The association between vital signs and clinical outcomes in emergency department patients of different age categories

Abstract

BackgroundAppropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category.AimsTo assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories.MethodsObservational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81–100, 101–120, 121–140, >140 mm Hg).ResultsWe included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients.ConclusionFor SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.

Use TRIPOD when validating clinical prediction models

“…Why MEWS was not complete or not recorded at all remains uncertain. Although the authors state that the MEWS was recorded across the entire spectrum of disease severity, in a large multicentre quality registry of the Netherlands,3 we found the number of missing vital signs to be associated with mortality and admission. Excluding observations with incomplete MEWS may therefore have caused considerable selection and information bias and might have been mitigated by reporting missing value proportions or by multiple imputations of missing values following appropriate analyses, as recommended by TRIPOD 2.…”

External Validation of COVID-19 Risk Scores during Three Waves of Pandemic in a German Cohort—A Retrospective Study

“…The different baseline characteristics (especially the average age, ICU admission rates, and mortality rates) of the derivation cohorts and differences in epidemiological conditions (e.g., healthcare systems, need for triage) might be the reason for differences of performance in our cohort. It has been demonstrated before that the impact of changing vital sign categories on prognosis in terms of mortality is larger in older patients [23]. This can be especially discussed for the derivation cohort of COVID-GRAM with a mean age of 48.9 years in comparison with our cohort with a mean age of 65 years.…”

Factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the emergency department

“…However, the study did not report clear cut-off points for SBP, DBP, SpO 2 , or heart rate and did not provide AORs for mortality. The AOR for RR gradually increased between 10 and 19 breaths/min with a substantial increase in mortality at 22 breaths/min [ 16 ]. Tringali et al’s study reported that DBP values below 70 mmHg were associated with increased all-cause mortality in patients aged 45 years or older who encountered outpatient care [ 17 ].…”