Outcome und Charakteristika internistischer Notfallpatienten mit dem Schwerpunkt der Identifikation und Bewertung von Prädiktoren für die intrahospitale Mortalität

Einleitung Das Patientenaufkommen in deutschen Krankenhäusern und Notaufnahmen steigt kontinuierlich an. Demgegenüber steht die stetige Verknappung der Ressourcen im Gesundheitssystem. Dies betrifft nicht nur die Reduktion von Krankenhäusern und Krankenhausbetten, sondern auch Einsparungen im Personalbereich. Zeitgleich steigt der Anteil unbesetzter Arztstellen. Im Bereich der Notfallmedizin muss eine adäquate und effiziente Notfallversorgung trotz knapper Ressourcen und erhöhtem Patientenaufkommen gewährleistet werden. Um diesen Anforderungen zu entsprechen, wird durch den Einsatz von Triageverfahren, Behandlungsalgorithmen, Risikoscores und detaillierten Standard Operating Procedures (SOPs) ein möglichst effizienter und standardisierter Notaufnahmeprozess angestrebt. Durch diese Maßnahmen sollen lange Wartezeiten oder eine ungerechtfertigte Entlassung von Patienten verhindert werden. Die initiale Untersuchung liefert essentielle Daten zur Risikostratifizierung der Patienten. Ziel der vorliegenden Arbeit ist es, unter diesen bei Aufnahme erhobenen Vital- und Laborparametern geeignete Prädiktoren für die intrahospitale Mortalität von unselektierten internistischen Notfallpatienten zu identifizieren. Methodik Es handelt sich um eine prospektive Beobachtungsstudie. Der Studienzeitraum erstreckte sich vom 15. Februar 2009 bis zum 15. Februar 2010. Es wurden Daten von zwei Notaufnahmen der Charité verwendet. Insgesamt wurden 34.333 Patienten in diese Studien einbezogen. Bei den verwendeten Daten handelt es sich um Sekundärdaten aller konservativer Patienten, welche im Rahmen von Qualitätssicherungsmaßnahmen aus dem Krankenhausinformationssystem (KIS) abgefragt wurden. Patienten, welche lebend entlassen wurden und im Krankenhaus verstorbene Patienten wurden hinsichtlich ihrer Charakteristika, Diagnosen und bezüglich des Krankenhausverlaufes verglichen. Labor- und Vitalparameter, welche bei Aufnahme erhoben wurden, wurden als Prädiktoren für einen fatalen intrahospitalen Verlauf bivariat, in multivariaten Regressionsmodellen, sowie anhand von ROC-Kurven (receiver operating characteristics), analysiert. Ergebnisse Sowohl in bivariaten Analysen, als auch unter Verwendung multivariater Regressionsmodelle und CART-Analyse, konnten insbesondere die Biomarker C-reaktives Protein (CRP) und die Erythrozytenverteilungsbreite (RDW) als Prädiktoren für das Versterben der Patienten während des initialen Krankenhausaufenthaltes identifiziert werden. C-reaktives Protein zeigte in der bivariaten Analyse ein relatives Risiko für den intrahospitalen Exitus von 7,6 (95%-Konfidenzintervall: 6,4-8,9) bei einem Cut-Off von 7,19 mg/dl und erzielte eine Fläche unter der ROC-Kurve von 0,795 (95%-Konfidenzintervall: 0,776-0,813). RDW zeigte in der bivariaten Analyse ein relatives Risiko von 6,9 (95%-Konfidenzintervall: 5,9-8,1) bei einem Cut-Off von 16,2% und erzielte eine Fläche unter der ROC-Kurve von 0,805 (95%-Konfidenzintervall: 0,788-0,823). In einem multivariaten Regressionsmodell gemeinsam mit anderen Prädiktoren konnten diese Ergebnisse bestätigt werden, die ermittelten Odds Ratios unter Verwendung der oben genannten Cut-Offs waren für CRP 3,7 (95%-Konfidenzintervall: 3,01-3,52) und für RDW 2,91 (95%-Konfidenzintervall: 2,37-3,58). Die Kombinierte ROC-Kurve aus allen Parametern des endgültigen Modelles zeigte eine Fläche unter der Kurve von 0,863 (95%-Konfidenzintervall: 0,848-0,877). Schlussfolgerung Die beschriebenen Ergebnisse zeigen, dass CRP und RDW Potential für die Risikostratifizierung unselektierter, internistischer Notfallpatienten aufweisen. Eine Kombination dieser Marker gemeinsam mit dem Alter der Patienten scheint generell dazu geeignet, Patienten mit einem erhöhten Mortalitätsrisiko zeitnah nach der Aufnahme zu identifizieren. Eine Risikostratifizierung anhand dieser Parameter könnte insbesondere in Situationen des Overcrowdings in der Notaufnahme hilfreich sein. Inwiefern die Zuweisung von Patienten mit erhöhtem Risiko zu einem priorisierten Behandlungsprozess geeignet ist das Outcome der Patienten zu verbessern muss in Interventionsstudien untersucht werden.Introduction In German hospitals and Emergency Departments a time trend of ever increasing patient numbers has been observed over recent years while, at the same time, resources, including number of hospitals, hospital beds and also qualified personnel have been decreasing. In order to assure an adequate and efficient treatment despite these facts, the importance of effective triage-systems, early risk-stratification and a good quality management with detailed standard operating procedures (SOPs) is increasing. The first physical and laboratory examinations of the patients, usually performed early after admission to the ED, provide essential information for an early risk- assessment. In this analysis, the value of the routine vital and laboratory parameters obtained at admission was assessed for their potential role in risk stratification. The investigated endpoint was the in-hospital mortality. Methods In this observational study, secondary data of all patients who attended the internal Emergency Departments of the Charité Campus Virchow Klinikum and Benjamin Franklin between 15th February 2009 and 15th February 2012 were retrieved from the hospital information system in an IT-supported, automated way (n=34.333). Laboratory and vital parameters were investigated as potential predictors for a fatal in-hospital outcome in bivariate and multivariate analyses. Additionally, the area under the ROC-Curve (receiver operating characteristic) was calculated for every single predictor and also for the final regression model. Results C-reactive protein (CRP) and Red cell distribution width (RDW) were the best predictors of mortality in bivariate analysis with an area under the ROC-curve of 0.805 (95%-Confidence interval: 0.788-0.823) and 0.795 (95%-Confidence interval: 0.776-0.813) respectively. In univariate analysis, CRP showed a relative risk of 7.6 (95%-Confidence interval: 6.4-8.9) at a cut-off value of 7.19 mg/dl. The relative risk for RDW was 6.9 (95%-Confidence interval: 5.9-8.1) at a cut-off-level of 16.2%. In multivariate analysis, the odds ratios at the respective cut-off points were 3.7 (95%-Confidence interval: 3.01-3.52) for CRP and 2.91 (95%-Confidence interval: 2.37-3.58) for RDW. All predictors in the final regression model in combination achieved an area under the curve of 0.863 (95%-Confidence interval: 0.848-0.877). Additionally, CART-Analysis was performed and revealed similar results. Conclusion The results of this analysis are indicating that CRP and RDW have potential as predictors for an unfavorable in-hospital course in unselected internal ED-patients. Both markers in combination with age might be useful for the early identification of patients with an increased risk for in-hospital mortality. Risk stratification by the identified markers might be particularly useful in the setting of overcrowding. The clinical impact of risk-stratification and prioritized treatment of high-risk patients on patient´s outcome needs to be evaluated in further interventional studies

