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Kraaijvanger N, Raven W, van Dijken T, Gresnigt F. The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department. Int J Emerg Med 2024; 17:30. [PMID: 38429763 PMCID: PMC10905834 DOI: 10.1186/s12245-024-00606-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Expertise in toxicology is essential for acute care providers, as intoxicated patients frequently present to Emergency Departments. These patients can be challenging for care providers because they often present with uncertain substance exposure and unknown dose and timing of these exposures. METHODS The Dutch Society of Emergency Physicians has developed an mnemonic to support treating physicians in a structured approach for the management of (undifferentiated) intoxicated patients. RESULTS The PIRATE mnemonic was developed, which includes the following aspects and sequence of care for the intoxicated patient: primary survey, investigation & identification, risk assessment, ADME (comprising pharmacokinetic therapeutic targets: absorption, distribution, metabolism, elimination), therapy and evaluation. CONCLUSION The toxicology section of the Dutch Society of Emergency Physicians developed the PIRATE mnemonic to provide a structured approach in the management of patients presenting with acute intoxications to Emergency Departments. It summarizes the essential steps and priorities required in the care of intoxicated patients. Further, it provides a common strategy for all specialties involved in the care of the acutely intoxicated patient, contributing to developing greater competence in poisoning management.
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Affiliation(s)
- Nicole Kraaijvanger
- Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands.
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands.
| | - Wouter Raven
- Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
| | - Trudy van Dijken
- Diakonessenhuis, Bosboomstraat 1, Utrecht, 3582 KE, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
| | - Femke Gresnigt
- OLVG hospital, Oosterpark 9, Amsterdam, 1091 AC, the Netherlands
- Toxicology section of Dutch Society of Emergency Physicians, Utrecht, the Netherlands
- Medical toxicology at Dutch Poison Information Center, Utrecht, the Netherlands
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Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med 2023; 51:881-891. [PMID: 36951452 PMCID: PMC10262984 DOI: 10.1097/ccm.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN International multicenter cohort study. SETTING Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
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Affiliation(s)
- Bart Gerard Jan Candel
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | | | - Mikkel Brabrand
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South-West Jutland, Esbjerg, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Raven W, de Hond A, Bouma LM, Mulder L, de Groot B. Does machine learning combined with clinical judgment outperform clinical judgment alone in predicting in-hospital mortality in old and young suspected infection emergency department patients? Eur J Emerg Med 2023; 30:205-206. [PMID: 37103898 DOI: 10.1097/mej.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
| | - Anne de Hond
- Clinical AI Implementation and Research Lab, Department of Information Technology and Digital Innovation
- Department of Information Technology and Digital Innovation
| | - Lisa-Milou Bouma
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef, RC, Leiden
| | - Leandra Mulder
- Department of Information Technology and Digital Innovation
| | - Bas de Groot
- Department of Emergency Medicine
- Department of Emergency Medicine, Radboud University Medical Centre, Geert Grooteplein-Zuid, Nijmegen, The Netherlands
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Candel BGJ, Raven W, Nissen SK, Morsink MEB, Gaakeer MI, Brabrand M, van Zwet EW, de Jonge E, de Groot B. THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY. J Emerg Med 2023:S0736-4679(23)00255-X. [PMID: 37394368 DOI: 10.1016/j.jemermed.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/25/2023] [Accepted: 04/10/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Marlies E B Morsink
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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Zwaans JJM, Raven W, Rosendaal AV, Van Lieshout EMM, Van Woerden G, Patka P, Haagsma JA, Rood PPM. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J 2022; 39:650-654. [PMID: 35882525 DOI: 10.1136/emermed-2021-211540] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/04/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with traumatic wounds frequently present to the ED. Literature on whether to treat these wounds sterile or non-sterile is sparse. Non-sterile treatment has the advantage of saving resources and costs, and could be of value in health settings where sterile materials are not readily available. Our objective was to compare the rate of wound infection after suturing traumatic lacerations with non-sterile gloves and dressings versus sterile gloves, dressings and drapes in the ED. We hypothesised that non-sterile gloves and dressings would be non-inferior to sterile gloves, dressings and drapes. The non-inferiority margin was set at 2%. METHODS A multicentre single-blinded randomised controlled trial testing for non-inferiority of non-sterile gloves and dressings versus sterile gloves, dressings and drapes for suturing of traumatic wounds was performed in 3 EDs in The Netherlands. Adults with uncomplicated wounds were included from July 2012 to December 2016. At the time of treatment, patient and wound characteristics and management were documented. The outcome was wound infection, which was identified during follow-up in the treating ED at 5-14 days postprocedure. RESULTS From 2468 eligible patients, 1480 were randomised in a sterile (n=747) or non-sterile (n=733) protocol. Baseline characteristics were similar in both study arms. The observed wound infection rate in the non-sterile group was 5.7% (95% CI 4.0% to 7.5%) vs 6.8% (95% CI 5.1% to 8.8%) in the sterile group. The mean difference of the wound infection rate of the two groups was -1.1% (95% CI -3.7% to 1.5%). CONCLUSION Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves, dressings and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED. TRIAL REGISTRATION NUMBER NL 34798.078.11, NTR3541.
