Predicting in-hospital mortality among non-trauma patients based on vital sign changes between prehospital and in-hospital: An observational cohort study

Abstract

ObjectiveTo prevent misjudgment of the severity of patients in the emergency department who initially seem non-severe but are in a critical state, methods that differ from the conventional viewpoint are needed. We aimed to determine whether vital sign changes between prehospital and in-hospital could predict in-hospital mortality among non-trauma patients.MethodsThis observational cohort study was conducted in two tertiary care hospitals. Patients were included if they were transported by ambulance for non-trauma-related conditions but were excluded if they experienced prehospital cardiopulmonary arrest, were pregnant, were aged <15 years, had undergone inter-hospital transfer, or had complete missing data regarding prehospital or in-hospital vital signs. The main outcome was in-hospital mortality, and the study variables were changes in vital signs, pulse pressure, and/or shock index between the prehospital and in-hospital assessments. Logistic regression analyses were performed to obtain adjusted odds ratios for each variable. Receiver operating characteristic curve analyses were performed to identify cut-off values that produced a positive likelihood ratio of ≥2.ResultsAmong the 2,586 eligible patients, 170 died in the two hospitals. Significantly elevated risks of in-hospital mortality were associated with changes in the Glasgow Coma Scale (cut-off ≤–3), respiratory rate (no clinically significant cut-off), systolic blood pressure (cut-off ≥47 mmHg), pulse pressure (cut-off ≥55 mmHg), and shock index (cut-off ≥0.3).ConclusionsNon-trauma patients who exhibit changes in some vital signs between prehospital and in-hospital have an increased risk of in-hospital mortality. Therefore, it is useful to incorporate these changes in vital signs to improve triaging and predict the occurrence of in-hospital mortality.

Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

“…Such a decrease is associated with future clinical deterioration and the need of M/V or vasopressin with a high sensitivity [ 17 ]. One study demonstrated that prehospital hemodynamic variability was associated with clinical deterioration [ 18 ]. In another study, repeated BP measurements in the ER were related to improved outcome prediction compared to single measurements, but in the same study, repeated measurements of other vital signs failed to improve the prognostic ability [ 14 ].…”

Development and Internal Validation of a Model Predicting Safe, Early Discharge Among Patients Presenting to the Emergency Department with an Infection.

“…[11,64,65] Several studies conclude that early changes in vital signs or scores are associated with patient outcomes like mortality or ICU admission. [11,35,[63][64][65][66] These studies show that, compared to patients with deteriorating vital signs, patients with vital sign normalization had a lower risk of mortality. Only one, however, analyzed repeated determination of vital signs in order to predict safe, early discharge.…”

“…Multiple studies have analyzed the value of repeated vital sign measurements on patient outcome. Available studies either analyzed individual vital sign measurements [63] or combined these measurements in scores like the qSOFA or MEWS [11,35,[64][65][66]. Three studies compared single with repeated vital sign or score measurements and demonstrated that repeated measurements are superior in predicting clinical course of infectious or septic patients in the ED.…”

Equivalency between the shock index and subtracting the systolic blood pressure from the heart rate: an observational cohort study

“…The shock index (SI) is an indicator of the severity of hypovolemic shock and is calculated by dividing the heart rate (HR) by systolic blood pressure (SBP) [ 1 ]. It serves to predict the mortality, need for blood transfusion, or necessity of intensive care unit admission among patients with trauma [ 2 – 7 ], postpartum haemorrhage [ 8 , 9 ], acute myocardial infarction [ 10 , 11 ], stroke [ 12 , 13 ], sepsis [ 14 , 15 ], and other critical conditions [ 16 , 17 ]. Numerous previous studies have demonstrated that the SI demonstrates superior prediction for mortality to traditional vital signs, although it has some limitations, including its low sensitivity especially for the elderly or obstetric patients [ 2 – 17 ].…”