Point‐of‐care testing for influenza in a university emergency department: A prospective study

Background: Seasonal influenza is a burden for emergency departments (ED). The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures. Objectives The aim of this study was to investigate whether point-of-care (POC) PCR testing can be used to reduce staff sick days and improve diagnostic and therapeutic procedures. Methods: Using a cross-over design, the cobas (R) Liat (R) Influenza A/B POC PCR test (Liat) was compared with standard clinical practice during the 2019/2020 influenza season. All adult patients (aged >= 18 years) with fever (>= 38 degrees C) and respiratory symptoms were included. Primary end points were the prevalence of influenza infections in the ED and staff sick days. Secondary end points were frequency of antiviral and antibacterial therapy, time between admission and test result or treatment initiation, patient disposition, ED length of stay (LOS), and for inpatients mortality and LOS. Nurses were interviewed about handling and integration of POC testing. The occurrence of SARS-CoV-2 infections coincided with the second half of the study. Results A total of 828 patients were enrolled in the study. All 375 patients of the intervention group were tested with Liat, and 103 patients of them (27.6%) tested positive. During the intervention period, staff sick days were reduced by 34.4% (P = .023). Significantly, more patients in the intervention group received antiviral therapy with neuraminidase inhibitors (7.2% vs 3.8%, P = .028) and tested patients received antibiotics more frequently (40.0% vs 31.6%, P = .033). Patients with POC test were transferred to external hospitals significantly more often (5.6% vs 1.3%, P = .01). Conclusion: We conclude that POC testing for influenza is useful in the ED, especially if it is heavily frequented by patients with respiratory symptoms

