1
|
Kristensen DT, Øvlisen AK, Jakobsen LH, Severinsen MT, Hannig LH, Starklint J, Hilsøe MH, Vallentin AP, Brabrand M, Hasselbalch HC, El Galaly TC, Roug AS. Metformin use and risk of myeloproliferative neoplasms - a Danish population-based case-control study. Blood Adv 2024:bloodadvances.2023012266. [PMID: 38758071 DOI: 10.1182/bloodadvances.2023012266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/18/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Previous studies have suggested that metformin has beneficial effects beyond its glucose-lowering properties, particularly in terms of its potential as an antineoplastic and cancer-preventive agent. In this study, we aimed to investigate the association between metformin use and the risk of myeloprolifera-tive neoplasms (MPN). We conducted a population-based case-control study utilizing Danish registers. Cases with MPN diagnosed between 2010-2018 were identified and metformin use prior to the MPN diagnosis was ascertained. We compared metformin use among cases with MPN and an age- and sex matched control group from the Danish general population to estimate age- and sex-adjusted odds ratios (ORs) and fully adjusted odds ratios (aORs) for the association between metformin use and risk of MPN. The study population included 3,816 cases and 19,080 controls. Overall, 7.0% of cases and 8.2% of controls were categorized as ever-users of metformin resulting in an OR for MPN of 0.84 (95% CI, 0.73-0.96) and an aOR of 0.70 (95% CI, 0.61-0.81). Long-term metformin use (≥5 years) was more infrequent and comprised 1.1% of cases and 2.0% of controls resulting in an OR of 0.57 (95% CI, 0.42-0.79) and an aOR of 0.45 (95% CI, 0.33-0.63). A dose-response relationship was observed when cumulative duration of treatment was analyzed, and this was consistent in stratified analyses of sex, age, and MPN subtypes. In conclusion, metformin use was associated with significantly lower odds of an MPN diagnosis, indi-cating its potential cancer-preventive effect. Due to the retrospective design, causality cannot be in-ferred.
Collapse
Affiliation(s)
| | | | | | | | - Louise Hur Hannig
- Department of Internal Medicine, Vejle Hospital, Vejle, Denmark, Vejle, Denmark
| | - Jørn Starklint
- Department of Internal Medicine, Section for Hematology, Regional Hospital West, Gødstrup, Denmark, Herning, Denmark
| | - Morten Hagemann Hilsøe
- Department of Hematology, Hospital of Southwest Jutland, Esbjerg, Denmark, Esbjerg, Denmark
| | - Anders Pommer Vallentin
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Denmark, Copenhagen, Denmark
| | | | | | | | | |
Collapse
|
2
|
Arnold I, Kuster T, Busch JM, Kellett JG, Brabrand M, Bingisser R, Nickel CH. Both acuity and long term prognosis are important Emergency Department metrics: comparison of mobility assessment with the Emergency Severity Index. Acute Med 2023; 22:120-129. [PMID: 37746680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes. DESIGN Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI. RESULTS Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality. CONCLUSION SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.
Collapse
Affiliation(s)
- I Arnold
- MD, Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - T Kuster
- MD, Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - J M Busch
- MD, Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - J G Kellett
- MD, Department of Emergency Medicine, Hospital of Southwest Jutland, Denmark
| | - M Brabrand
- MD, Department of Emergency Medicine, Odense University Hospital, Denmark
| | - R Bingisser
- MD, Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - C H Nickel
- MD, Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
3
|
Brabrand M, Brabrand M, Bogh SB, Fløjstrup M, Frederiksen H. The incidence and mortality of neutropenic fever in hematologic patients did not change during the SARS-CoV2 pandemic. Acute Med 2023; 22:201-203. [PMID: 38284635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
During the current SARS-CoV2 pandemic, fear of nosocomial infection could keep neutropenic patients from contacting the healthcare system with infection. We analyzed nationwide hospital contacts for neutropenic fever during the first seven weeks of the Danish shelter at home order. Using national registers, we extracted data on all unplanned hospital contacts due to neutropenic fever. We included 311 admissions, 13-30 per week, and found no difference between 2017-2019 and 2020. The incidence rate ratio varied between 0.68 and 1.11 with no effect on mortality. Thus, our data indicate that Danish neutropenic patients are admitted with fever, even during a pandemic.
Collapse
Affiliation(s)
- M Brabrand
- Department of Hematology, Odense University Hospital, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark. Instutute of Regional Health Research, University of Southern Denmark, Denmark. Department of Emergency Medicine, Odense University Hospital, Denmark
| | - S B Bogh
- OPEN, University of Southern Denmark, Denmark
| | - M Fløjstrup
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark. Instutute of Regional Health Research, University of Southern Denmark, Denmark
| | - H Frederiksen
- Department of Hematology, Odense University Hospital, Denmark, Institute of Clinical Research, University of Southern Denmark, Denmark
| |
Collapse
|
4
|
Kellett J, Bogh SB, Ekelund U, Brabrand M. Can the ECG be used to estimate age-related survival? QJM 2022; 115:298-303. [PMID: 33970281 DOI: 10.1093/qjmed/hcab134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/19/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are few reports of the relationship between electrocardiogram (ECG) findings and the age-related survival of acutely ill patients. AIM This study compared the 1-year survival curves of patients attending two Danish emergency departments (EDs) with normal and abnormal ECGs. Patients were divided into age groups from 20 to 90 years of age, and an abnormal ECG was defined as low QRS voltage (i.e. lead I + II <1.4 mV) or QTc interval prolongation >434 ms. METHODS A retrospective register-based observational study on 35 496 patients attending two Danish EDs, with 100% follow-up for 1 year. RESULTS ECG abnormality increases linearly with age, and between 30 and 70 years of age. Patients aged 20-29 years with ECG abnormalities are more than four times more likely to die within a year than patients of the same age with a normal ECG. An individual with an abnormal ECG has the same risk of dying within a year as an individual with a normal ECG who is 10 years older. After 70 years of age this tight relationship ends, but for younger individuals with an abnormal ECG the increase in mortality is even higher. CONCLUSION An ECG may be a simple practical estimate of age-related survival. For a patient under 70 years, an abnormal QRS voltage or a prolonged QTc interval may increase 1-year mortality to that of a patient ∼10 years older.
