning scores reliably identify patients at risk of imminent death, but do not provide insight into what may be wrong with the patient or what to do about it.

OBJECTIVE

Our aim was to explore whether the Shock Index (SI), pulse pressure (PP), and ROX Index can place acutely ill medical patients in pathophysiologic categories that could indicate the interventions required.

METHODS

A retrospective post-hoc analysis of previously obtained and reported clinical data for 45,784 acutely ill medical patients admitted to a major regional referral Canadian hospital between 2005 and 2010 and validated on 107,546 emergency admissions to four Dutch hospitals between 2017 and 2022.

RESULTS

SI, PP, and ROX values divided patients into eight mutually exclusive physiologic categories. Mortality was highest in patient categories that included ROX Index value < 22, and a ROX Index value < 22 multiplied the risk of any other abnormality. Patients with a ROX Index value < 22, PP < 42 mm Hg, and SI > 0.7 had the highest mortality and accounted for 40% of deaths within 24 h of admission, whereas patients with a PP ≥ 42 mm Hg, SI ≤ 0.7, and ROX Index value ≥ 22 had the lowest risk of death. These results were the same in both the Canadian and Dutch patient cohorts.

CONCLUSIONS

SI, PP, and ROX Index values can place acutely ill medical patients into eight mutually exclusive pathophysiologic categories with different mortality rates. Future studies will assess the interventions needed by these categories and their value in guiding treatment and disposition decisions.

Clinical characteristics of and risk factors for secondary bloodstream infection after pneumonia among patients infected with methicillin-resistant Staphylococcus aureus

Purpose

To investigate the clinical features and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia (MP) with secondary MRSA bloodstream infections (MRSA-BSI) (termed MP-BSI) compared with MP alone and to study the incidence of MP-BSI among patients with MP.

Methods

This was a retrospective, single-center study with clinical data derived from previous medical records. The cases were divided into groups: MP alone and MP-BSI. The determination of independent risk factors for MP-BSI relied on logistic regression analysis. Additionally, the crude outcomes were compared.

Results

A total of 435 patients with MP were recruited, with 18.9% (82/435) having MP-BSI. The median age was 62 (interquartile range, 51,72) years, and 74.5% of the patients were male. Multivariate analysis revealed that immunosuppression, community-acquired MP (CA-MP), time from initial to targeted antibiotic use, high Sequential Organ Failure Assessment (SOFA) score, increased respiratory rate, and elevated γ-GT level (all p < 0.05) were independent risk factors for MP-BSI, while targeted treatment with linezolid was a protective factor. Patients with MP-BSI had a longer duration of hospitalization (median days, 27.5 vs. 19, p = 0.001), a higher 28-day mortality rate (24.4% vs. 11.0%, p = 0.001), and a higher in-hospital mortality rate (26.8% vs. 14.7%, p = 0.009) than those with MP alone.

Conclusion

Secondary MRSA-BSI among patients with MP is not rare. Immunosuppression, CA-MP, time from initial to targeted antibiotic use, high SOFA score, increased respiratory rate and elevated γ-GT level are all independent risk factors for MP-BSI; however, linezolid, as a targeted antibiotic, is a protective factor. Moreover, patients with MP may have worse clinical outcomes when they develop MRSA-BSI.

Prognostic value of serial score measurements of the national early warning score, the quick sequential organ failure assessment and the systemic inflammatory response syndrome to predict clinical outcome in early sepsis

BACKGROUND AND IMPORTANCE

Sepsis is a common and potentially lethal syndrome, and early recognition is critical to prevent deterioration. Yet, currently available scores to facilitate recognition of sepsis lack prognostic accuracy.

OBJECTIVE

To identify the optimal time-point to determine NEWS, qSOFA and SIRS for the prediction of clinical deterioration in early sepsis and to determine whether the change in these scores over time improves their prognostic accuracy.

DESIGN

Post hoc analysis of prospectively collected data.

SETTINGS AND PARTICIPANTS

This study was performed in the emergency department (ED) of a tertiary-care teaching hospital. Adult medical patients with (potential) sepsis were included.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was clinical deterioration within 72 h after admission, defined as organ failure development, the composite outcome of ICU-admission and death. Secondary outcomes were the composite of ICU-admission/death and a rise in SOFA at least 2. Scores were calculated at the ED with 30-min intervals. ROC analyses were constructed to compare the prognostic accuracy of the scores.

RESULTS

In total, 1750 patients were included, of which 360 (20.6%) deteriorated and 79 (4.5%) went to the ICU or died within 72 h. The NEWS at triage (AUC, 0.62; 95% CI, 0.59-0.65) had a higher accuracy than qSOFA (AUC, 0.60; 95% CI, 0.56-0.63) and SIRS (AUC, 0.59; 95% CI, 0.56-0.63) for predicting deterioration. The AUC of the NEWS at 1 h (0.65; 95% CI, 0.63-0.69) and 150 min after triage (0.64; 95% CI, 0.61-0.68) was higher than the AUC of the NEWS at triage. The qSOFA had the highest AUC at 90 min after triage (0.62; 95% CI, 0.58-0.65), whereas the SIRS had the highest AUC at 60 min after triage (0.60; 95% CI, 0.56-0.63); both are not significantly different from triage. The NEWS had a better accuracy to predict ICU-admission/death <72 h compared with qSOFA (AUC difference, 0.092) and SIRS (AUC difference, 0.137). No differences were found for the prediction of a rise in SOFA at least 2 within 72 h between the scores. Patients with the largest improvement in any of the scores were more prone to deteriorate.

CONCLUSION

NEWS had a higher prognostic accuracy to predict deterioration compared with SIRS and qSOFA; the highest accuracy was reached at 1 h after triage.

National Early Warning Score and New-Onset Atrial Fibrillation for Predicting In-Hospital Mortality or Transfer to the Intensive Care Unit in Emergency Department Patients with Suspected Bacterial Infections

Purpose

There are conflicting data regarding the role of the National Early Warning Score 2 (NEWS2) in predicting adverse outcomes in patients with infectious diseases. New-onset atrial fibrillation (NO-AF) has been suggested as a sepsis-defining sign of organ dysfunction. This study aimed to examine the prognostic accuracy of NEWS2 and whether NO-AF can provide prognostic information in emergency department (ED) patients with suspected bacterial infections.

Patients and Methods

Secondary analyses of data from a prospective observational cohort study of adults admitted in a 6-month period with suspected bacterial infections. We used the composite endpoint of in-hospital mortality or transfer to the intensive care unit as the primary outcome. The prognostic accuracy of NEWS2 and quick sequential organ failure assessment (qSOFA) and covariate-adjusted area under the receiver operating curves (AAUROC) were used to describe the performance of the scores. Logistic regression analysis was used to examine the association between NO-AF and the composite endpoint.

Results

A total of 2055 patients were included in this study. The composite endpoint was achieved in 198 (9.6%) patients. NO-AF was observed in 80 (3.9%) patients. The sensitivity and specificity for NEWS2 ≥5 were 70.2% (63.3–76.5) and 60.2% (57.9–62.4), respectively, and those for qSOFA ≥2 were 26.3% (20.3–33.0) and 91.0% (89.6–92.3), respectively. AAUROC for NEWS2 and qSOFA were 0.68 (0.65–0.73) and 0.63 (0.59–0.68), respectively. The adjusted odds ratio for achieving the composite endpoint in 48 patients with NO-AF who fulfilled the NEWS2 ≥5 criteria was 2.71 (1.35–5.44).

Conclusion

NEWS2 had higher sensitivity but lower specificity and better, albeit poor, discriminative ability to predict the composite endpoint compared to qSOFA. NO-AF can provide important prognostic information.

Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage

Background

One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis.

Methods

Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate.

Results

50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64–0.92] compared to 0.59 [0.41–0.73] for cardiac output (CO), 0.68 [0.49–0.80] for cardiac index (CI), and 0.63 [0.36–0.80] for heart rate (HR) for predicting hospital admission.

Conclusions

CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.

Level of vital and laboratory values on arrival, and increased risk of 7-day mortality among adult patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim of the study was to provide evidence for, at which vital and laboratory values, increased risk of 7-day mortality in acute adult patients on arrival to an emergency department (ED).

DESIGN

A population-based cohort study.

SETTING

ED at Odense University Hospital, Denmark.

PARTICIPANTS

All patients ≥18 years with a first-time contact within the study period, 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 7-day all-cause mortality.Variables were first recorded vital and laboratory values included in risk stratification scores; respiratory frequency, blood pressure, heart rate, Glasgow Coma Scale, temperature, saturation, creatinine, PaO₂, platelet count and bilirubin. The association between values and mortality was described using a restricted cubic spline. A predefined 7-day mortality of 2.5% was chosen as a relevant threshold.

