Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study

<p>Abstract</p> <p>Background</p> <p>Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.</p> <p>Methods</p> <p>The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T_vitals, and presenting complaint, T_complaint. The more urgent of the two determines the final triage category, T_final. We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.</p> <p>Results</p> <p>The covariates, T_vitals, T_complaintand T_finalwere all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO₂), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T_complaintmore urgent than T_vitals, the opposite was true in just 6% of the patients.</p> <p>Conclusion</p> <p>The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.</p

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This article is intended as a generic guide to evidencebased airway management for all categories of pre-hospital personnel. It is based on a review of relevant literature but the majority of the studies have not been performed under realistic, pre-hospital conditions and the recommendations are therefore based on a low level of evidence (D). The advice given depends on the qualifications of the personnel available in a given emergency medical service (EMS). Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for the use of most techniques in the treatment of patients with airway reflexes. For anaesthesiologists, the Task Force commissioned by the Scandinavian Society of Anaesthesia and Intensive Care Medicine recommends endotracheal intubation (ETI) following rapid sequence induction when securing the pre-hospital airway, although repeated unsuccessful intubation attempts should be avoided independent of formal qualifications. Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask-ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non-anaesthesiologists primarily use a supraglottic airway device. A supraglottic device such as the laryngeal tube or the intubation laryngeal mask should also be available as a backup device for anaesthesiologists in failed ETI. Accepted for publication 25 February 2008 Key words: Pre-hospital; airway management; endotracheal intubation; laryngeal mask airway; laryngeal tube airway; combitube; emergency medical systems. Purpose T HIS article is intended as a guide to evidencebased pre-hospital airway management. The available litterature on pre-hospital airway management reflects vast differences in pre-hospital emergency medicine service (EMS) organisation, qualification levels, training programmes and even terminology. These differences make comparisons between systems and treatment protocols difficult at best. The conduct of clinical trials in pre-hospital airway management is hampered by the 2001/20/ EC directive of the European Parliament concerning informed consent. This paper describes selected equipment and techniques available for pre-hospital airway management. Advice given differs, depending on which category of personnel is available in a given EMS. Our baseline assumption is that a certain level of education and training is necessary for the safe use of a specific technique. Distinction must be made between personnel trained and experienced in providing and monitoring anaesthesia and other groups of personnel with limited or no anaesthetic skills. This distinction dictates which drugs and equipment that should be available in the prehospital setting. Differences between regions and systems Paramedic-based systems are the rule in the United States, whereas physician-based pre-hospital systems are common in Europe. Ideally, the best person to manage the pre-hospital airway should 89

Cost-effectiveness of Out-of-Hospital Continuous Positive Airway Pressure for Acute Respiratory Failure

Study objective: We determine the cost-effectiveness of out-of-hospital continuous positive airway pressure (CPAP) compared with standard care for adults presenting to emergency medical services with acute respiratory failure. Methods: We developed an economic model using a United Kingdom health care system perspective to compare the costs and health outcomes of out-of-hospital CPAP to standard care (inhospital noninvasive ventilation) when applied to a hypothetical cohort of patients with acute respiratory failure. The model assigned each patient a probability of intubation or death, depending on the patient's characteristics and whether he or she had out-of-hospital CPAP or standard care. The patients who survived accrued lifetime quality-adjusted life-years (QALYs) and health care costs according to their age and sex. Costs were accrued through intervention and hospital treatment costs, which depended on patient outcomes. All results were converted into US dollars, using the Organisation for Economic Co-operation and Development purchasing power parities rates. Results: Out-of-hospital CPAP was more effective than standard care but was also more expensive, with an incremental cost-effectiveness ratio of £20,514 per QALY ($29,720/QALY) and a 49.5$29,000/QALY) threshold. The probability of out-of-hospital CPAP's being cost-effective at the £20,000 per QALY ($29,000/QALY) threshold depended on the incidence of eligible patients and varied from 35.4% when a low estimate of incidence was used to 93.8% with a high estimate. Variation in the incidence of eligible patients also had a marked influence on the expected value of sample information for a future randomized trial. Conclusion: The cost-effectiveness of out-of-hospital CPAP is uncertain. The incidence of patients eligible for out-of-hospital CPAP appears to be the key determinant of cost-effectiveness