Collapse
Affiliation(s)
- J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S B Bogh
- Odense Patient Data Explorative Network, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - U Ekelund
- Department of Emergency and Internal Medicine, Skåne University Hospital at Lund, Lund, Sweden
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| |
Collapse
|
5
|
Hasselbalch HC, Knudsen TA, Sørensen AL, Christensen SF, Larsen MK, Bak M, El Fassi D, Cordua S, Brabrand M, Thomsen G, Stentoft J, Starklint J, Ellervik C, Wienecke T, Bruun NE, Eickhardt-Dalbøge CE, Kjær L, Skov V. [Elevated blood cell counts and vascular disease with the myeloproliferative neoplasms as model diseases]. Ugeskr Laeger 2021; 183:V03210282. [PMID: 34709157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Recent studies have shown the Philadelphia-negative myeloproliferative neoplasms (MPN) to be massively underdiagnosed and often preceded by a long pre-diagnostic phase of several years, in which many patients suffer serious vascular events. In this review, we focus on the urgent need for earlier diagnosis and treatment of MPN. Such efforts are foreseen to decrease morbidity and mortality for the individual patients and potentially reduce costs for health and social care systems.
Collapse
|
6
|
Jauslin AS, Kellett J, Brabrand M, Simon NR, Rueegg M, Twerenbold R, Osswald S, Bassetti S, Tschudin-Sutter S, Siegemund M, Rentsch K, Bingisser R, Nickel CH. D-dimer levels for Risk Stratification in Patients with Suspected COVID-19 - A Prospective Observational Study. Acute Med 2021; 20:193-203. [PMID: 34679137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Elevated D-dimer levels have been observed in COVID-19 and are of prognostic value, but have not been compared to an appropriate control group. METHODS Observational cohort study including emergency patients with suspected or confirmed COVID-19. Logistic regression defined the association of D-dimer levels, COVID-19 positivity, age, and gender with 30-day-mortality. RESULTS 953 consecutive patients (median age 58, 43% women) presented with suspected COVID-19: 12 (7.4%) patients with confirmed SARS-CoV-2-infection died, compared with 28 (3.5%) patients without SARS-CoV-2-infection. Overall, most (56%) patients had elevated D-dimer levels (≥0.5mg/l). Age (OR 1.07, CI 1.05-1.10), D-dimer levels ≥0.5mg/l (OR 2.44, CI 0.98-7.39), and COVID-19 (OR 2.79, CI 1.28-5.80) were associated with 30-day-mortality. CONCLUSION D-dimer levels are effective prognosticators in both patient groups.
Collapse
Affiliation(s)
- A S Jauslin
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - J Kellett
- MD, Department of Emergency Medicine, Hospital of South West Jutland, 6700 Esbjerg, Denmark
| | - M Brabrand
- MD, PhD, Department of Emergency Medicine, Hospital of South West Jutland, 6700 Esbjerg, Denmark
| | - N R Simon
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - M Rueegg
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - R Twerenbold
- MD, Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
| | - S Osswald
- MD, Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
| | - S Bassetti
- MD, Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - S Tschudin-Sutter
- MD, Division of Infectious Disease & Hospital Epidemiology, University Hospital Basel, 4031 Basel, Switzerland
| | - M Siegemund
- MD, Department of Intensive Care, University Hospital Basel, 4031 Basel, Switzerland
| | - K Rentsch
- PhD, Department of Laboratory Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - R Bingisser
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| | - C H Nickel
- MD, Emergency Department, University Hospital Basel, 4031 Basel, Switzerland
| |
Collapse
|
7
|
Jensen NH, Sze-Long Lo R, Hung K, Lorentzen M, Laugesen S, Posth S, Hansen S, Jensen K, Kellett J, Graham CA, Brabrand M. Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study. Acute Med 2021; 20:101-109. [PMID: 34190736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status. METHODS Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression. RESULTS 726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition. CONCLUSION Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.
Collapse
Affiliation(s)
- N H Jensen
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - R Sze-Long Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - Kkc Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - M Lorentzen
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S Laugesen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - S Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - S Hansen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - K Jensen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| |
Collapse
|
8
|
Posth S, Anteskog ET, Brabrand M. Elevated level of urea is a good predictor for 30-day all-cause mortality in acutely admitted medical patients. Acute Med 2021; 20:174-181. [PMID: 34679134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To assess the correlation between urea and mortality in acutely ill medical patients admitted to hospital. METHODS We included consecutively admitted adult patients from the medical admission unit at a regional Danish hospital. Data on mortality was extracted. The association with 30-day mortality was described using cubic splines, and discriminatory power, crude association and adjusted analyses were performed. RESULTS We included 5,894 patients, with a 30-day mortality of 5.6%. We found a dose-response relation between urea and 30-day mortality with an increase from 2.7% to 19.5% (p<0.001). CONCLUSION Elevated urea is strongly associated with 30-day all-cause mortality in acutely admitted medical patients with acceptable discrimination and good calibration.
Collapse
Affiliation(s)
- S Posth
- MD clinical associate professor, Department of Emergency Medicine, Odense University Hospital
| | - E T Anteskog
- MD, Department of Emergency Medicine, Odense University Hospital
| | - M Brabrand
- MD PhD professor, Department of Emergency Medicine, Odense University Hospital
| |
Collapse
|
9
|
Jensen RO, Lo R, Kellett JG, Graham CA, Brabrand M. Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review. Acute Med 2021; 20:131-139. [PMID: 34190740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses. METHODS Design was based on the PRISMA criteria and a systematic search of 6 databases was performed. RESULTS Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression. CONCLUSIONS Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.
