Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool

Background Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities. Methods A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score–Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed. Results 13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M. Discussion Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

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Association between Shock Index and Emergency Department Cardiac Arrest

Emergency Medicine International ◽

10.1155/2021/9138449 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Chao-Tung Chen ◽

Pei-Ming Wang ◽

Chao-Hsin Wu ◽

Chih-Wei Wei ◽

Tai-Lin Huang

Keyword(s):

At Risk ◽

Emergency Department ◽

Cardiac Arrest ◽

Hospital Mortality ◽

Screening Tool ◽

Vital Signs ◽

Shock Index ◽

Patients At Risk ◽

Injured Patients ◽

The Relationship

Background. In the emergency department (ED), early identification of patients at risk of cardiac arrest is paramount, especially in the context of overcrowding. The shock index (SI) is defined as the ratio of heart rate to systolic blood pressure. It is a tool used for predicting the prognosis of critically ill and injured patients. In this study, we have discussed the relationship between SI and cardiac arrest in the ED. Methods. Patients who experienced cardiac arrest in the ED were classified into two groups, SI ≥ 0.9 and < 0.9, according to their triage vital signs. The association between SI ≥ 0.9 and in-hospital mortality was analyzed in five different etiologies of cardiac arrest, including hypoxia, cardiac cause, bleeding, sepsis, and other metabolic problems. Results. In total, 3,313 patients experienced cardiac arrest in the ED. Among them, 1,909 (57.6%) had a SI of ≥0.9. The incidence of SI ≥ 0.9 in the five etiologies was 43.5% (hypoxia), 58.1% (cardiac cause), 56.1% (bleeding), 58.0% (sepsis), and 65.5% (other metabolic problems). SI was associated with in-hospital mortality (adjusted odds ratio (aOR), 1.6; 95% confidence interval (CI), 1.5–1.8). The aOR (CI) in the five etiologies was 1.3 (1.1–1.6) for hypoxia, 1.8 (1.6–2.1) for cardiac cause, 1.3 (0.98–1.7) for bleeding, 1.3 (1.03–1.6) for sepsis, and 1.9 (1.5–2.1) for other metabolic problems. Conclusion. More than half of the patients who experienced cardiac arrest in the ED had a SI ≥ 0.9. The SI was also associated with in-hospital mortality after cardiac arrest in the ED. SI maybe used as a screening tool to identify patients at risk of cardiac arrest in the ED and a predictor of mortality in those experiencing cardiac arrest in the ED.

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Pain Catastrophizing, rather than Vital Signs, Associated with Pain Intensity in Patients Presenting to the Emergency Department for Pain

Pain Management Nursing ◽

10.1016/j.pmn.2016.12.001 ◽

2017 ◽

Vol 18 (2) ◽

pp. 102-109 ◽

Cited By ~ 1

Author(s):

Phoebe R. Block ◽

Beverly E. Thorn ◽

Shweta Kapoor ◽

Jessica White

Keyword(s):

Emergency Department ◽

Pain Intensity ◽

Pain Catastrophizing ◽

Vital Signs

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Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

BMJ Open ◽

10.1136/bmjopen-2020-037238 ◽

2020 ◽

Vol 10 (9) ◽

pp. e037238

Author(s):

Mineji Hayakawa ◽

Takashi Tagami ◽

Hiroaki IIjima ◽

Daisuke Kudo ◽

Kazuhiko Sekine ◽

...

Keyword(s):

Emergency Department ◽

Severe Bleeding ◽

Transfusion Strategy ◽

Ethical Guidelines ◽

Restrictive Transfusion ◽

Cluster Randomised ◽

Transfusion Requirements ◽

Injured Patients ◽

Restrictive Transfusion Strategy ◽

Rbc Transfusion

IntroductionResuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies.Methods and analysisThis is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70–90 or 100–120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician’s judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages.Ethics and disseminationThe trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses.Trial registration numberUMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

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Development and validation of an early warning tool for sepsis and decompensation in children during emergency department triage

Scientific Reports ◽

10.1038/s41598-021-87595-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Louis Ehwerhemuepha ◽

Theodore Heyming ◽

Rachel Marano ◽

Mary Jane Piroutek ◽

Antonio C. Arrieta ◽

...