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Affiliation(s)
- Juliette J M Zwaans
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Arthur V Rosendaal
- Department of Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Geesje Van Woerden
- Department of Emergency Medicine, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Juanita A Haagsma
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Pleunie P M Rood
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Candel BGJ, Raven W, Lameijer H, Thijssen WAMH, Termorshuizen F, Boerma C, de Keizer NF, de Jonge E, de Groot B. Correction: The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients. Crit Care 2022; 26:132. [PMID: 35545789 PMCID: PMC9092866 DOI: 10.1186/s13054-022-04008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Emergency Medicine, Máxima Medical Centre, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Wendy A M H Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Fabian Termorshuizen
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Candel BGJ, Raven W, Lameijer H, Thijssen WAMH, Temorshuizen F, Boerma C, de Keizer NF, de Jonge E, de Groot B. The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients. Crit Care 2022; 26:112. [PMID: 35440007 PMCID: PMC9020059 DOI: 10.1186/s13054-022-03986-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 01/20/2023] Open
Abstract
Background Treatment and the clinical course during Emergency Department (ED) stay before Intensive Care Unit (ICU) admission may affect predicted mortality risk calculated by the Acute Physiology and Chronic Health Evaluation (APACHE)-IV, causing lead-time bias. As a result, comparing standardized mortality ratios (SMRs) among hospitals may be difficult if they differ in the location where initial stabilization takes place. The aim of this study was to assess to what extent predicted mortality risk would be affected if the APACHE-IV score was recalculated with the initial physiological variables from the ED. Secondly, to evaluate whether ED Length of Stay (LOS) was associated with a change (delta) in these APACHE-IV scores. Methods An observational multicenter cohort study including ICU patients admitted from the ED. Data from two Dutch quality registries were linked: the Netherlands Emergency department Evaluation Database (NEED) and the National Intensive Care Evaluation (NICE) registry. The ICU APACHE-IV, predicted mortality, and SMR based on data of the first 24 h of ICU admission were compared with an ED APACHE-IV model, using the most deviating physiological variables from the ED or ICU. Results A total of 1398 patients were included. The predicted mortality from the ICU APACHE-IV (median 0.10; IQR 0.03–0.30) was significantly lower compared to the ED APACHE-IV model (median 0.13; 0.04–0.36; p < 0.01). The SMR changed from 0.63 (95%CI 0.54–0.72) to 0.55 (95%CI 0.47–0.63) based on ED APACHE-IV. Predicted mortality risk changed more than 5% in 321 (23.2%) patients by using the ED APACHE-IV. ED LOS > 3.9 h was associated with a slight increase in delta APACHE-IV of 1.6 (95% CI 0.4–2.8) compared to ED LOS < 1.7 h. Conclusion Predicted mortality risks and SMRs calculated by the APACHE IV scores are not directly comparable in patients admitted from the ED if hospitals differ in their policy to stabilize patients in the ED before ICU admission. Future research should focus on developing models to adjust for these differences. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03986-2.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Emergency Medicine, Máxima Medical Centre, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Wendy A M H Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Fabian Temorshuizen
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Raven W, van den Hoven EMP, Gaakeer MI, Ter Avest E, Sir O, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, Nickel CH, de Groot B. The association between presenting complaints and clinical outcomes in emergency department patients of different age categories. Eur J Emerg Med 2022; 29:33-41. [PMID: 34406137 DOI: 10.1097/mej.0000000000000860] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND IMPORTANCE Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent. OBJECTIVE To assess the frequency and association of PCs with hospitalization and mortality across age categories. METHODS An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs). RESULTS We included 172 104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)]. CONCLUSIONS Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality.