Collapse
Affiliation(s)
- R O Jensen
- MD, Department of Emergency Medicine, Odense University Hospital, Denmark
| | - Rsl Lo
- MB BCh BaO, Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Department of Emergency Medicine, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, People's Republic of China
| | - J G Kellett
- MB BCh BAO (Medicine), Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - C A Graham
- MD MPH, Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Department of Emergency Medicine, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, People's Republic of China
| | - M Brabrand
- MD PhD, Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| |
Collapse
|
10
|
Brabrand M, Nissen SK, Hanson S, Fløjstrup M. Clinical thermography at extreme temperatures. Acute Med 2021; 20:236. [PMID: 34679145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Every day, emergency departments and acute medical units all over the world receive and assess thousands of patients. Most are stable, but a few require immediate stabilization. To identify these, all patients are routinely triaged and have vital signs measured. Our group has shown that thermographic images of the face can be an alternative method for identifying patients at increased risk of 30-day mortality. In our previous studies, the thermographic images were taken after the patients had been inside for at least 30 minutes. However, to identify patients at risk, the images have to be available as quickly as triage, i.e. at the door when the patient arrives. Therefore, we have performed a small study, with the aim of illustrating the effect of such heat-gradients on thermal images of the face.
Collapse
Affiliation(s)
- M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, 6700 Esbjerg, Denmark
| | | | | | | |
Collapse
|
11
|
Brabrand M, Frederiksen H. Risks of Solid and Lymphoid Malignancies in Patients with Myeloproliferative Neoplasms: Clinical Implications. Cancers (Basel) 2020; 12:cancers12103061. [PMID: 33092233 PMCID: PMC7589412 DOI: 10.3390/cancers12103061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 09/01/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 01/21/2023] Open
Abstract
Simple Summary Patients with chronic myeloproliferative neoplasms (MPNs) such as polycythemia vera and essential thrombocythemia have an elevated risk of acute leukemia. Recently, it has been recognized that the risk of solid cancers is also increased. In the past decade, several studies have compared cancer frequency in patients with MPNs with the general population. In our study, we present results sampled from 12 previous studies, totaling more than 65,000 patients with MPNs identified through large registries. Patients with MPNs were compared to the age/sex-matched general population. Our results show that risk of new cancers is 1.5–3.0-fold elevated in patients with MPNs. In particular, lymphomas and cancers of the skin, lung, kidney, and thyroid gland occur more frequently. The difference in cancer occurrence is highest in the age group 60–79 years. Our results indicate that clinical follow up of patients with MPNs should include awareness of the increased cancer risk. Abstract In the past decade, several studies have reported that patients with chronic myeloproliferative neoplasms (MPNs) have an increased risk of second solid cancer or lymphoid hematological cancer. In this qualitative review study, we present results from studies that report on these cancer risks in comparison to cancer incidences in the general population or a control group. Our literature search identified 12 such studies published in the period 2009–2018 including analysis of more than 65,000 patients. The results showed that risk of solid cancer is 1.5- to 3.0-fold elevated and the risk of lymphoid hematological cancer is 2.5- to 3.5-fold elevated in patients with MPNs compared to the general population. These elevated risks apply to all MPN subtypes. For solid cancers, particularly risks of skin cancer, lung cancer, thyroid cancer, and kidney cancer are elevated. The largest difference in cancer risk between patients with MPN and the general population is seen in patients below 80 years. Cancer prognosis is negatively affected due to cardiovascular events, thrombosis, and infections by a concurrent MPN diagnosis mainly among patients with localized cancer. Our review emphasizes that clinicians caring for patients with MPNs should be aware of the very well-documented increased risk of second non-myeloid cancers.
Collapse
Affiliation(s)
- Mette Brabrand
- Department of Haematology, Odense University Hospital, 5000 Odense, Denmark;
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Henrik Frederiksen
- Department of Haematology, Odense University Hospital, 5000 Odense, Denmark;
- Department of Clinical Epidemiology, Aarhus University Hospital, 8200 Aarhus, Denmark
- Correspondence:
| |
Collapse
|
12
|
De Bie Dekker AJR, Dijkmans JJ, Todorovac N, Hibbs R, Boe Krarup K, Bouwman AR, Barach P, Fløjstrup M, Cooksley T, Kellett J, Bindels AJGH, Korsten HHM, Brabrand M, Subbe CP. Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation. Resuscitation 2020; 157:3-12. [PMID: 33027620 DOI: 10.1016/j.resuscitation.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 02/04/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management. METHODS A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes. RESULTS 32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ2 = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication. CONCLUSIONS Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.
Collapse
Affiliation(s)
- A J R De Bie Dekker
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - J J Dijkmans
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - N Todorovac
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - R Hibbs
- Integral Business Support Ltd, Wrexham, United Kingdom
| | - K Boe Krarup
- Department of Anesthesiology, Odense University Hospital, Odense, Denmark
| | - A R Bouwman
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - P Barach
- Department of Anesthesiology and Critical care, Wayne State University School of Medicine, Detroit; Jefferson College of Population Health, PA, USA
| | - M Fløjstrup
- Institute of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - T Cooksley
- Department of Acute and Internal Medicine, The Christie Hospital, Manchester, United Kingdom
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - A J G H Bindels
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - H H M Korsten
- Department of Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark; Institute of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - C P Subbe
- Department of Acute Medicine, Ysbyty Gwynedd and Bangor University, Bangor, United Kingdom
| |
Collapse
|
13
|
Lyngholm L, Nickel CH, Kellett J, Chang S, Cooksley T, Brabrand M. Normal gait, albumin and d-dimer levels identify low risk emergency department patients: a prospective observational cohort study with 365-day 100% follow-up. QJM 2020; 113:86-92. [PMID: 31504931 DOI: 10.1093/qjmed/hcz226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/12/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND If survival could be reliably predicted many patients could be safely managed outside of hospital in an ambulatory care setting. AIM Comparison of common laboratory findings, co-morbidities, mobility and vital signs as predictors of mortality of acutely ill emergency department (ED) attendees. DESIGN Prospective observational study. METHODS Secondary analysis of 1334 consenting acutely ill patients attending a Danish ED. RESULTS 67 (5%) out of 1334 patients died within 100 days. After logistic regression seven predictors of 100 days mortality remained significant: an albumin level ≤34 gm/l, D-dimer level >0.51 mg/l, an Asadollahi score (based on admission laboratory data and age) ≥12, a platelet count <159 X 1000/ml, impaired mobility on presentation, a respiratory rate ≥30 bpm and a Charlson co-morbidity index ≥3. Only 5 of the 442 without any of these variables died within 365 days. Only one of the 517 patients with a stable independent gait and normal d-dimer and albumin levels died within 100 days, none died within 30 days of assessment and 12 died within 365 days. Of the remaining 817 patients 66 (8%) died within 100 days. CONCLUSION These findings suggest that normal gait, albumin and d-dimer levels are the most parsimonious way of identifying low risk ED patients.
