In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

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NT-ProBNP Predicts Total Mortality, Emergency Department Visits, Hospitalization, Intensive-Care Unit Admission, and Cardiovascular Events in Hemodialysis Patients

Journal of Clinical Medicine ◽

10.3390/jcm8020238 ◽

2019 ◽

Vol 8 (2) ◽

pp. 238

Author(s):

Yi-Hsin Chen ◽

Yun-Ching Fu ◽

Ming-Ju Wu

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Cardiovascular Events ◽

Predictive Ability ◽

Hemodialysis Patients ◽

Emergency Department Visits ◽

Time Dependent ◽

Icu Admission ◽

Ed Visits

N-terminal pro b-type natriuretic peptide (NT-proBNP) was considered a prognostic factor for mortality in hemodialysis patients in previous studies. However, NT-proBNP has not been fully explored in terms of predicting other clinical outcomes in hemodialysis patients. This study aimed to investigate if NT-proBNP could predict emergency department (ED) visits, hospitalization, admission to intensive-care unit (ICU), and cardiovascular incidents in hemodialysis patients. Serum NT-proBNP and other indicators were collected in 232 hemodialysis patients. Patients were followed up for three years or until mortality. Outcomes included mortality, number of ED visits, hospitalizations, admissions to ICU, and cardiovascular events. NT-proBNP was found to predict recurrent ER visits, hospitalization, admission to ICU, cardiovascular events, and mortality, after adjusting for covariates. Time-dependent area under the curve (AUC) was used to evaluate the NT-proBNP predicting ability. Using time-dependent AUC, NT-proBNP has good predictive ability for mortality, ED visit, hospitalization, ICU admission, and cardiovascular events with the best predictive ability occurring at approximately 1 year, and 5th, 62nd, 63rd, and 63rd days respectively. AUC values for predicting mortality, hospitalization, and ICU admission decreased significantly after one year. NT-proBNP can be applied in predicting ED visits but is only suitable for the short-term. NT-proBNP may be used for predicting mortality in the long term.

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COVID outcome prediction in the emergency department (COPE): using retrospective Dutch hospital data to develop simple and valid models for predicting mortality and need for intensive care unit admission in patients who present at the emergency department with suspected COVID-19

BMJ Open ◽

10.1136/bmjopen-2021-051468 ◽

2021 ◽

Vol 11 (9) ◽

pp. e051468

Author(s):

David van Klaveren ◽

Alexandros Rekkas ◽

Jelmer Alsma ◽

Rob J C G Verdonschot ◽

Dick T J J Koning ◽

...

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Outcome Prediction ◽

Characteristic Curve ◽

Hospital Death ◽

Hospital Data ◽

Dutch Hospital ◽

Icu Admission ◽

Second Wave

ObjectivesDevelop simple and valid models for predicting mortality and need for intensive care unit (ICU) admission in patients who present at the emergency department (ED) with suspected COVID-19.DesignRetrospective.SettingSecondary care in four large Dutch hospitals.ParticipantsPatients who presented at the ED and were admitted to hospital with suspected COVID-19. We used 5831 first-wave patients who presented between March and August 2020 for model development and 3252 second-wave patients who presented between September and December 2020 for model validation.Outcome measuresWe developed separate logistic regression models for in-hospital death and for need for ICU admission, both within 28 days after hospital admission. Based on prior literature, we considered quickly and objectively obtainable patient characteristics, vital parameters and blood test values as predictors. We assessed model performance by the area under the receiver operating characteristic curve (AUC) and by calibration plots.ResultsOf 5831 first-wave patients, 629 (10.8%) died within 28 days after admission. ICU admission was fully recorded for 2633 first-wave patients in 2 hospitals, with 214 (8.1%) ICU admissions within 28 days. A simple model—COVID outcome prediction in the emergency department (COPE)—with age, respiratory rate, C reactive protein, lactate dehydrogenase, albumin and urea captured most of the ability to predict death. COPE was well calibrated and showed good discrimination for mortality in second-wave patients (AUC in four hospitals: 0.82 (95% CI 0.78 to 0.86); 0.82 (95% CI 0.74 to 0.90); 0.79 (95% CI 0.70 to 0.88); 0.83 (95% CI 0.79 to 0.86)). COPE was also able to identify patients at high risk of needing ICU admission in second-wave patients (AUC in two hospitals: 0.84 (95% CI 0.78 to 0.90); 0.81 (95% CI 0.66 to 0.95)).ConclusionsCOPE is a simple tool that is well able to predict mortality and need for ICU admission in patients who present to the ED with suspected COVID-19 and may help patients and doctors in decision making.