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Affiliation(s)
- Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
| | | | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Centre Groningen, Groningen
| | - Ozcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden
| | | | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
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Candel BG, Dap S, Raven W, Lameijer H, Gaakeer MI, de Jonge E, de Groot B. Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study. Eur J Intern Med 2022; 95:74-79. [PMID: 34521584 DOI: 10.1016/j.ejim.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). METHODS Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. RESULTS Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. CONCLUSIONS Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.
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Affiliation(s)
- Bart Gj Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands; Department of Emergency Medicine, Máxima Medical Center, De Run 4600, Veldhoven, DB 5504, the Netherlands.
| | - Saimi Dap
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, AD 8934, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Adrz Hospital, 's-Gravenpolderseweg 114, Goes, RA 4462, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
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Candel BGJ, van Ingen IB, van Doormalen IPH, Raven W, Mignot-Evers LAA, de Jonge E, de Groot B. The difference between the patients' initial and previously measured systolic blood pressure as predictor of mortality in older emergency department patients. Eur Geriatr Med 2021; 13:359-365. [PMID: 34826112 DOI: 10.1007/s41999-021-00588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess how often baseline systolic blood pressure (SBP) could be retrieved from the Electronic Health Record (EHR) in older Emergency Department (ED) patients. Second, to assess whether the difference between baseline SBP and initial SBP in the ED (ΔSBP) was associated with 30-day mortality. METHODS A multicenter hypothesis-generating cohort study including patients ≥ 70 years. EHRs were searched for baseline SBPs. The association between ΔSBP and 30-day mortality was investigated. RESULTS Baseline SBP was found in 220 out of 300 patients (73.3%; 95%CI 68.1-78.0%). In 72 patients with normal initial SBPs (133-166 mmHg) in the ED, fifteen (20.8%) had a negative ΔSBP with 20.0% mortality. A negative ΔSBP was associated with 30-day mortality (AHR 4.7; 1.7-12.7). CONCLUSION Baseline SBPs are often available in older ED patients. The ΔSBP has prognostic value and could be used as an extra variable to recognize hypotension in older ED patients. Future studies should clarify whether the ΔSBP improves risk stratification in the ED.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands. .,Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - Iris B van Ingen
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris P H van Doormalen
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisette A A Mignot-Evers
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands.,Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
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De Hond A, Raven W, Kant I, Schinkelshoek L, Steyerberg E, De Groot B. Prediction of hospital admission from the emergency department: Clinician involvement, intended use, and interpretability. Int J Med Inform 2021; 155:104585. [PMID: 34601239 DOI: 10.1016/j.ijmedinf.2021.104585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Anne De Hond
- Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands; Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Ilse Kant
- Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands; Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Laurens Schinkelshoek
- Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands; Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Bas De Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
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De Hond A, Raven W, Schinkelshoek L, Gaakeer M, Ter Avest E, Sir O, Lameijer H, Hessels RA, Reijnen R, De Jonge E, Steyerberg E, Nickel CH, De Groot B. Machine learning for developing a prediction model of hospital admission of emergency department patients: Hype or hope? Int J Med Inform 2021; 152:104496. [PMID: 34020171 DOI: 10.1016/j.ijmedinf.2021.104496] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Early identification of emergency department (ED) patients who need hospitalization is essential for quality of care and patient safety. We aimed to compare machine learning (ML) models predicting the hospitalization of ED patients and conventional regression techniques at three points in time after ED registration. METHODS We analyzed consecutive ED patients of three hospitals using the Netherlands Emergency Department Evaluation Database (NEED). We developed prediction models for hospitalization using an increasing number of data available at