Collapse
Affiliation(s)
- L Lyngholm
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - J Kellett
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - S Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
- Department of Clinical Biochemistry, Hospital of South West Jutland, Esbjerg, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| |
Collapse
|
14
|
Lindow T, Wiiala J, Lundager Forberg J, Lassen AT, Brabrand M, Platonov PG, Ekelund U. Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome. J Electrocardiol 2020; 58:165-170. [PMID: 31901697 DOI: 10.1016/j.jelectrocard.2019.12.012] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION In the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients. MATERIAL AND METHODS We included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients. RESULTS In total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20. CONCLUSIONS This study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.
Collapse
Affiliation(s)
- T Lindow
- Department of Clinical Physiology, Department of Research and Development, Växjö Central Hospital, Sweden; Clinical Physiology, Clinical Sciences, Lund University, Sweden.
| | - J Wiiala
- Emergency Medicine, Clinical Sciences, Skåne University Hospital, Lund University, Sweden
| | - J Lundager Forberg
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - A T Lassen
- Department of Emergency Medicine, Odense University, Hospital, Odense, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Odense University, Hospital, Odense, Denmark
| | - P G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - U Ekelund
- Emergency Medicine, Clinical Sciences, Skåne University Hospital, Lund University, Sweden
| |
Collapse
|
15
|
Blessing KF, Brabrand M, Graumann O, Foldrup A, Mussmann B. Can the examination time in CT and conventional x-ray be reduced in an emergency department with integrated radiology unit? A retrospective study. Acute Med 2020; 19:21-25. [PMID: 32226953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Quick radiological diagnosis is often needed in order to allow the clinicians to make a diagnosis. The purpose of this study was to measure examination time for radiology procedures before and after physical integration of a radiology unit in the ED. We retrospectively acquired data from the radiology information system and compared time from referral to end of radiological examination before and after physical integration of the radiology unit in the ED for 19,897 X-ray and 6,940 CT examinations. After integration examination time for X-ray examinations was reduced by 5 to 14 minutes (p<0.001). For CT head and chest examination time was reduced by 7 to 15 minutes (p<0.003) while examination time for CT abdomen was prolonged by 4 minutes (p=0.78).
Collapse
Affiliation(s)
- K F Blessing
- Department of Radiology Odense University Hospital
| | - M Brabrand
- Department of Emergency Medicine Odense University Hospital
| | - O Graumann
- Research and Innovation Unit of Radiology, University of Southern Denmark
| | - A Foldrup
- Department of Clinical Research University of Southern Denmark
| | - B Mussmann
- Research and Innovation Unit of Radiology, University of Southern Denmark Faculty of Health Sciences, Oslo Metropolitan University, Norway
| |
Collapse
|
16
|
Bentsen LP, Lassen AT, Titlestad IL, Brabrand M. A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study. Acute Med 2020; 19:76-82. [PMID: 32840257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND The aim of this study was to investigate 30-day mortality for COPD patients treated by ambulances in the period before and after implementation of a pre-hospital oxygen protocol. METHODS Prehospital High-flow oxygen was used from April to September 2012 and titrated oxygen from April to September 2013. Primary outcome was 30-day mortality. RESULTS 707 patients were included; 209 in the high-flow group and 498 in the titration group. Of these, 56 and 132 arrived with acute exacerbation (AE). Overall 30-day mortality was 11.5% vs. 9.4% (p=0.41), respectively. For patients with AE, it was 19.6% vs. 4.6% (p=0.001). CONCLUSION Change of treatment protocol is associated with a lower 30-day mortality for patients registered with acute exacerbation, but not for all COPD patients.
Collapse
Affiliation(s)
- L P Bentsen
- MD, Emergency Department, Odense University Hospital
| | - A T Lassen
- MD DMSc, Emergency Department, Odense University Hospital and University of Southern Denmark
| | - I L Titlestad
- MD PhD, Department of Respiratory Medicine, Odense University Hospital
| | - M Brabrand
- MD PhD, Emergency Department, Hospital of South West Jutland and Emergency Department, Odense University Hospital and University of Southern Denmark
| |
Collapse
|
17
|
Lyngholm LE, Nickel CH, Kellett J, Chang S, Cooksley T, Brabrand M. A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study. QJM 2019; 112:675-680. [PMID: 31179506 DOI: 10.1093/qjmed/hcz140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/27/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. DESIGN In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. SETTING The Hospital of South West Jutland. PATIENTS All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. MAIN RESULTS The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (≥0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02-0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. CONCLUSION Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.