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Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study

Western Journal of Emergency Medicine ◽

10.5811/westjem.2021.6.52212 ◽

2021 ◽

Vol 22 (5) ◽

pp. 1124-1130

Author(s):

Chu-Lin Tsai ◽

Dean-An Ling ◽

Tsung-Chien Lu ◽

Jasper Lin ◽

Chien-Hua Huang ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Resource Use ◽

Admission Rate ◽

National Database ◽

Return Visit ◽

Icu Admission ◽

Inpatient Outcomes ◽

Ed Visits ◽

Admission Group

Introduction: Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods: This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results: Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72-0.84), and lower costs (adjusted difference, -5,198 New Taiwan dollars, 95% CI, -6,224 to -4,172). Conclusion: Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

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Factors contributing to delay intensive care unit admission of critically ill patients from the adult emergency Department in Tikur Anbessa Specialized Hospital

BMC Emergency Medicine ◽

10.1186/s12873-021-00518-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Helen Teklie ◽

Hywet Engida ◽

Birhanu Melaku ◽

Abdata Workina

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Intensive Care Unit Admission ◽

Critically Ill ◽

Critically Ill Patients ◽

Transfer Time ◽

Multivariate Logistic Regression ◽

Icu Admission ◽

Specialized Hospital

Abstract Background The transfer time for critically ill patients from the emergency department (ED) to the Intensive care unit (ICU) must be minimal; however, some factors prolong the transfer time, which may delay intensive care treatment and adversely affect the patient’s outcome. Purpose To identify factors affecting intensive care unit admission of critically ill patients from the emergency department. Patients and methods A cross-sectional study design was conducted from January 13 to April 12, 2020, at the emergency department of Tikur Anbesa Specialized Hospital. All critically ill patients who need intensive care unit admission during the study period were included in the study. A pretested structured questionnaire was adapted from similar studies. The data were collected by chart review and observation. Then checked data were entered into Epi-data version 4.1 and cleaned data was exported to SPSS Version 25 for analysis. Descriptive statistics, bivariate and multivariate logistic regression were used to analyze the data. Result From the total of 102 critically ill patients who need ICU admission 84.3% of them had prolonged lengths of ED stay. The median length of ED stay was 13.5 h with an IQR of 7–25.5 h. The most common reasons for delayed ICU admission were shortage of ICU beds 56 (65.1%) and delays in radiological examination results 13(15.1%). On multivariate logistic regression p < 0.05 male gender (AOR = 0.175, 95% CI: (0.044, 0.693)) and shortage of ICU bed (AOR = 0.022, 95% CI: (0.002, 0.201)) were found to have a significant association with delayed intensive care unit admission. Conclusion there was a delay in ICU admission of critically ill patients from the ED. Shortage of ICU bed and delay in radiological investigation results were the reasons for the prolonged ED stay.

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Validation of Modified Paediatric Triage Score in a Tertiary Care Hospital

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2020/45187.14204 ◽

2020 ◽

Author(s):

Bandya Sahoo ◽

Reshmi Mishra ◽

Mukesh Kumar Jain ◽

Sibabratta Patnaik

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Scoring System ◽

Tertiary Care ◽

P Value ◽

Care Hospital ◽

Clinical Variables ◽

Icu Admission ◽

Physical Variables

Introduction: The global burden of paediatric mortality is high and majority of the deaths are preventable by providing timely access to specialised emergency care. An appropriate triage in a busy emergency department can identify the sickest patient for early intervention. Aim: To develop a simple score based on physical variables alone and assess its validation so as to predict Intensive Care Unit (ICU) admission. Materials and Methods: This prospective hospital based study included 936 children, aged 1 month to 18 years. Baseline demographic data along with clinical variables were noted in a pre-designed proforma at the time of admission. A scoring system was developed based on severity of various clinical variables i.e., heart rate, respiratory rate, respiratory effort, Oxygen Saturation (SpO2), Capillary Refill Time (CFT), temperature, level of consciousness and behaviour. The outcome i.e., admission to ward or Pediatric Intensive Care Unit (PICU) of the patient was correlated with the study variables and total score. An association of modified PETS with the PICU admission was done using Chi-square test. A p-value of <0.01 was considered as statistically significant. Results: The modified Paediatric Triage Score (PETS) which is developed based on eight physical variables, is reliable in discriminating the children with ward and ICU admission. A score of ≥6 leads to 14.8 times higher risk of getting admitted to ICU as compared to a child with score of <6. A cut-off of ≥6 for modified PETS score has a sensitivity of 79.6% and specificity of 79.2% in predicting ICU admission. Conclusion: This simple clinically developed scoring system based on physical variables alone with an optimal cut-off of ≥6 can predict severity of illness and need for PICU admission in Emergency Department with acceptable validity and can serve as a potentially excellent screening tool.

