Prehospital Vital Signs Accurately Predict Initial Emergency Department Vital Signs

AbstractIntroduction:Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals.Hypothesis/Problem:The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well.Methods:Patients meeting criteria for highest levels of TTA at a Level I trauma center (2008-2018) were included. Those with absent or missing prehospital vital signs were excluded. Demographics, injury data, and prehospital and first ED vital signs were abstracted. Prehospital and initial ED vital signs were compared using Bland-Altman intraclass correlation coefficients (ICC) with good agreement as >0.60; fair as 0.40-0.60; and poor as <0.40).Results:After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15).Conclusion:Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.

Download Full-text

Abstract 343: Prediction of Lifesaving Interventions Using Changes in Vital Signs from Prehospital Scene to Emergency Department

Circulation ◽

10.1161/circ.130.suppl_2.343 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Jorge H Mena Munoz ◽

Ashley Petersen ◽

Francis X Guyette

Keyword(s):

Emergency Department ◽

Decision Trees ◽

Recursive Partitioning ◽

Vital Signs ◽

Large Change ◽

Predictive Performance ◽

Classification Performance ◽

Secondary Outcome ◽

Classification Error ◽

Trauma Patients

Objective: We investigate whether changes in vital signs between the prehospital scene and emergency department (ED) can be used to develop triage tools to predict the need for life-saving interventions (LSI) and survival in trauma patients. Methods: We analyzed a prospective cohort with any prehospital systolic blood pressure (SBP) ≤ 90 mmHg or Glasgow Coma Scale ≤ 8 who were admitted to an ED at 11 sites of the Resuscitation Outcomes Consortium. The primary outcome was the need for in-hospital LSI (e.g. invasive airway management, invasive bleeding control, blood transfusion, craniotomy, cardiopulmonary resuscitation). Secondary outcome was survival to hospital discharge. Changes in heart rate (HR), SBP, shock index (SI), and respiratory rate (RR) from first prehospital assessment to first ED assessment were considered as predictors in addition to sex, age, mechanism of injury, trauma center level, duration of transport, type of transport, and prehospital fluid volume. Decision trees for each outcome were developed using binary recursive partitioning with predictive performance measured using sensitivity, specificity, and classification error. Results: 5625 subjects were included in our analysis with 49% in need of LSI and 21% dying prior to discharge. Patients needing an LSI tended to either: (1) have an increasing SI (delta ≥ 0.22), (2) have a decreasing SI (delta < 0.22) and >500 mL prehospital fluids, or (3) have a decreasing SI (delta < 0.22), ≤500 mL prehospital fluids, and large change in RR (delta ≥ 9.5 or delta < -7.5). Those surviving to discharge tended to either: (1) have a decreasing SI (delta < 0.57) and a HR that did not decrease greatly (delta > -47) or (2) have an increase in SI (0.57 ≤ delta < 1) and a declining RR (delta < 5). LSI tree had a sensitivity of 58.7% and specificity of 63.3%. Survival tree had sensitivity of 96.2% and specificity of 21.3%. Conclusion: Though the decision trees were constructed with the best data in terms of initial triage and early secondary triage, the classification performance was limited. This highlights the difficulties of developing vital sign based triage tools to predict the need for LSI and survival.

Download Full-text

Delayed injuries in the emergency department in hospitalised trauma patients

Trauma ◽

10.1177/1460408619837845 ◽

2019 ◽

Vol 22 (1) ◽

pp. 64-69

Author(s):

Serhat Orun ◽

Ayhan Akoz ◽

Ali Duman ◽

Kenan Ahmet Turkdogan ◽

Mevlüt Türe ◽

...

Keyword(s):

Emergency Department ◽

Injury Rate ◽

Trauma Team ◽

Trauma Patients ◽

Missed Injuries ◽

Missed Injury ◽

Radiology Reports ◽

Hospitalised Patients ◽

Clinical Consequences ◽

Emergency Service Workers

Introduction Busy emergency departments are associated with medical errors in care and evaluation for unstable trauma patients. Our study aimed to determine the extent, causes and adverse clinical consequences of missed injuries and delayed diagnoses in patients hospitalised with trauma in a Turkish Level 3 emergency department, and provide recommendations for emergency service workers and supervisors to help them reduce the number of injury diagnoses that are delayed. Methods In our prospective study, a total of 515 emergency department patients presenting with trauma between 1 July 2014 and 1 July 2015 were examined by an emergency physician and by a consultant, if necessary. Identified injuries were recorded using case forms, and hospitalised patients were discharged when their treatment was completed. After the patients were discharged their files were reviewed again and new injuries, different from those recorded in the case forms, were investigated. Results Of the 515 patients included, it was shown that an injury diagnosis had been delayed in 21 (3.9%). Of these injuries, 65% were related to the musculoskeletal system. Insufficient clinical evaluation of 95% of the patients who had a missed injury was identified, and, in 70% of missed injuries, the radiology reports had been delayed or incorrectly completed. Conclusion We believe that the delayed injury rate can be reduced in trauma patients with the use of fast and reliable radiological support and the intervention of a multidisciplinary trauma team.

