Emergency medicine journal : EMJ
-
As patient numbers presenting to emergency departments (ED) increase, with their myriad of comorbidities, early hospital admission prediction and demand modelling are crucial both in the ED and beyond. The Glasgow admission prediction score (GAPS) (figure 1)1 has already been shown to be accurate in predicting hospital admission from the ED at the point of triage.2 As demand on EDs increase, data driven models such as GAPS will become increasingly important for predicting patient course. However, GAPS has not previously been tested beyond the point of admission.emermed;34/12/A864-b/F1F1F1Figure 1 AIM: To assess whether GAPS has the ability to predict hospital length of stay (LOS), six-month mortality and six-month hospital readmission. ⋯ In total 1420 patients were recruited, 39.6% of these patients were initially admitted to hospital. At six months, 30.6% of patients had been readmitted and 5.6% of patients had died. For those admitted at first presentation, the chance of being discharged at any one time fell by 4.3% (95% confidence interval (CI) 3.2%-5.3%) per GAPS point increase. Figure 2 displays the Kaplan Meier curves for 6 month mortality. Cox regression showed a significant association between GAPS and mortality, with a hazard increase of 9% (95% CI:6.9% to 11.2%) for every point increase on GAPS. Figure 3 displays the Kaplan Meier curves for 6 month hospital readmission.emermed;34/12/A864-b/F2F2F2Figure 2 DISCUSSION: GAPS is a simple tool which utilises data routinely collected at triage. It is predictive of hospital admission, hospital length of stay, six-month all-cause mortality and six-month hospital readmission. Therefore, GAPS could be employed to aid staff in hospital bed planning, clinical decision making and ED resource allocation and utilisation.emermed;34/12/A864-b/F3F3F3Figure 3 REFERENCES: Logan E, et al. Predicating admission at triage. Presented at International Acute Medicine Conference, Edinburgh 2016.Cameron A, et al. A simple tool to predict admission at the time of triage. Emergency Medicine Journal2014.
-
The predominant cause of preventable death from trauma is bleeding. Many patients need resuscitation with massive blood transfusion (MBT). In some theatres of military operation there is limited blood product availability and walking donor panels can be required. This study aimed to produce a tool to predict the need for MBT using information available on patient arrival at the ED for patients sustaining battlefield trauma. ⋯ The derivation dataset was made up of 1298 casualties with a massive blood transfusion rate of 21.2% (n=275). The validation dataset contained 1186; MBT rate 6.7% (n=79). The majority of patients were young, male and with penetrating injury. Univariate regression analyses showing the predictive value of the variables within the MASH score are shown in table 1. A decision rule was produced using a combination of injury pattern, clinical observations and pre-hospital interventions. The test characteristics for three cut off thresholds for the rule are shown in Table 2 alongside the sensitivity analysis. The proposed rule, using a score of 3 or greater, demonstrated a sensitivity of 82.7% and a specificity of 88.8% for prediction of MBT, with an AUROC of 0.93 (95% CI:0.91 to 0.95).emermed;34/12/A869-b/T1F1T1Table 1Univariate regression analysis of variables included in the MASH score in the derivation dataset which predict the requirement for 6 units of pRBCs in 4 hours or 10 units of pRBCs in 24 hoursemermed;34/12/A869-b/T2F2T2Table 2Performance of the MASH score in derivation and validation datasets showing test characteristics for three values of the MASH score with 95% confidence intervals with sensitivity analysis for a score of 3 in the validation dataset CONCLUSIONS: This study has produced the first military scoring system that uses clinical observations, injuries sustained and pre-hospital interventions to predict the need for MBT and therefore the requirement for an emergency donor panel in resource-limited environments. The MASH score has higher sensitivity and specificity than previous military prediction tools, and has the advantage of only using information which is rapidly available in the resuscitation bay. This is of importance to civilian practitioners with increasing possibility of major terrorist attacks.
-
Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. ⋯ During the study period, 218 985 adult patients were included in the TARN database. 127 233 (58.1%) had complete data: 55.6% male, aged 61.4 (IQR 43.1-80.0) years, Injury Severity Score 9 (IQR 9-16), 96.5% suffered blunt trauma and 24 791 (19.5%) were Priority One. The MPTT (sensitivity 57.6%, specificity 71.5%) outperformed all existing triage methods with a 44.7% absolute reduction in undertriage compared with existing UK civilian methods. AUROC comparison supported the use of the MPTT over other tools (P<0.001.) CONCLUSION: Within a civilian trauma registry population, the MPTT demonstrates improved performance at predicting need for LSI, with the lowest rates of undertriage and an appropriate level of overtriage. We suggest the MPTT be considered as an alternative to existing triage tools.
-
The 2015 RCEM End of Life Care best practice guideline highlighted the need for organ and tissue donation to be a usual part of end of life care in the Emergency Department (ED). NICE guideline states that all deaths meeting defined clinical triggers in the ED (in practice - mechanical ventilation, plan to withdraw life sustaining treatment, death expected) should prompt timely referral to organ donation services. Any family discussion in the ED regarding organ donation should be held collaboratively with a specialist nurse for organ donation (SNOD). What is the evidence in UK EDs that this is always the case? ⋯ In 2017, with the endorsement of RCEM, NHS Blood and Transplant published Organ Donation and the Emergency Department: A Strategy for Implementation of Best Practice. The strategy promotes identification and referral of potential organ donors in the emergency department and collaborative approach of their families when withdrawal of treatment is planned in the Emergency Department. Most importantly it is emphasised that organ donation should be firmly established as a usual part of end of life care irrespective of the location of the patient.emermed;34/12/A877-b/F1F1F1Figure 1Audited deaths in ED by organ donation region 1st april 2015 to 31st march 2016emermed;34/12/A877-b/F2F2F2Figure 2Died in emergency department meeting PDA referral criteria 1st April 2016 to 31st March 2017emermed;34/12/A877-b/F3F3F3Figure 3Families approaches regarding organ donation in the ED 1st April 2016 to 31st March 2017.
-
To determine whether clinical features (in the form of a clinical decision rule) or d-dimer can be used to select pregnant or postpartum women with suspected PE for diagnostic imaging. ⋯ Clinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging.