Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients

Malinovska, Alexandra; Pitasch, Laurentia; Geigy, Nicolas; Nickel, Christian H.; Bingisser, Roland

doi:10.5811//westjem.2019.4.40031

Cited by 17 publications

(32 citation statements)

References 25 publications

(40 reference statements)

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“…Some of the original predictors, such as time of presentation and pain score, were selected out due to concerns of model overfitting. The inclusion of older age in the EDICAS highlights the importance of age in the triage process 30 because a previous study suggested that older patients requiring an immediate life-saving intervention were more likely to be missed by using the Emergency Severity Index at triage. 31 The addition of arrival by ambulance to this ED-specific tool seems quite reasonable because this variable should be readily available in most EDs.…”

Section: Discussionmentioning

confidence: 99%

Development and Validation of a Novel Triage Tool for Predicting Cardiac Arrest in the Emergency Department

Tsai

Wang

et al. 2022

WestJEM

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Background: Early recognition and prevention of in-hospital cardiac arrest (IHCA) have played an increasingly important role in the chain of survival. However, clinical tools for predicting IHCA are scarce, particularly in the emergency department (ED). We sought to estimate the incidence of ED-based IHCA and to develop and validate a novel triage tool, the Emergency Department In-hospital Cardiac Arrest Score (EDICAS), for predicting ED-based IHCA. Methods: In this retrospective cohort study we used electronic clinical warehouse data from a tertiary medical center with approximately 100,000 ED visits per year. We extracted data from 733,398 ED visits over a seven-year period. We selected one ED visit per person and excluded out-of-hospital cardiac arrest or children. Patient demographics and computerized triage information were included as potential predictors. Results: A total of 325,502 adult ED patients were included. Of these patients, 623 (0.2%) developed ED-based IHCA. The EDICAS, which includes age and arrival mode and categorizes vital signs with simple cut-offs, showed excellent discrimination (area under the receiver operating characteristic [AUROC] curve, 0.87) and maintained its discriminatory ability (AUROC, 0.86) in cross-validation. Previously developed early warning scores showed lower AUROC (0.77 for the Modified Early Warning Score and 0.83 for the National Early Warning Score) when applied to our ED population. Conclusion: In-hospital cardiac arrest in the ED is relatively uncommon. We developed and internally validated a novel tool for predicting imminent IHCA in the ED. Future studies are warranted to determine whether this tool could gain lead time to identify high-risk patients and potentially reduce ED-based IHCA.

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Section: Discussionmentioning

confidence: 99%

Development and Validation of a Novel Triage Tool for Predicting Cardiac Arrest in the Emergency Department

Tsai

Wang

et al. 2022

WestJEM

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“…One of the benefits of the ESI algorithm is its ability to be adapted and enhanced for a specific patient population [ 19 ] [ 19 ].. Malinovska et al [ 21 ] found that a modification of the ESI allowed for improved mortality prediction in patients older than 65 years. In our cancer patient population, the addition of temperature and systolic blood pressure to the “danger zone” vital signs addressed and identified red flags prior to respiratory or hemodynamic deterioration and provided further insight into the degree of illness at the triage junction, suggesting hemodynamic stability, metabolic reserve, and systemic response to the infection [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19