Collapse
Affiliation(s)
- L E Lyngholm
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Switzerland
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
| | - S Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark
- Department of Clinical Biochemistry, Hospital of South West Jutland, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, UK
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Department of Emergency Medicine, Odense University Hospital, Denmark
| |
Collapse
|
18
|
Brabrand M, Hansen KN, Laursen CB, Larsen TS, Vestergaard H, Abildgaard N. Frequency and etiology of pulmonary hypertension in patients with myeloproliferative neoplasms. Eur J Haematol 2019; 102:227-234. [DOI: 10.1111/ejh.13197] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mette Brabrand
- Department of Haematology Odense University Hospital Odense Denmark
| | | | | | | | | | - Niels Abildgaard
- Department of Haematology Odense University Hospital Odense Denmark
| |
Collapse
|
19
|
Jensen MM, Kellett JG, Hallas P, Brabrand M. Fever increases heart rate and respiratory rate; a prospective observational study of acutely admitted medical patients. Acute Med 2019; 18:141-143. [PMID: 31536050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The relationship between increase in body temperature, heart rate, and respiratory rate has only been studied in young, healthy subjects. AIM To show the changes in heart and respiratory rate associated with fever in acutely admitted medical patients. DESIGN A prospective observational cohort study. METHODS Vital parameters from 4,493 patients were retrospectively extracted. Linear and multiple variable regression analysis was used to calculate the change in heart and temperature rate for every degree rise in temperature (i.e. ΔHR/°C and ΔRR/°C) in the entire study group and in those with low (<36.1°C), normal (36.1-38°C) and high (>38°C) body temperatures. RESULTS The ΔHR/°C and ΔRR/°C was 7.2±0.4 beats per minute (bpm) and 1.4 ±0.1 (1.2 to 1.62) breaths per minute (bpm). Adjusting for age, oxygen saturation and mean blood pressure, the results were 6.4±0.4 (5.7 to 7.1) bpm and 1.2±0.1 (1.0 to 1.4) bpm. In low, normal and high body temperature the ΔHR/°C were 2.7±1.9, 6.9±1.9 and 7.4±0.9 bpm, respectively; for ΔRR/°C the values were -0.5±0.5, 1.5±0.5 and 2.3±0.3 bpm, respectively. CONCLUSIONS We only found a modest association between fever and changes in heart rate and respiratory rate.
Collapse
Affiliation(s)
- M M Jensen
- Department of Emergency Medicine, Rigshospitalet Glostrup, Valdemar Hansens Vej 1-23, DK-2600 Glostrup, Danmark
| | - J G Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - P Hallas
- Department of Emergency Medicine, Rigshospitalet Glostrup, Valdemar Hansens Vej 1-23, DK-2600 Glostrup, Danmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| |
Collapse
|
20
|
Brabrand M, Knudsen T, Hallas J, Graham CA, Kellett J. The PARIS score can reliably predict 7-day all-cause mortality for both acute medical and surgical patients: an international validation study. QJM 2018; 111:721-725. [PMID: 30124965 DOI: 10.1093/qjmed/hcy174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We believe errors in the risk assessment of acutely ill patients occur because only vital signs without concurrent functional capacity are considered. We, therefore, developed the PARIS risk score based on blood pressure, age, respiratory rate, loss of independence and oxygen saturation. AIM Validation of the PARIS score in four independent cohorts from three countries. METHODS Retrospective cohort study of acutely ill patients admitted to hospitals in Denmark, Ireland and Uganda. Vital signs and functional capacity (registered as ability to stand or walk or get into bed unaided) was recorded upon arrival. Patients were followed up for 7 days (Denmark and Ireland) or until discharge (Uganda) and mortality recorded. The discriminatory power (ability to identify patients at increased risk) was determined using area under the receiver operating characteristics curve (AUROC) and calibration (precision) using Hosmer-Lemeshow goodness of fit test. RESULTS Out of 14 447 patients, 327 (2.3%) died within 7 days: median age was 59 (39-75) years and 7458 (51.8%) were female. Seven-day mortality increased from 0.3% with a score of 0-26.7% with a score of 5. The score's AUROC as 0.833 [95% confidence interval (95% CI) 0.811-0.856], 0.817 (95% CI 0.792-0.842) and 0.894 (95% CI 0.813-0.974) for all patients, medical patients and surgical patients, respectively. However, except for surgical patients, calibration of the score was poor. CONCLUSION The PARIS score can identify both high and low risk acutely admitted medical and surgical patients, but calibration was poor for medical patients.
Collapse
Affiliation(s)
- M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, Odense C, Denmark
| | - T Knudsen
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Department of Medicine, Hospital of South West Jutland, Finsensgade 35, Esbjerg, Denmark
| | - J Hallas
- Department of Clinical Pharmacology, Odense University Hospital, J. B. Winsløws Vej 19, 2., Odense C, Denmark
| | - C A Graham
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
- Emergency Medicine Academic Unit, Chinese University of Hong Kong, 2/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Denmark
- Centre South West Jutland, Institute of Regional Health Research, University of Southern Denmark, Finsensgade 35, Esbjerg, Denmark
| |
Collapse
|
21
|
Graversgaard Hansen T, Brandes A, Brabrand M, Ekelund U, Lundager J, Jensen H, Pottegaard A, Lassen AT. P1286Atrial fibrillation and infection among acute patients in the Emergency Department: a multicentre cohort study of prevalence and prognosis. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1286] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - A Brandes
- Odense University Hospital, Department of Cardiology, Odense, Denmark
| | - M Brabrand
- Sydvestjysk Hospital, Department of Emergency Medicine, Esbjerg, Denmark
| | - U Ekelund
- Skane University Hospital, Department of Emergency Medicine, Lund, Sweden
| | - J Lundager
- Hospital of Helsingborg, Emergency Medicine, Helsingborg, Sweden
| | - H Jensen
- Odense University Hospital, Department of Emergency Medicine, Odense, Denmark
| | - A Pottegaard
- University of Southern Denmark, Department of Clinical Pharmacology, Odense, Denmark
| | - A T Lassen
- Odense University Hospital, Department of Emergency Medicine, Odense, Denmark
| |
Collapse
|
22
|
Brabrand M, Kellett J, Opio M, Cooksley T, Nickel CH. Should impaired mobility on presentation be a vital sign? Acta Anaesthesiol Scand 2018; 62:945-952. [PMID: 29512139 DOI: 10.1111/aas.13098] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/31/2018] [Accepted: 02/10/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Vital signs are routinely used to assess acutely ill patients, but they do not detect all patients at risk of death. This retrospective multicenter cohort study compares the prediction of death by impaired mobility with age, co-morbidities, and vital sign changes. METHODS On first assessment, patients from a combined cohort of 9684 Danish and Irish patients and a separate cohort of 1010 Ugandan patients were stratified by impaired mobility on presentation (IMOP), vital sign changes assessed by the National Early Warning Score (NEWS), the Charlson Co-morbidity Index, and age. RESULTS Fourteen percent of Danish and Irish patients had IMOP compared with 42% of Ugandan patients. The odds ratios of IMOP for 7-day mortality were similar for both cohorts (i.e. 11.8, 95% CI 5.8-24.0 for Ugandan patients versus 6.7, 95% CI 5.0-9.0 for Danish and Irish patients). Univariate analysis of Ugandan patients showed that none of the parameters tested (i.e. low blood pressure, pulse, elevated respiratory rate, hypothermia, low oxygen saturation, old age, and coma) had a statistically higher odds ratio for either 7-day mortality than IMOP. Multivariate logistic regression analysis of Danish and Irish patients also showed that none of these parameters or the Charlson Co-morbidity Index had a statistically higher odds ratio than IMOP for either 7-day or 30-day mortality. CONCLUSION Immobility on presentation is a vital sign and predicts mortality for acutely ill patients independently of the traditional vital signs, age, and co-morbidities.