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A Peculiar Case of Invasive Streptococcus pneumoniae

Case Reports in Infectious Diseases ◽

10.1155/2017/1530507 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3

Author(s):

Adeel Rafi Ahmed ◽

Liam Townsend ◽

Helen Tuite ◽

Catherine Fleming

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Streptococcus Pneumoniae ◽

Respiratory Distress ◽

Multiorgan Failure ◽

Community Acquired Pneumonia ◽

Icu Admission ◽

Severe Community Acquired Pneumonia ◽

Peculiar Case

Patients commonly present to the emergency department with acute respiratory distress; however, the differentials are broad and at times difficult to distinguish. We describe a case of severe community-acquired pneumonia (CAP) secondary to invasive Streptococcus pneumoniae. The patient was intubated within 3 h of presentation and suffered multiorgan failure within 72 h of intensive care unit (ICU) admission. This case is a stark illustration of how the most common bacteria associated with CAP can be fatal and highlights the associated markers of severity. It also outlines other potential complications including a very rare phenomenon of cardiomyopathy with myocarditis associated with S. pneumoniae bacteraemia.

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Association of an Emergency Department–embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Use

Annals of the American Thoracic Society ◽

10.1513/annalsats.201912-912oc ◽

2020 ◽

Vol 17 (12) ◽

pp. 1599-1609

Author(s):

George L. Anesi ◽

Jayaram Chelluri ◽

Zaffer A. Qasim ◽

Marzana Chowdhury ◽

Rachel Kohn ◽

...

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Critical Care ◽

Intensive Care ◽

Critical Care Unit ◽

Hospital Outcomes

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National Early Warning Score for predicting intensive care unit admission among elderly patients with influenza infections in the emergency department: an effective disposition tool during the influenza season

BMJ Open ◽

10.1136/bmjopen-2020-044496 ◽

2021 ◽

Vol 11 (6) ◽

pp. e044496

Author(s):

Te-Hao Wang ◽

Jing-Cheng Jheng ◽

Yen-Ting Tseng ◽

Li-Fu Chen ◽

Jui-Yuan Chung

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Logistic Regression ◽

Intensive Care ◽

Elderly Patients ◽

Early Warning Score ◽

Influenza Epidemic ◽

Epidemic Season ◽

Icu Admission ◽

National Early Warning Score

ObjectiveDuring the influenza epidemic season, the fragile elderlies are not only susceptible to influenza infections, but are also more likely to develop severe symptoms and syndromes. Such circumstances may pose a significant burden to the medical resources especially in the emergency department (ED). Disposition of the elderly patients with influenza infections to either the ward or intensive care unit (ICU) accurately is therefore a crucial issue.Study designRetrospective cohort study.Setting and participantsElderly patients (≥65 years) with influenza visiting the ED of a medical centre between 1 January 2010 and 31 December 2015.Primary outcome measuresDemographic data, vital signs, medical history, subtype of influenza, national early warning score (NEWS) and outcomes (mortality) were analysed. We investigated the ability of NEWS to predict ICU admission via logistic regression and the receiver operating characteristic (ROC) analysis.ResultsWe included 409 geriatric patients in the ED with a mean age of 79.5 years and approximately equal sex ratio. The mean NEWS ±SD was 3.4±2.9, and NEWS ≥8 was reported in 11.0% of the total patients. Logistic regression revealed that NEWS ≥8 predicted ICU admission with an OR of 5.37 (95% CI 2.61 to 11.04). The Hosmer-Lemeshow goodness-of-fit test was calculated as 0.95, and the adjusted area under the ROC was 0.72. An NEWS ≥8 is associated with ICU-admission and may help to triage elderly patients with influenza infections during the influenza epidemic season.ConclusionThe high specificity of NEWS ≥8 to predict ICU admission in elderly patients with influenza infection during the epidemic season may avoid unnecessary ICU admissions and ensure proper medical resource allocation.