triage, ∼30 min (including vital signs) and ∼2 h (including laboratory tests) after ED registration, using ML (random forest, gradient boosted decision trees, deep neural networks) and multivariable logistic regression analysis (including spline transformations for continuous predictors). Demographics, urgency, presenting complaints, disease severity and proxies for comorbidity, and complexity were used as covariates. We compared the performance using the area under the ROC curve in independent validation sets from each hospital. RESULTS We included 172,104 ED patients of whom 66,782 (39 %) were hospitalized. The AUC of the multivariable logistic regression model was 0.82 (0.78-0.86) at triage, 0.84 (0.81-0.86) at ∼30 min and 0.83 (0.75-0.92) after ∼2 h. The best performing ML model over time was the gradient boosted decision trees model with an AUC of 0.84 (0.77-0.88) at triage, 0.86 (0.82-0.89) at ∼30 min and 0.86 (0.74-0.93) after ∼2 h. CONCLUSIONS Our study showed that machine learning models had an excellent but similar predictive performance as the logistic regression model for predicting hospital admission. In comparison to the 30-min model, the 2-h model did not show a performance improvement. After further validation, these prediction models could support management decisions by real-time feedback to medical personal.
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Affiliation(s)
- Anne De Hond
- Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands; Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Laurens Schinkelshoek
- Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands; Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Menno Gaakeer
- Department of Emergency Medicine, Adrz Hospital, 's-Gravenpolderseweg 114, 4462 RA, Goes, the Netherlands
| | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Centre Groningen, Hanzeplein1, 9713 GZ, Groningen, the Netherlands
| | - Ozcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Houtlaan 4, 6525 XZ, Nijmegen, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, the Netherlands
| | - Roger Apa Hessels
- Department of Emergency Medicine, Elisabeth-TweeSteden Hospital, Doctor Deelenlaan 5, 5042 AD, Tilburg, the Netherlands
| | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Centre, Lijnbaan 32, 2512 VA, The Hague, the Netherlands
| | - Evert De Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Bas De Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, the Netherlands
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Keshtgar MRS, Chicken DW, Waddington WA, Raven W, Ell PJ. A training simulator for sentinel node biopsy in breast cancer: a new standard. Eur J Surg Oncol 2005; 31:134-40. [PMID: 15698728 DOI: 10.1016/j.ejso.2004.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2004] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Sentinel node biopsy is becoming the staging investigation of choice for early breast cancer. Optimal identification of the sentinel node requires the utilization of a radionuclide in combination with blue dye. Gamma probe guided surgery is a skill that is currently unfamiliar to many surgeons. Appropriate training within the surgical skills laboratory could play a major role in the widespread implementation of this technique, but no suitable model currently exists for this purpose. AIM To develop a realistic phantom for the teaching and practice of the core new skills required of a surgeon to perform gamma probe guided sentinel node biopsy in breast cancer. METHODS We describe the development of our sentinel node biopsy simulator which consists of a torso with its arm extended in an operating position. The replaceable breast and axilla are constructed from a thermoplastic elastomer gel, which has similar physical and radiation attenuation properties to that of human tissue. Radionuclide injection sites and radioactive sentinel nodes are simulated by hollow blue coloured PVC beads filled with Technetium-99m. The model allows demonstration and practice of injection techniques, imaging techniques and gamma probe guided removal of sentinel nodes. CONCLUSION We believe that training for sentinel node biopsy should begin in the surgical skills laboratory. The model we have developed is able to provide an accurate simulation of all new practical skills required for accurate sentinel node identification. It is an important aid to training in the sentinel lymph node biopsy procedure for breast carcinoma.
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Affiliation(s)
- M R S Keshtgar
- Academic Department of Surgery, University College London, 67-73 Riding House Street, London W1W 7EJ, UK.
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McFarland JT, Lee MY, Reinsch J, Raven W. Reactions of beta-(2-furyl)propionyl coenzyme A with "general" fatty acyl-CpA dehydrogenase. Biochemistry 1982; 21:1224-9. [PMID: 7074078 DOI: 10.1021/bi00535a018] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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