Download Full-text

Reliability and Validity of Data for 2 Newly Developed Shuttle Run Tests in Children With Cerebral Palsy

Physical Therapy ◽

10.1093/ptj/86.8.1107 ◽

2006 ◽

Vol 86 (8) ◽

pp. 1107-1117 ◽

Cited By ~ 76

Author(s):

Olaf Verschuren ◽

Tim Takken ◽

Marjolijn Ketelaar ◽

Jan Willem Gorter ◽

Paul JM Helders

Keyword(s):

Cerebral Palsy ◽

Intraclass Correlation ◽

Reliability And Validity ◽

Correlation Coefficients ◽

Treadmill Test ◽

Children With Cerebral Palsy ◽

Level I ◽

Test Retest Reliability ◽

Shuttle Run ◽

Gmfcs Level

Abstract Background and Purpose. The purpose of this study was to examine the reliability and validity of data obtained with 2 newly developed shuttle run tests (SRT-I and SRT-II) to measure aerobic power in children with cerebral palsy (CP) who were classified at level I or II on the Gross Motor Function Classification System (GMFCS). The SRT-I was developed for children at GMFCS level I, and the SRT-II was developed for children at GMFCS level II. Subjects. Twenty-five children and adolescents with CP (10 female, 15 male; mean age=11.9 years, SD=2.9), classified at GMFCS level I (n=14) or level II (n=11), participated in the study. Methods. To assess test-retest reliability of data for the 10-m shuttle run tests, the subjects performed the same test within 2 weeks. To examine validity, the shuttle run tests were compared with a GMFCS level–based treadmill test designed to measure peak oxygen uptake. Results. Statistical analyses revealed test-retest reliability for exercise time (number of levels completed) (intraclass correlation coefficients of .97 for the SRT-I and .99 for the SRT-II) and reliability for peak heart rate attained during the final level (intraclass correlation coefficients of .87 for the SRT-I and .94 for the SRT-II). High correlations were found for the relationship between data for both shuttle run tests and data for the treadmill test (r=.96 for both). Discussion and Conclusion. The results suggest that both 10-m shuttle run tests yield reliable and valid data. Moreover, the shuttle run tests have advantages over a treadmill test for children with CP who are able to walk and run (GMFCS level I or II). [Verschuren O, Takken T, Ketelaar M, et al. Reliability and validity of data for 2 newly developed shuttle run tests in children with cerebral palsy. Phys Ther. 2006;86:1107–1117.]

Download Full-text

An App to Assess Young Children’s Perceptions of Movement Competence

Journal of Motor Learning and Development ◽

10.1123/jmld.2017-0039 ◽

2018 ◽

Vol 6 (s2) ◽

pp. S252-S263 ◽

Cited By ~ 1

Author(s):

Lisa M. Barnett ◽

Owen Makin

Keyword(s):

Intraclass Correlation ◽

Correlation Coefficients ◽

Future Research ◽

Children's Perceptions ◽

Intraclass Correlation Coefficients ◽

Children’S Perceptions ◽

Digital Assessment ◽

Android App ◽

Test Retest Reliability ◽

Good Agreement

Assessing young children’s perceptions is commonly done one on one with an interviewer. An app enables several children to complete the scale at once. The objective was to describe an app to assess children’s perceptions of movement competence and then present consistency of child responses. The Pictorial Scale of Perceived Movement Skill Competence (PMSC) has fundamental movement skill (FMS; e.g., catch) and play items (e.g., cycling). The PMSC android app has the same items and images but children complete it independently with audio. Intraclass correlation coefficients (ICC) assessed i) test-retest reliability using the PMSC app on 18 items in 42 children (M = 6.8 yrs) and ii) consistency between measures for 13 FMS items in 44 children (M = 8.5 yrs). Over time (M = 6.9 days, SD = 0.35) the full PMSC had good consistency (ICC = 0.79, 95% CI 0.64–0.88) and the FMS items had moderate consistency (ICC = 0.68, 95% CI 0.47–0.81). There was good agreement between the app and interview for FMS items (ICC = 0.86, 95% CI 0.76–0.92). Locomotor items were less consistent. The PMSC app can generally be recommended. Future research could investigate how different forms of digital assessment affect children’s perception.