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CRB-65: Predictor for Intensive Care Unit Admission in Patients with Biliary Tract Infection Presenting to An Emergency Department

10.22514/sv.2020.16.0049 ◽

2020 ◽

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Tract Infection ◽

Hospital Mortality ◽

Biliary Tract ◽

Screening Tools ◽

High Morbidity ◽

Biliary Tract Infection ◽

Icu Admission

Objectives: Biliary tract infection (BTI) is a common cause of bacteremia and is associated with high morbidity and mortality. However, studies on screening tools to predict disease severity in BTI patients are lacking. This study aimed to comparatively validate CRB, CRB-65, quick Sequential Organ Failure Assessment (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS) in predicting the clinical outcomes of BTI patients. Methods: This retrospective cohort study included patients with BTI who visited the emergency department of a medical center between February 2018 and March 2020. Baseline patient data were compared to assess the prevalence of intensive care unit (ICU) admission and in-hospital mortality. The effectiveness of CRB, CRB-65, qSOFA, and SIRS scores as indicators of ICU admission and in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. Results: This study included 745 patients, of whom 111 (14.8%) were admitted to the ICU and 20 (2.7%) died in-hospital. AUROC values (95% CI) for predicting ICU admission and in-hospital mortality were as follows: CRB, 0.774 and 0.707 (0.742 –0.803 and 0.673 – 0.739); CRB - 65, 0.816 and 0.735 (0.786 – 0.843 and 0.0.702 – 0.766); qSOFA, 0.779 and 0.724 (03747 – 0.808 and 0.690 – 0.755); and SIRS, 0.686 and 0.659 (0.651 – 0.719 and 0.623 – 0.693), respectively. Conclusions: CRB-65 can be used as useful screening tools to predict ICU admission in patients with BTI on presentation to the emergency department.

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A Risk Score to Predict Admission to Intensive Care Unit in Patients With COVID-19: The ABC-GOALS Score

10.1101/2020.05.12.20099416 ◽

2020 ◽

Cited By ~ 4

Author(s):

Juan M. Mejia-Vilet ◽

Bertha M. Cordova-Sanchez ◽

Dheni Fernandez-Camargo ◽

R. Angelica Mendez-Perez ◽

Luis Eduardo Morales-Buenrostro ◽

...

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Intensive Care ◽

Clinical Laboratory ◽

Area Under The Curve ◽

Laboratory Model ◽

Clinical Model ◽

Icu Admission ◽

Department Evaluation ◽

Development And Validation

Background. COVID-19 pandemic poses a burden on hospital resources and intensive care unit (ICU) occupation. This study aimed to provide a scoring system that, assessed upon first-contact evaluation at the emergency department, predicts the need for ICU admission. Methods. We prospectively assessed patients admitted to a COVID-19 reference center in Mexico City between March 16th and May 21st, and split them into development and validation cohorts. Patients were segregated into a group that required admission to ICU, and a group that never required ICU admission and was discharged from hospitalization. By logistic regression, we constructed predictive models for ICU admission, including clinical, laboratory, and imaging findings from the emergency department evaluation. The ABC-GOALS score was created by assigning values to the weighted odd ratios. The score was compared to other COVID-19 and pneumonia scores through the area under the curve (AUC). Results. We included 569 patients divided into development (n=329) and validation (n=240) cohorts. One-hundred-fifteen patients from each cohort required admission to ICU. The clinical model (ABC-GOALSc) included sex, obesity, the Charlson comorbidity index, dyspnea, arterial pressure, and respiratory rate at triage evaluation. The clinical plus laboratory model (ABC-GOALScl) added serum albumin, glucose, lactate dehydrogenase, and S/F ratio to the clinical model. The model that included imaging (ABC-GOALSclx) added the CT scan finding of >50% lung involvement. The model AUC were 0.79 (95%CI 0.74-0.83) and 0.77 (95%CI 0.71-0.83), 0.86 (95%CI 0.82-0.90) and 0.87 (95%CI 0.83-0.92), 0.88 (95%CI 0.84-0.92) and 0.86 (95%CI 0.81-0.90) for the clinical, laboratory and imaging models in the development and validation cohorts, respectively. The ABC-GOALScl and ABC-GOALSclx scores outperformed other COVID-19 and pneumonia-specific scores. Conclusion. The ABC-GOALS score is a tool to evaluate patients with COVID-19 at admission to the emergency department, which allows to timely predict their risk of admission to an ICU.

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