RESULTS

We included 40 423 patients, 52.5% women, median age 57 (IQR 38-74) years and 7-day mortality 2.8%. Seven-day mortality of 2.5% had thresholds of respiratory frequency <12 and >18/min, systolic blood pressure <112 and >192 mm Hg, heart rate <54 and >102 beats/min, temperature <36.0°C and >39.8°C, saturation <97%, Glasgow Coma Scale score <15, creatinine <41 and >98 µmol/L for PaO₂ <9.9 and >12.3 kPa, platelet count <165 and >327×10⁹/L and bilirubin >12 µmol/L.

CONCLUSION

Vital values on arrival, outside the normal ranges for the measures, are indicative of increased risk of short-term mortality, and most of the value thresholds are included in the lowest urgency level in triage and risk stratification scoring systems.

The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise

Respiratory rate is a fundamental vital sign that is sensitive to different pathological conditions (e.g., adverse cardiac events, pneumonia, and clinical deterioration) and stressors, including emotional stress, cognitive load, heat, cold, physical effort, and exercise-induced fatigue. The sensitivity of respiratory rate to these conditions is superior compared to that of most of the other vital signs, and the abundance of suitable technological solutions measuring respiratory rate has important implications for healthcare, occupational settings, and sport. However, respiratory rate is still too often not routinely monitored in these fields of use. This review presents a multidisciplinary approach to respiratory monitoring, with the aim to improve the development and efficacy of respiratory monitoring services. We have identified thirteen monitoring goals where the use of the respiratory rate is invaluable, and for each of them we have described suitable sensors and techniques to monitor respiratory rate in specific measurement scenarios. We have also provided a physiological rationale corroborating the importance of respiratory rate monitoring and an original multidisciplinary framework for the development of respiratory monitoring services. This review is expected to advance the field of respiratory monitoring and favor synergies between different disciplines to accomplish this goal.

Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

The vital signs or laboratory test results of sepsis patients may change before clinical deterioration. This study examined the differences in prognostic performance when systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA) scores, National Early Warning Score (NEWS), and lactate levels were repeatedly measured. Scores were obtained at arrival to triage, 1 h after fluid resuscitation, 1 h after vasopressor prescription, and before leaving the emergency room (ER) in 165 patients with septic shock. The relationships between score changes and in-hospital mortality, mechanical ventilation, admission to the intensive care unit, and mortality within seven days were compared using areas under receiver operating characteristic curve (AUROCs). Scores measured before leaving the ER had the highest AUROCs across all variables (SIRS score 0.827 [0.737–0.917], qSOFA score 0.754 [0.627–0.838], NEWS 0.888 [0.826–0.950], SOFA score 0.835 [0.766–0.904], and lactate 0.872 [0.805–0.939]). When combined, SIRS + lactate (0.882 [0.804–0.960]), qSOFA + lactate (0.872 [0.808–0.935]), NEWS + lactate (0.909 [0.855–0.963]), and SOFA + lactate (0.885 [0.832–0.939]) showed improved AUROCs. In patients with septic shock, scoring systems show better predictive performances at the timepoints reflecting changes in vital signs and laboratory test results than at the time of arrival, and combining them with lactate values increases their predictive powers.

Translation of evidence into policy to improve clinical practice: the development of an emergency department rapid response system

BACKGROUND

Undetected clinical deterioration is a major cause of high mortality events in Emergency Department (ED) patients. Yet, there is no known model to guide the recognition and response to clinical deterioration in the ED, integrating internal and external resources.

METHODS

An integrative review was firstly conducted to identify the critical components of recognising and responding to clinical deterioration in the ED. Components identified from the review were analysed by clinical experts and informed the development of an ED Clinical Emergency Response System (EDCERS).

RESULTS

Twenty four eligible studies were included in the review. Eight core components were identified: 1) vital sign monitoring; 2) track and trigger system; 3) communication plan; 4) response time; 5) emergency nurse response; 6) emergency physician response; 7) critical care team response; and 8) specialty team response. These components informed the development of the EDCERS protocol, integrating responses from staff internal and external to the ED.

CONCLUSIONS

EDCERS was based on the best available evidence and considered the cultural context of care. Future research is needed to determine the useability and impact of EDCERS on patient and health outcomes.

