Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Abstract

Abstract. Objectives:The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). Methods: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. Results: Eighty-one patients aged 64 Ϯ 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 Ϯ 2.7 hours and the hospital length of stay was 12.2 Ϯ 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 Ϯ 6.0) vs survivors (19.8 Ϯ 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p Յ 0.001). The hourly rates of change (decreases) in APACHE II, SAPS II, and MODS scores were significantly greater during the ED stay (Ϫ0.55 Ϯ 0.64, Ϫ1.02 Ϯ 1.10, and Ϫ0.16 Ϯ 0.43, respectively) than subsequent periods of hospitalization in survivors (p < 0.05). There was a significant decrease in APACHE II and SAPS II predicted mortality during the ED stay (Ϫ8.0 Ϯ 14.0% and Ϫ6.0 Ϯ 14.0%, respectively, p < 0.001) and equally at 24 hours in the ICU (Ϫ7.0 Ϯ 13.0% and Ϫ4.0 Ϯ 16.0%, respectively, p Յ 0.02). The APACHE II and SAPS II predicted mortality approached actual in-hospital mortality at approximately 12 hours and 36 hours after ED admission (in the ICU), respectively. Conclusions: The care provided during the ED stay for critically ill patients significantly impacts the progression of organ failure and mortality. Although this period is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. This study emphasizes the importance of ED intervention. It also suggests that unique physiologic assessment methodologies should be developed to examine the quality of patient care, improve the accuracy of prognostic decisions, and objectively measure the impact of clinical interventions and pathways in the ED setting.

A Retrospective Study on the Compliance with Surviving Sepsis Campaign Guideline in Patients with Sepsis Admitted to Intensive Care Unit in Hong Kong

“…This is why blood culture taken before antibiotic administration within 3 h of diagnosis of sepsis is included in the Surviving Sepsis Campaign guideline. However, it is known that blood cultures are only positive in around one third of samples [13] and that up to one third of all patients will have cultures from all sites to be negative [16]. This is reflected in our study by the finding of 41% of patients having no growth from all culture sites.…”

“…In this study, the mean age of our patients was 63.6 years, which was slightly older than the MOSAICS cohort of 59.2 years [10] and was similar to SOFA score between different sex and age. The time of transition from clinical stability to organ dysfunction, the 'golden hours', can be in the emergency department [13], general ward [14] or ICU [15] and requires early recognition and active intervention to prevent sepsis related mortality. 'Golden hours' may be picked up outside intensive care unit with the use of quick-SOFA score, which identifies patients with suspected sepsis who are at greater risk for a poor outcome.…”

An observational cohort study of triage for critical care provision during pandemic influenza: ‘clipboard physicians’ or ‘evidenced based medicine’?

“…using the worst physiological values that occurred at any point during the first 24 h of ICU care. However, a SOFA score of > 11 (or the overall range of scores) for patients on the ward may not have the same associated mortality as a score > 11 in patients already receiving critical care: a number of studies thus significantly overestimate mortality [17]. Therefore some differences can be expected between percentage survival in studies that use the SOFA score correctly, as opposed to ours which calculated the SOFA score on admission, or using Christian's triage tool which calculates the SOFA score on the ward.…”

Emergency Treatment and Nursing Activities of Severe Trauma Patients according to Elapsed Time and Vital Signs

“…중증외상환자의 응급실 체류에 관련된 국내외 선행연구들을 살 펴보면, 응급실 체류시간이 중증도와 (Park, 2012) 예후 (Clarke, Trooskin, Doshi, Greenwald, & Mode, 2000;Nguyen, et al, 2000), 사망 에 미치는 영향 (Chang et al, 2012;Kim, Song, & Song, 2008)과 권역응 급의료센터 체류시간에 관련된 요인 (Chun, 2008;Kwon et al, 2011 …”