Lipe¹,

Bourenane²,

Wattana³

et al. 2022

The American Journal of Emergency Medicine

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Objective To evaluate a modified emergency severity index (mESI)-based triage of cancer patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED) and determine the associations between mESI level and ED disposition, hospital length of stay, and overall survival. Methods Medical records were retrospectively reviewed for all patients who presented to our institution's ED between March 22, 2020, and March 12, 2021, and tested positive for SARS-CoV-2. Results A total of 306 cancer patients tested positive for SARS-CoV-2, with 45% of patients triaged to level 2 (emergent) and 55% to level 3 (urgent). Among all patients, 61.8% were admitted to the hospital, 15.7% were admitted to the intensive care unit, 2.9% were sent for observation, and 19.6% were discharged. Although demographic and clinical characteristics did not significantly vary by triage level, we observed significant differences in ED length of stay (urgent = 6.67 h, emergent = 5.97 h; p < 0.01). Hospital and intensive care unit admission rates were also significantly higher among emergent patients than among urgent patients ( p < 0.05). There were 75 deaths (urgent = 32; emergent = 43), and the 30-day mortality rate was significantly higher among emergent patients (urgent = 8%, emergent = 15%; p < 0.05). The mESI level persisted as a significant factor associated with overall survival (hazard ratio = 1.7, 95% confidence interval = 1.09–2.81) in multivariable analysis. Conclusion The mESI level is associated with ED disposition, ED length of stay, and overall survival in cancer patients presenting with COVID-19. These results indicate that the mESI triage tool can be effectively used in cancer patients with COVID-19, whose condition can rapidly deteriorate.

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“…Particularly in sepsis and COVID-19, the perception of fever may be impaired, and hyperthermia might be missing at an early stage [ 22 , 23 ]. Such patients may be tagged with an “incoherent history” [ 13 ] or delirium that often goes unnoticed at presentation and during the early hours of ED work-up [ 24 ]. Further, it is noteworthy that the vast majority of hypothermic patients in our cohort did not report on subjective feelings of fever.…”

Section: Discussionmentioning

confidence: 99%

“…Further, we have previously shown that an “incoherent history” in patients with nonspecific complaints is predictive of serious outcomes [ 13 ]. The discordance between the patients’ information (considered to be subjective) and objective measurements by caregivers may indeed be a signal similar to a “red flag”.…”

Section: Introductionmentioning

confidence: 99%

Prevalence and Prognosis of Fever Symptoms, Hypo-, and Hyperthermia in Unselected Emergency Patients

Malinovska

Nickel

et al. 2021

JCM

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Assessments of history and body temperature are cornerstones of the diagnostic workup in all patients presenting to emergency departments (ED). Yet, the objective measurement of temperature and the subjective perception of fever can differ. This is a secondary exploratory analysis of a consecutive all-comer study, performed at an adult ED in Switzerland. Trained medical students interviewed all patients if fever was present. Altered temperature (>38.0 °C/<36.0 °C) measured at triage using an ear thermometer was used as the reference standard for diagnostic performance. In case of a disagreement between fever symptoms and altered temperature, discordance was noted. Outcome measures for case severity (acute morbidity, hospitalization, intensive care, and in-hospital mortality) were extracted from the electronic health records. Odds ratios (OR) for discordance between signs and symptoms and outcomes were calculated. Among 2183 patients, 325 patients reported fever symptoms. The sensitivity of fever symptoms as a test for altered temperature was 36.3%. Specificity was 91.5%. The negative predictive value was 84.1%, positive likelihood ratio was 4.2 and negative likelihood ratio was 0.7. The adjusted OR for discordance between fever symptoms and altered temperature was 1.71 (95% CI: 1.2–2.44) for acute morbidity, 1.56 (95% CI: 1.13–2.15) for hospitalization, and 1.12 (95% CI: 0.64–1.59) for intensive care. Unadjusted OR for mortality was 1.5 (95% CI: 0.69–3.25). Fever symptoms and altered temperature broadly overlap, but presentations can be stratified according to concordance between signs and symptoms. In case of discordance, the odds for acute morbidity and hospitalization are increased. Discordance may therefore be further investigated as a red flag for a serious outcome.

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Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients

Cited by 17 publications

References 25 publications

Development and Validation of a Novel Triage Tool for Predicting Cardiac Arrest in the Emergency Department

Development and Validation of a Novel Triage Tool for Predicting Cardiac Arrest in the Emergency Department

A modified emergency severity index level is associated with outcomes in cancer patients with COVID-19

Prevalence and Prognosis of Fever Symptoms, Hypo-, and Hyperthermia in Unselected Emergency Patients

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