Keyword(s):

Emergency Department ◽

Severe Sepsis ◽

Early Warning ◽

Characteristic Curve ◽

Vital Signs ◽

Warning System ◽

Receiver Operator Characteristic Curve ◽

Warning Signs ◽

Gradient Boosting ◽

Stochastic Gradient Boosting

AbstractThis study was designed to develop and validate an early warning system for sepsis based on a predictive model of critical decompensation. Data from the electronic medical records for 537,837 visits to a pediatric Emergency Department (ED) from March 2013 to December 2019 were collected. A multiclass stochastic gradient boosting model was built to identify early warning signs associated with death, severe sepsis, non-severe sepsis, and bacteremia. Model features included triage vital signs, previous diagnoses, medications, and healthcare utilizations within 6 months of the index ED visit. There were 483 patients who had severe sepsis and/or died, 1102 had non-severe sepsis, 1103 had positive bacteremia tests, and the remaining had none of the events. The most important predictors were age, heart rate, length of stay of previous hospitalizations, temperature, systolic blood pressure, and prior sepsis. The one-versus-all area under the receiver operator characteristic curve (AUROC) were 0.979 (0.967, 0.991), 0.990 (0.985, 0.995), 0.976 (0.972, 0.981), and 0.968 (0.962, 0.974) for death, severe sepsis, non-severe sepsis, and bacteremia without sepsis respectively. The multi-class macro average AUROC and area under the precision recall curve were 0.977 and 0.316 respectively. The study findings were used to develop an automated early warning decision tool for sepsis. Implementation of this model in pediatric EDs will allow sepsis-related critical decompensation to be predicted accurately after a few seconds of triage.

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237 The Association of Pain Scores and Vital Signs in the Emergency Department

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2011.06.266 ◽

2011 ◽

Vol 58 (4) ◽

pp. S256

Author(s):

J. Betcher ◽

K. Kutsche ◽

M. Ebadi-Tehrani ◽

C. Springsteen ◽

J. Phu ◽

...

Keyword(s):

Emergency Department ◽

Vital Signs ◽

Pain Scores

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Determinants of pyelonephritis onset in patients with obstructive urolithiasis

Urologia Journal ◽

10.1177/03915603211035244 ◽

2021 ◽

pp. 039156032110352

Author(s):

Georges Abi Tayeh ◽

Ali Safa ◽

Julien Sarkis ◽

Marwan Alkassis ◽

Nour Khalil ◽

...

Keyword(s):

Emergency Department ◽

Renal Colic ◽

Demographic Data ◽

Vital Signs ◽

Kidney Injury ◽

Stone Size ◽

Positive Urine ◽

Life Threatening ◽

Fat Stranding ◽

Obstructive Pyelonephritis

Background: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. Objective: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. Methods: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. Results: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes ( p = 0.03), elevated CRP ( p = 0.01), stone size (>5 mm) ( p = 0.03), dilatation of renal pelvis ( p = 0.01), peri-renal fat stranding ( p = 0.02), and positive nitrites on urinalysis ( p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. Conclusion: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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Trauma-Informed Care for Violently Injured Patients in the Emergency Department

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2018.10.018 ◽

2019 ◽

Vol 73 (2) ◽

pp. 193-202 ◽

Cited By ~ 12

Author(s):

Kyle R. Fischer ◽

Katherine M. Bakes ◽

Theodore J. Corbin ◽

Joel A. Fein ◽

Erica J. Harris ◽

...

Keyword(s):

Emergency Department ◽

Trauma Informed Care ◽

Trauma Informed ◽

Injured Patients

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The association between abnormal vital sign groups and undesirable patient outcomes

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907917752959 ◽

2018 ◽

Vol 25 (3) ◽

pp. 137-145

Author(s):

Marina Lee ◽

David McD Taylor ◽

Antony Ugoni

Keyword(s):

Emergency Department ◽

Confidence Interval ◽

Patient Outcomes ◽

Vital Sign ◽

Odds Ratio ◽

Medical Emergency Team ◽

Vital Signs ◽

Medical Emergency ◽

Emergency Team ◽

Abnormal Vital Sign

Introduction: To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death. Method: We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses). Results: Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8). Conclusion: Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.

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