Collapse
Affiliation(s)
- M. Brabrand
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
- Department of Emergency Medicine; Odense University Hospital; Odense Denmark
| | - J. Kellett
- Department of Emergency Medicine; Hospital of South West Jutland; Esbjerg Denmark
| | - M. Opio
- Department of Medicine; Kitovu Hospital; Kitovu Uganda
| | - T. Cooksley
- Department of Acute Medicine; University Hospital of South Manchester; Manchester UK
| | - C. H. Nickel
- Emergency Department; University Hospital Basel; Basel Switzerland
| |
Collapse
|
23
|
Atkins TEH, Öhman MC, Cooksley T, Brabrand M. Acute medical risk scores: is MARS out of this world? QJM 2018; 111:511. [PMID: 29660075 DOI: 10.1093/qjmed/hcy085] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- T E H Atkins
- From the Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - M C Öhman
- From the Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Southmoor Road, Wythenshawe, M23 9LT, Manchester
| | - M Brabrand
- From the Department of Emergency Medicine, Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
- Department of Emergency Medicine, Odense Universitetshospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| |
Collapse
|
24
|
Abstract
BACKGROUND The Medical Admission Risk System (MARS) uses 11 physiological and laboratory data and had promising results in its derivation study for predicting 5- and 7- day mortality. AIM To perform an external independent validation of the MARS score. DESIGN An unplanned secondary cohort study. METHODS Patients admitted to the medical admission unit at The Hospital of South West Jutland were included from 2 October 2008 until 19 February 2009 and 23 February 2010 until 26 May 2010 were analysed. Validation of the MARS scores using 5- and 7- day mortality was the primary endpoint. RESULTS Patients of 5858 were included in the study. Patients of 2923 (49.9%) were women with a median age of 65 years (15-107). The MARS score had an area under the receiving operator characteristic curve of 0.858 (95% CI: 0.831-0.884) for 5-day mortality and 0.844 (0.818-0.870) for 7 day mortality with poor calibration for both outcomes. CONCLUSION The MARS score had excellent discriminatory power but poor calibration in predicting both 5- and 7-day mortality. The development of accurate combination physiological/laboratory data risk scores has the potential to improve the recognition of at risk patients.
Collapse
Affiliation(s)
- M C Öhman
- Department of Emergency Medicine, The Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - T E H Atkins
- Department of Emergency Medicine, The Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Southmoor Road, M23 9LT, Wythenshawe, Manchester
| | - M Brabrand
- Department of Emergency Medicine, The Hospital of South West Jutland, Finsensgade 35, 6700 Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark
| |
Collapse
|
25
|
Holm L, Brabrand M. The prognostic implication of the SOFA score on acutely admitted medical patients. Acute Med 2018; 17:182-187. [PMID: 30882101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To investigate the prognostic implication of the SOFA score on all acutely admitted medical patients, to see how well it could predict 30-day mortality and ICU-admission. MAIN OUTCOME MEASURES Discriminatory power was calculated as AUROC. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit. RESULTS AUROC for 30-day mortality was 0.68, (95% CI, 0.64 to 0.71) and ICU admission 0.71, (95% CI, 0.66 to 0.76). Goodness of fit for 30-day mortality and ICU admission was acceptable. CONCLUSIONS The SOFA score showed average ability to predict 30-day mortality and ICU admission with acceptable calibration. When substituting GCS with AVPU the performance of the SOFA score was unacceptable.
Collapse
Affiliation(s)
- L Holm
- MD, Department of Surgery, Vejle Hospital
| | - M Brabrand
- MD PhD clinical associate professor - University of Southern Denmark and Research Director - Department of Emergency Medicine, Hospital of South West Jutland
| |
Collapse
|
26
|
Nannan Panday RS, Subbe CP, van Galen LS, Kellett J, Brabrand M, Nickel CH, Nanayakkara PWB. Changes in vital signs post discharge as a potential target for intervention to avoid readmission. Acute Med 2018; 17:77-82. [PMID: 29882557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≤ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate. Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.