Influence of Weekday and Seasonal Trends on Urgency and In-hospital Mortality of Emergency Department Patients

Background: Given the scarcity of resources, the increasing use of emergency departments (ED) represents a major challenge for the care of emergency patients. Current health policy interventions focus on restructuring emergency care with the help of patient re-direction into outpatient treatment structures. A precise analysis of ED utilization, taking into account treatment urgency, is essential for demand-oriented adjustments of emergency care structures. Methods: Temporal and seasonal trends in the use of EDs were investigated, considering treatment urgency and hospital mortality. Secondary data of 287,119 ED visits between 2015 and 2017 of the two EDs of Charité Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum were analyzed. Result: EDs were used significantly more frequently on weekends than on weekdays (Mdn = 290 vs. 245 visits/day; p < 0.001). The proportion of less urgent, outpatient emergency visits on weekends was above average. Holiday periods were characterized by at least 6, and at most 176 additional ED visits. In a comparison of different holidays, most ED visits were observed at New Year (+68% above average). In addition, a significant increase in in-hospital mortality on holidays was evident among inpatients admitted to hospital via the ED (3.0 vs. 3.2%; p < 0.001), with New Year's Day being particularly striking (5.4%). Conclusion: These results suggest that, in particular, the resource planning of outpatient emergency treatment capacities on weekends and holidays should be adapted to the increased volume of non-urgent visits in EDs. Nevertheless, treatment capacities for the care of urgent, inpatient emergencies should not be disregarded and further research projects are necessary to investigate the causes of increased mortality during holiday periods

a qualitative study comparing urban and rural sites

Objectives: The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low- acuity conditions for visiting an ED. Methods: We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites. Results: A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same. Conclusions: We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation. Trial registration number: DRK S0000605

Suitability of current definitions of ambulatory care sensitive conditions for research in emergency department patients: a secondary health data analysis

Objective: The aim of this study was to investigate the suitability of existing definitions of ambulatory care sensitive conditions (ACSC) in the setting of an emergency department (ED) by assessing ACSC prevalence in patients admitted to hospital after their ED stay. The secondary aim was to identify ACSC suitable for specific application in the ED setting. Design: Observational clinical study with secondary health data. Setting: Two EDs of the Charite-Universitatsmedizin Berlin. Participants: All medical ED patients of the 'The Charite Emergency Medicine Study' (CHARITEM) study, who were admitted as inpatients during the 1-year study period (n=13 536). Outcome measures: Prevalence of ACSC. Results: Prevalence of ACSC in the study population differed significantly depending on the respective ACSC set used. Prevalence ranged between 19.1% (95% CI 18.4% to 19.8%; n=2586) using the definition by Albrecht et al and 36.6% (95% CI 35.8% to 37.5%; n=4960) using the definition of Naumann et al. (p<0.001). Overall ACSC prevalence (ie, when using all diagnoses used in any of the assessed ACSC-definitions) was 48.1% (95% CI 47.2% to 48.9%; n=6505). Some frequently observed diagnoses such as 'convulsion and epilepsy' (prevalence: 3.4%, 95% CI 3.1% to 3.7%; n=455), 'diseases of the urinary system' (prevalence: 1.4%; 95% CI 1.2% to 1.6%; n=191) or 'atrial fibrillation and flutter' (prevalence: 1.0%, 95% CI 0.8% to 1.2%, n=134) are not included in all of the current ACSC definitions. Conclusions: The results highlight the need for an optimised, ED-specific ACSC definition. Particular ACSC diagnoses (such as 'convulsion and epilepsy' or 'diseases of the urinary system' and others) seem to be of special relevance in an ED population but are not included in all available ACSC definitions. Further research towards the development of a suitable and specific ACSC definition for research in the ED setting seems warranted

Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross‐sectional findings from the EMASPOT study

Background: This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs. Methods: Multimorbid patients, aged ≥50 years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record. Results: A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9 ≥10), generalized anxiety disorder (12.2% GAD-7 ≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs. Conclusions: MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions

Cost analysis of early discharge using combined copeptin/cardiac troponin testing versus serial cardiac troponin testing in patients with suspected acute coronary syndrome