Download Full-text

Standing Orders for Field Intravenous Lines Do Not Shorten Prehospital Time in Trauma Patients

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00039613 ◽

1992 ◽

Vol 7 (3) ◽

pp. 271-276 ◽

Cited By ~ 4

Author(s):

Bartholomew J. Tortella ◽

Robert F. Lavery ◽

Ronald P. Cody ◽

Mindi Salant

Keyword(s):

Trauma Center ◽

Radio Telemetry ◽

Randomized Study ◽

Vital Signs ◽

Trauma Team ◽

High Volume ◽

Trauma Patients ◽

Study Objective ◽

Severity Scores ◽

Prehospital Time

AbstractStudy Objective:No randomized, prospective studies have been conducted that examine how standing orders for establishing intravenous (IV) lines in trauma patients affect prehospital time. The purpose of this randomized, prospective study was to determine if standing orders for IV lines in the field shorten prehospital time.Design:A prospective, randomized study was conducted.Setting:Trauma patients (n = 521) were randomized prospectively on an even-/odd-day basis over a one-year period from 1 April 1988 to 1 April 1989. Patients were sorted into an IV Standing Orders (SO) arm (n = 258) and a No Standing Orders (NO) arm (n = 263) in which On-Line [Direct] Medical Command (OLMC) was required before IV initiation.Participants:Trauma patients, paramedics in a high-volume, urban, EMS system, and medical-command physicians on the trauma team at a Level 1 trauma center.Results:No significant differences were found in demographics, prehospital vital signs, mechanism of injury, or trauma severity scores between the two treatment arms. Scene times were similar for the two groups (IV SO = 11.4 minutes, and NO = 10.6 minutes, p = .1675) as was IV success rate (92% vs. 88%, p = .1729).Conclusion:When compared to OLMC in this EMS system, IV standing orders did not affect scene time. This supports the concept that only spinal stabilization and airway management be performed at the scene and other ALS maneuvers (e.g., IVs) be performed in the ambulance, preferably en route to a Trauma Center. Since IV standing orders had no documented, adverse effects and led to focused, concise radio telemetry reports, this EMS system adopted their use on a permanent basis.

Download Full-text

A comparative study of designated trauma team leaders on trauma patient survival and emergency department length-of-stay

CJEM ◽

10.1017/s1481803500014871 ◽

2007 ◽

Vol 9 (02) ◽

pp. 105-110 ◽

Cited By ~ 17

Author(s):

Garnet E. Cummings ◽

Damon C. Mayes

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Injury Severity ◽

Patient Survival ◽

Negative Impact ◽

Trauma Team ◽

Regression Modeling ◽

Outcome Variable ◽

Trauma Patients ◽

Trauma Severity

ABSTRACT Objectives: There is controversy over who should serve as the Trauma Team Leader (TTL) at trauma-receiving centres. This study compared survival and emergency department (ED) length-of-stay between patients cared for by 3 different groups of TTLs: surgeons, emergency physicians (EPs) on call for trauma cases and EPs on shift in the ED. Methods: We performed a retrospective cohort study involving all adult major blunt trauma patients (aged 17 and older) who were admitted to 2 level I trauma centres and who were entered into a provincial Trauma Registry between March 2000 and April 2002. The study was designed to compare the effect of TTL-type on survival and ED length-of-stay, while controlling for sex, age, and trauma severity as defined by the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). Analysis was performed using linear regression modeling (for the ED lenght-of-stay outcome variable), and logistic regression modeling (for the surivial outcome variable). Results: There were 1412 patients enrolled in the study. The study population comprised 74% men and 26% women, with a mean age of 44.7 years (43.1, 46.6 and 42.8 years for surgeons, on-call EPs and on-shift EPs, respectively). The overall mean ISS was 23.2 (23.7 for surgeons, 22.9 for on-call EPs and 23.3 for on-shift EPs) and the overall average RTS was 7.6 (7.6 for surgeons, 7.6 for on-call EPs and 7.5 for on-shift EPs). The overall median ED length-of-stay was 5.3 hours (4.5, 5.3 and 5.6 hours for surgeons, on-call EPs and on-shift EPs, respectively; p = 0.07) and the overall survival was 87% (86% surgeon, 88% on-call EP, 87% on-shift EP; p = 0.08). No statistically significant relationship was found between TTL-type and ED length-of-stay (p = 0.42) or survival (p = 0.43) using multivariate modeling. Conclusion: Our results suggest that surgeons, on-call EPs, or on-shift EPs can act as the TTL without a negative impact on patient survival or ED length-of-stay.