Collapse
Affiliation(s)
- R S Nannan Panday
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Amsterdam Cardiovascular Sciences, Academic Medical Center, VU University Medical Center, Amsterdam, The Netherlands
| | - C P Subbe
- Department of Acute Medicine, Ysbyty Gwynedd Hospital, Bangor, Wales, United Kingdomn, School of Medical Sciences, Bangor University, Bangor, Wales, United Kingdom
| | - L S van Galen
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark, Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - P W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
27
|
Björkbom DM, Brabrand M. Delayed onset pulmonary edema following toxic smoke inhalation; a systematic review. Acute Med 2018; 17:203-211. [PMID: 30882103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Fire smoke inhalation cause a wide range of symptoms immediately or after a relatively asymptomatic period. In this review, we will focus on delayed onset pulmonary edema (DOPE); the incidence and duration of potential delay. As the symptoms may not present immediately, seemingly healthy patients could be inadvertently be sent home. Therefore, many authors recommend observation for 6-24 hours depending on the extent of inhalation injury. METHODS A systematic literature search in Embase, Medline, and Cochrane library was performed on 14 April 2016. All studies describing smoke exposure and delayed pulmonary edema were included. Additional relevant studies were identified snowballing based on included studies. RESULTS We included seven studies, with a total of 135 patients, describing pulmonary edema. Symptoms generally developed after a relatively asymptomatic period (up to 36 hours post-injury) until mechanical ventilation was needed. However, pulmonary edema developing after 36 hours was most likely due to other factors related to burn injury (excessive intravenous fluids, de novo heart failure, infection or problems related to intubation). CONCLUSION Delayed onset pulmonary edema can develop as late as 36 hours postinjury after a relatively uneventful phase. But it would have been rare to have been completely asymptomatic before developing pulmonary edema.
Collapse
Affiliation(s)
- D M Björkbom
- Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark
| |
Collapse
|
28
|
Opio MO, Mutiibwa G, Kellett J, Brabrand M. Does how the patient feels matter? A prospective observational study of the outcome of acutely ill medical patients who feel their condition has improved on their first re-assessment after admission to hospital. QJM 2017; 110:545-549. [PMID: 28402554 DOI: 10.1093/qjmed/hcx072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although asking how a patient feels is the first enquiry most clinicians make the value of the answer has never been examined in acutely ill patients. METHODS Prospective observational study that compared the predictive value of how well acutely ill medical patients felt after admission to a resource poor sub-Saharan hospital with their mental alertness, mobility and vital signs. RESULTS In total, 403 patients were studied. Patients who felt better when re-assessed 18.0 SD 9.1 h after admission to hospital were less likely to die in hospital (OR 0.18 95% CI 0.08-0.43, P = 0.00001) and more likely to be independent of others at discharge (OR 5.64 95% CI 3.04-10.47, P = 0.00001). Feeling better was an independent predictor of in-hospital death along with vital sign changes and gait stability, and an independent predictor of independence at discharge along with vital sign changes, gait stability and female gender. CONCLUSION In this patient cohort a subjective feeling of improvement at the first re-assessment after admission to hospital is a powerful independent predictor of reduced in-hospital mortality.
Collapse
Affiliation(s)
| | | | - J Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| |
Collapse
|
29
|
van Galen LS, Cooksley T, Merten H, Brabrand M, Terwee CB, H Nickel C, Subbe CP, Kidney R, Soong J, Vaughan L, Weichert I, Kramer MHH, Nanayakkara PWB. Physician consensus on preventability and predictability of readmissions based on standard case scenarios. Neth J Med 2016; 74:434-442. [PMID: 27966437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Policy makers struggle with unplanned readmissions as a quality indicator since integrating preventability in such indicators is difficult. Most studies on the preventability of readmissions questioned physicians whether they consider a given readmission to be preventable, from which conclusions on factors predicting preventable readmissions were derived. There is no literature on the interobserver agreement of physician judgement. AIM To assess the degree of agreement among physicians regarding predictability and preventability of medical readmissions. DESIGN An online survey based on eight real-life case scenarios was distributed to European physicians. METHODS Physicians were requested to rate from the first four (index admission) scenarios whether they expected these patients to be readmitted within 30 days (the predictability). The remaining four cases, describing a readmission, were used to assess the preventability. The main outcome was the degree of agreement among physicians determined using the intra class correlation coefficient (ICC). RESULTS 526 European medical physicians completed the survey. Most physicians had internal medicine as primary specialism. The median years of clinical experience was 11. ICC for predictability of readmission was 0.67 (moderate to good) and ICC for preventability of readmission was 0.13 (poor). CONCLUSION There was moderate to good agreement among physicians on the predictability of readmissions while agreement on preventability was poor. This study indicates that assessing preventability of readmissions based solely on the judgement of physicians is far from perfect. Current literature on the preventability of readmissions and conclusions derived on the basis of physician opinion should be interpreted with caution.
Collapse
Affiliation(s)
- L S van Galen
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Henriksen DP, Havshøj U, Pedersen PB, Laursen CB, Jensen HK, Brabrand M, Lassen AT. Hospitalized acute patients with fever and severe infection have lower mortality than patients with hypo- or normothermia: a follow-up study. QJM 2016; 109:473-479. [PMID: 26961550 DOI: 10.1093/qjmed/hcw022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Severe infection is a frequent cause of admission to an acute medical unit (AMU). However, not all infected patients present with fever. The aim was to assess differences in 30-day mortality among patients hospitalized with community-acquired severe infection presenting with hypothermia, normothermia or fever. METHODS A retrospective single-center follow-up at an AMU from August 1, 2009 to August 31, 2011. Patients were included the first time they presented with severe infection within the study period. Temperature was categorized into hypothermia (<36.0ºC), normothermia (36.0ºC-38.0ºC) and fever (>38.0ºC). Severe infection was defined as a discharge diagnosis indicating infection combined with organ failure within the first 24 h after arrival. Multivariable Cox regression analysis was computed to assess the association between temperature and 30-day mortality. RESULTS A total of 2128 patients with severe infection were included. 3.0% (N = 64) were hypothermic, 57.1% (N = 1216) normothermic and 39.9% (N = 848) had fever at arrival. Crude 30-day mortality was 16.1% (N = 342, 95%CI 14.5-17.7%); 37.5% (N = 24, 95% CI 25.7-50.5%) for hypothermic patients, 18.3% (N = 223, 95%CI 16.2-20.6%) for normothermic patients and 11.2% (N = 95, 95%CI 9.2-13.5%) for patients with fever. Compared to normothermic patients, the adjusted hazard ratio of 30-day mortality among hypothermic patients was 1.62 (95%CI 1.06-2.49) and 0.74 (95%CI 0.58-0.94) among patients with fever. CONCLUSIONS Over half of the patients admitted to an AMU with severe infection were normothermic at arrival. Hypothermia was associated with an increased risk of short-term mortality, whereas patients with fever were associated with a lower risk compared to those with normothermia.