Background: Symptoms indicating acute coronary syndrome are commonly seen in emergency rooms, but only 10% of patients are actually diagnosed with acute myocardial infarction (AMI). The Guidelines for the diagnosis of patients with suspected AMI include either multiple testing of cardiac troponin (cTN) or a single combined test of cTN and copeptin, which facilitates earlier diagnosis or exclusion of AMI. The aim of the present analysis was to investigate the impact of combined copeptin/cTN testing on health care resource consumption and related costs both during and after initial hospital treatment. Methods and results: The analysis was based on the BIC-8 trial and financial data of participating study sites. A cost analysis was carried out primarily from the hospital perspective and secondarily from the perspective of German statutory health insurers. The underlying assumptions of the investigation were tested for robustness in additional sensitivity analyses. In total, the data of 713 patients (n = 359 combined copeptin/cTN testing, n = 354 serial cTN testing) were evaluated. From a hospital perspective, the combined copeptin/cTN testing showed a reduced number of medical procedures and a lower frequency of inpatient admissions. The average staff time was significantly reduced by a mean of 49 minutes (95% confidence interval (CI) 46 to 53) per patient, accompanied by a significant mean reduction of 131 minutes (95%CI 104 to 158) in the time patients stayed in the emergency room. The initial hospital treatment was less cost-intensive. Over the entire study period, no significant cost differences were observed between the groups for health insurance. Conclusion: The combined copeptin/cTN testing has the potential to save costs and staff time in acute care and for the entire hospital stay. The primary explanations for these findings are early identification and ruling out patients without AMI along with the associated reduced need for acute medical treatment

Suitability of the German version of the Manchester Triage System to redirect emergency department patients to general practitioner care: a prospective cohort study

Objectives: To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany. Design: Prospective cohort study. Setting: Single centre University Hospital Emergency Department. Participants: Adult, non-surgical ED patients. Exposure: A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS. Primary and secondary outcome measures: Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality). Results: A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n= 358) received a non-urgent triage category and 68.1% (n= 764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p= 0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher inhospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n= 4] vs 2.2% [n= 15]; p= 0.285) or for 1-year mortality (7.9% [n= 26] vs 10.5% [n= 72]; p= 0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR= 1.35; 95% CI 0.87 to 2.12; p= 0.185) and multivariate regression analyses (HR= 1.20; 95% CI 0.77 to 1.89; p= 0.420). Conclusions: The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care

Analyse von notfallmedizinischen Routinedaten aus Präklinik und Klinik

Background: In the 2018 advisory opinion concerning the realignment of healthcare, it is advocated that in order to relieve pressure on emergency departments (ED) prehospital medical emergency services should be given the option to directly transport suitable patients to doctors' offices. Objectives: To determine the prevalence of patients treated by prehospital emergency services that have the potential to be directly allocated to a primary care provider. Materials and methods: Preclinical and clinical data of adult patients who in a 2-month period were transported to the ED of a university hospital by an ambulance were evaluated. To determine a safe and meaningful transport directly to a doctor's office, a stepwise assessment was carried out: patients were categorized on the basis of the prehospital assessment of urgency as "urgent" (contact to doctor necessary within a maximum time of 30 min) and "less urgent" (contact to doctor not necessary within 30 min, maximum 120 min). "Less urgent" patients were further divided and those treated as outpatients were identified. This group was further restricted to cases whose administrative reception in the ED was documented Monday-Friday between 8 am and 7 pm. In addition, these cases were further differentiated with regard to medical content and compared with the triage results in the ED (Manchester Triage, MTS). Results: In all, 1260 patients were brought to the ED by ambulance within the study period (total number of patients treated in this time period n = 11,506); 894 cases had a documented prehospital level of urgency and could therefore be included. Of these n = 477 (53.4%) were categorized as "less urgent"; 317 (66.5%) of these "less urgent" cases were treated as outpatients in the ED, and n = 114 (23.9%) in a time frame potentially suitable for direct transport to doctors' offices, which is 1% of all patients treated in the ED in the time period examined. However, 70 of the cases suitable for doctors' office (63.6% of n = 110 with documented MTS) were rated more urgent in the ED. With regards to prehospital complaints and documented diagnosis we assume employment of a relevant amount of resources in the treatment of these cases. Conclusions: EDs could be relieved from every tenth patient brought in by prehospital emergency services (1% of all patients treated) during normal offices hours by direct allocation to doctors' offices. Regarding patient's safety this process however has to be seen critically as > 60% of these cases were potentially undertriaged. Necessary resources for diagnostics and treatment have to be available in the doctors' offices and known to prehospital emergency services. Primary assignment of patients to doctors' offices by prehospital emergency can only relieve urban EDs to a negligible extent, is potentially dangerous and linked to a tremendous logistic effort

Strukturierte Versorgung von Patient*innen mit atraumatischen Bauchschmerzen in der Notaufnahme

Background: Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context. Methods: In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU). Results: The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures. Discussion: The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term