Download Full-text

Mortality Risk Stratification in Elderly Trauma Patients Based on Initial Arterial Lactate and Base Deficit Levels

The American Surgeon ◽

10.1177/000313481107701014 ◽

2011 ◽

Vol 77 (10) ◽

pp. 1337-1341 ◽

Cited By ~ 20

Author(s):

Angela L. Neville ◽

Denis Nemtsev ◽

Raed Manasrah ◽

Scott D. Bricker ◽

Brant A. Putnam

Keyword(s):

Blood Pressure ◽

Risk Stratification ◽

Systolic Blood Pressure ◽

Vital Signs ◽

Base Deficit ◽

Trauma Patients ◽

Arterial Lactate ◽

Urban Level ◽

Level I ◽

Elderly Trauma Patients

Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.

Download Full-text

Using modified early warning score to predict need of lifesaving intervention in adult non-trauma patients in a tertiary state hospital

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907917751980 ◽

2018 ◽

Vol 25 (3) ◽

pp. 146-151 ◽

Cited By ~ 1

Author(s):

Leong Shian Peng ◽

Azhana Hassan ◽

Aida Bustam ◽

Muhaimin Noor Azhar ◽

Rashidi Ahmad

Keyword(s):

Emergency Department ◽

Critically Ill ◽

Early Warning ◽

Demographic Data ◽

Vital Signs ◽

Multivariate Logistic Regression Analysis ◽

Early Warning Score ◽

Trauma Patients ◽

Multivariate Logistic Regression ◽

Level Of Consciousness

Background: Modified early warning score has been validated in many uses in the emergency department. We propose that the modified early warning score performs well in predicting the need of lifesaving interventions in the emergency department, as a predictor of patients who are critically ill. Objective: The study aims to evaluate the use of modified early warning score in sorting out critically ill patients in the emergency department. Methods: The patients’ demographic data and first vital signs (blood pressure, heart rate, temperature, respiratory rate, and level of consciousness) were collected prospectively. Individual modified early warning score was calculated. The outcome was a patient received one or more lifesaving interventions toward the end of stay in emergency department. Multivariate logistic regression analysis was utilized to assess the association between modified early warning score and other potential predictors with outcome. Results: There are a total of 259 patients enrolled into the study. The optimal modified early warning score in predicting lifesaving intervention was ≥4 with a sensitivity of 95% and specificity of 81%. Modified early warning score ≥4 (odds ratio = 96.97, 95% confidence interval = 11.82–795.23, p < 0.001) was found to significantly increase the risk of receiving lifesaving intervention in the emergency department. Conclusion: Modified early warning score is found to be a good predictor for patients in need of lifesaving intervention in the emergency department.

Download Full-text

Factors Affecting Unscheduled Return Visits to the Emergency Department among Minor Head Injury Patients

BioMed Research International ◽

10.1155/2017/8963102 ◽

2017 ◽

Vol 2017 ◽

pp. 1-8

Author(s):

Kuo-Cheng Wang ◽

Chung-Hsien Chaou ◽

Peng-Huei Liu ◽

Cheng-Yu Chien ◽

Ching-Hsing Lee

Keyword(s):

Emergency Department ◽

Head Injury ◽

Demographic Data ◽

Vital Signs ◽

Minor Head Injury ◽

Discharge Instructions ◽

Factors Affecting ◽

Hospital Patients ◽

Gcs Score ◽

Triage Level

Study Objectives. Differences between returning and non-returning minor head injury (MHI) emergency department (ED) patients, between the characteristics of the first visit and revisit, and between admitted and nonadmitted returning patients were investigated. Methods. This was a retrospective study. All discharged ED patients with ICD-9 codes 850.0 to 850.9, 920, and 959.01 in 2013 were enrolled. Patients’ demographic data, vital signs, Glasgow Coma Scale, ED diagnosis, length of stay, triage levels, ED examinations performed, and comorbidities were recorded for analysis. Results. A total of 2,815 patients were enrolled. Of 57 (2%) patients who revisited the ED, 47 (82%) were discharged from the ED and ten (18%) were admitted to the hospital. Patients who returned to the ED were older, and they exhibited more comorbidities. Those who presented with vomiting, triage level of 1 or 2, and GCS score of <15 and who received more blood tests during their first visit were more likely to be admitted when they returned to the ED. Conclusions. Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and arranging timely clinical follow-ups may help reduce such patients’ return rate.

Download Full-text