Prognostic value of blood pressure drops during the first 24 h after hospital admission for risk stratification of community-acquired pneumonia: a retrospective cohort study

OBJECTIVES

Current risk stratification in community-acquired pneumonia (CAP) does not incorporate the dynamic nature of CAP evolution. Study aim was to evaluate the predictive value of early blood pressure (BP) drop and its consideration within the CRB-65 score.

METHODS

We performed a retrospective cohort study including consecutive adult hospitalized CAP patients 2013-2014 without documented treatment limitations or direct ICU admission. The CRB-65 score was calculated initially and re-calculated including any BP below the threshold (BP drop) within the first 24 h (CRB-65[BP24]). The primary endpoint was need for mechanical ventilation or vasopressors (MVVS) occurring after 24 h. Prognostic values were evaluated by uni- and multivariate and ROC curve analyses.

RESULTS

28/294 patients (9.5%) met the primary endpoint. Only 3 (11%) of them showed an initial BP of < 90 mmHg systolic or ≤ 60 mmHg diastolic, but 21 (75%) developed a BP drop within the first 24 h. 24/178 (13%) with and only 4/116 (3%) without any low BP during the first 24 h needed MVVS (p = 0.004). After multivariate analysis, the predictive value of BP drop was independent of other score parameters and biomarkers (all p < 0.01). In ROC analysis, the new CRB-65(BP24) showed a better prediction than the CRB-65 score (AUC 0.69 vs. 0.62, p = 0.04). 7/13 patients (54%) with MVVS despite an admission CRB-65 of 0 or 1 showed a BP drop.

CONCLUSIONS

In the evaluated cohort, BP drop within the first 24 h was significantly associated with more need for MVVS in CAP, and its consideration improved the prognostic value of the CRB-65 score.

Failure of vital sign normalization is more strongly associated than single measures with mortality and outcomes

BACKGROUND

Modified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality.

METHODS

We conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis.

RESULTS

Our analysis included 8322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96-2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23-1.44; p < 0.001). Likewise, each point of worsened MEWS was associated with increased odds of ICU admission (Triage-to-Last: OR 2.12, 95% CI 1.92-2.33 and Triage-to-Max: OR 1.52, 95% CI 1.45-1.60, respectively). Among patients with suspected infection, similar associations are found.

CONCLUSIONS

Dynamic vital signs in the emergency department, as categorized by delta MEWS, and failure to normalize abnormalities, were associated with increased mortality, ICU admission, LOS, and the diagnosis of sepsis. Our results suggest that MEWS scores that do not normalize, from triage onward, are more strongly associated with outcome than any single score.

A pilot study of respiratory rate derived from a wearable biosensor compared with capnography in emergency department patients

Purpose: Respiratory rate is assessed less frequently than other vital signs, and documented respiratory rates are often erroneous. This pilot study compared respiratory rates derived from a wearable biosensor to those derived from capnography. Methods: Emergency department patients with respiratory complaints were enrolled and had capnography via nasal cannula and a wireless, wearable biosensor from Philips applied for approximately one hour. Respiratory rates were obtained from both of these methods. We determined the difference between median respiratory rates obtained from the biosensor and capnography and the proportion of biosensor-derived respiratory rates that were within three breaths/minute of the capnography-derived respiratory rates for each patient. A Spearman correlation coefficient was calculated to assess the strength of the correlation between mean respiratory rates derived from both methods. Plots of minute-by-minute respiratory rates, per patient, for each monitoring method were shown to two physicians. The physicians identified time periods in which the respiratory rates appeared invalid. The proportion of time with invalid respiratory rates for each patient, for each method, was calculated and averaged. Results: We analyzed data for 17 patients. Median biosensor-derived respiratory rate was 20 breaths/minute (range: 7-40 breaths/minute) and median capnography-derived respiratory rate was 25 breaths/minute (range: 0-58 breaths/minute). Overall, 72.8% of biosensor-derived respiratory rates were within three breaths per minute of the capnography-derived respiratory rates. Overall mean difference was 3.5 breaths/minute (±5.2 breaths/minute). Respiratory rates appeared invalid 0.7% of the time for the biosensor and 5.0% of the time for capnography. Conclusion: Our pilot study suggests that the Philips wearable biosensor can continuously obtain respiratory rates that are comparable to capnography-derived respiratory rates among emergency department patients with respiratory complaints.