Collapse
Affiliation(s)
- D P Henriksen
- Department of Respiratory Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - U Havshøj
- Department of Emergency Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - P B Pedersen
- Department of Respiratory Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - C B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - H K Jensen
- Department of Emergency Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - M Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| | - A T Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense C DK-5000, Denmark
| |
Collapse
|
31
|
Fluitman KS, van Galen LS, Merten H, Rombach SM, Brabrand M, Cooksley T, Nickel CH, Subbe CP, Kramer MHH, Nanayakkara PWB. Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link. Eur J Intern Med 2016; 30:18-24. [PMID: 26775179 DOI: 10.1016/j.ejim.2015.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 10/18/2015] [Revised: 12/18/2015] [Accepted: 12/28/2015] [Indexed: 11/23/2022]
Abstract
IMPORTANCE Unplanned readmissions within 30days are a common phenomenon in everyday practice and lead to increasing costs. Although many studies aiming to analyze the probable causes leading to unplanned readmissions have been performed, an in depth-study analyzing the human (healthcare worker)-, organizational-, technical-, disease- and patient-related causes leading to readmission is still missing. OBJECTIVE The primary objective of this study was to identify human-, organizational-, technical-, disease- and patient-related causes which contribute to acute readmission within 30days after discharge using a Root-Cause Analysis Tool called PRISMA-medical. The secondary objective was to evaluate how many of these readmissions were deemed potentially preventable, and to assess which factors contributed to these preventable readmissions in comparison to non-preventable readmissions. DESIGN Cross-sectional retrospective record study. SETTING An academic medical center in Amsterdam, The Netherlands. PARTICIPANTS Fifty patients aged 18years and older discharged from an internal medicine department and acutely readmitted within 30days after discharge. MAIN OUTCOME MEASURES Root causes of preventable and unpreventable readmissions. RESULTS Most root causes for readmission were disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes. Half of the readmissions studied were considered to be potentially preventable. Preventable readmissions predominantly had human-related (coordination) failures. CONCLUSION AND RELEVANCE Our study suggests that improving human-related (coordinating) factors contributing to a readmission can potentially decrease the number of preventable readmissions.
Collapse
Affiliation(s)
- K S Fluitman
- Department of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - L S van Galen
- Department of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - H Merten
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - S M Rombach
- Department of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - M Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - T Cooksley
- Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK
| | - C H Nickel
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | | | - M H H Kramer
- Department of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- Department of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
| |
Collapse
|
32
|
Cooksley T, Nanayakkara PWB, Nickel CH, Subbe CP, Kellett J, Kidney R, Merten H, Van Galen L, Henriksen DP, Lassen AT, Brabrand M. Readmissions of medical patients: an external validation of two existing prediction scores. QJM 2016; 109:245-8. [PMID: 26163662 DOI: 10.1093/qjmed/hcv130] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospital readmissions are increasingly used as a quality indicator with a belief that they are a marker of poor care and have led to financial penalties in UK and USA. Risk scoring systems, such as LACE and HOSPITAL, have been proposed as tools for identifying patients at high risk of readmission but have not been validated in international populations. AIM To perform an external independent validation of the HOSPITAL and LACE scores. DESIGN An unplanned secondary cohort study. METHODS Patients admitted to the medical admission unit at the Hospital of South West Jutland (10/2008-2/2009; 2/2010-5/2010) and the Odense University Hospital (6/2009-8/2011) were analysed. Validation of the scores using 30 day readmissions as the endpoint was performed. RESULTS A total of 19 277 patients fulfilled the inclusion criteria. Median age was 67 (range 18-107) years and 8977 (46.6%) were female. The LACE score had a discriminatory power of 0.648 with poor calibration and the HOSPITAL score had a discriminatory power of 0.661 with poor calibration. The HOSPITAL score was significantly better than the LACE score for identifying patients at risk of 30 day readmission (P < 0.001). The discriminatory power of both scores decreased with increasing age. CONCLUSION Readmissions are a complex phenomenon with not only medical conditions contributing but also system, cultural and environmental factors exerting a significant influence. It is possible that the heterogeneity of the population and health care systems may prohibit the creation of a simple prediction tool that can be used internationally.
Collapse
Affiliation(s)
- T Cooksley
- From the Department of Acute Medicine, University Hospital of South Manchester, Manchester, UK,
| | | | | | | | | | - R Kidney
- St. James' Hospital, Dublin, Ireland and
| | - H Merten
- VU University Medical Center, Amsterdam, Netherlands
| | - L Van Galen
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | | |
Collapse
|
33
|
Bech C, Brabrand M, Lassen A. Prehospital transported patients: a resource for accessing prognostic risk factors. Crit Care 2015. [PMCID: PMC4470465 DOI: 10.1186/cc14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
34
|
Brabrand M. Admission to intensive care can be reliably predicted using only clinical judgment. Crit Care 2015. [PMCID: PMC4471151 DOI: 10.1186/cc14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
35
|
Hallas P, Folkestad L, Brabrand M. Level of training and experience in physicians performing interhospital transfers of adult patients in the internal medicine department. Emerg Med J 2009; 26:743-4. [DOI: 10.1136/emj.2008.066514] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|