Resus Today Summer 2019 by Media Publishing Company

Volume 6 No. 2

Summer 2019

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation

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CONTENTS

Resuscitation Today

EDITORS COMMENT

CLINICAL PAPER A irway Management in the Emergency Department (The OcEAN-Study) a prospective single centre observational cohort study

CLINICAL PAPER Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study

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EDITORS COMMENT

EDITORS COMMENT It’s interesting that this season’s edition relates to both the management of the patient’s airway in the Emergency Department, and the recognition of deterioration in the most serious of patients in the first place. Failure to manage a patient’s airway appropriately is always going to lead to poor prognoses and the observation of vital signs is… well, vital. Both of these issues are contentious and evolving, considered and developing. They professionally divide colleagues and create professional discussion – as well as offering the opportunity for high quality studies to develop even higher quality patient care.

RESUSCITATION TODAY - SUMMER 2019

“Resources for managing patients in an emergency setting are becoming more effective, and technology continues to improve patient outcomes, we find ourselves at a crossroads…”

As resources for managing patients in an emergency setting become more effective (when they are used well), and technology continues to improve patient outcomes, I suggest we find ourselves at a crossroads. There are options – but what direction should we go? Is it towards the high-tech intervention that continues to perfuse but offers little hope of positive long-term outcome? Do we aim for a back-to-basics approach of doing the simple things well and accept that if they are not effective then it was not to be? Is it about taking a true moral and ethical approach, with the individual at the centre of all of the decisions we make? Or, should we be looking at a combination of all of the above: a resuscitation road-map which allows high quality basic care, accompanied by modern technology that can assist with identifying arrest causation, but based on real-time, patient-focused decision-making? There are so many more aspects of resuscitation to be considered: causes; prevention; recognition; management; and decision-making to name but a few. And there are so many possibilities within those aspects too: the education; the skills; the tools; the people; the effects; the outcomes. Quite rightly, the time is upon us to break the taboo and talk about such topics as applying patient choice and dignity in dying alongside the more professionally concerning areas of legal and regulatory care. Resuscitation Today offers the opportunity to consider all of these aspects and more; and you are welcome to submit your own work for publication – I look forward to receiving submissions for review that range from ‘simple’ position-pieces to ‘complex’ analytical research papers. From novices who may be experimenting with their investigative genes, to experts in the field who can offer academic challenge to the ‘norm’. Get in touch, submit comments and work at: info@mediapublishingcompany.com

Paul Jones (MRes; BSc; fHEA; Paramedic)

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CLINICAL PAPER

AIRWAY MANAGEMENT IN THE EMERGENCY DEPARTMENT (THE OCEAN-STUDY) - A PROSPECTIVE SINGLE CENTRE OBSERVATIONAL COHORT STUDY Michael Bernhard1,2,3†, Sönke Nils Bax2,7*†, Thomas Hartwig2, Maryam Yahiaoui-Doktor4, Sirak Petros5, Sven Bercker6, Alexandra Ramshorn-Zimmer2 and André Gries2 Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. (2019) 27:20 doi: 10.1186/s13049-019-0599-1

Abstract Background Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). Methods Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form.

RESUSCITATION TODAY - SUMMER 2019

admitted to the RR. 150 (28.2%) CINT patients had received out-ofhospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. Conclusions OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future.

Results During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were

Keywords Airway management, Emergency department, Resuscitation room, Firstpass success, Complications

Background

Methods

Critically ill patients frequently require airway management in the field

Study design

or in the Emergency Department (ED) [1]. Several investigations have

This prospective single centre observational cohort [Observation of

shown that emergency airway management in the field and in the ED

airway management in Emergency Department (OcEAN)] study was

is associated with adverse events and complications (e.g., hypoxemia,

carried out from 1 September 2014 to 31 August 2015 in the ED of

oesophageal intubation, hypotension) [2, 3]. However, inadequate

the University Hospital of Leipzig, Germany. The OcEAN study was

oxygenation and ventilation will lead to wrong outcome and therefore

approved by the ethical committee of the Medical Faculty of the

emergency airway management is of priority in resuscitation of critically

University of Leipzig, Germany (265–14-25,082,014).

ill patients [4, 5]. Setting Studies have demonstrated that the number of intubation attempts

More than 34,000 patients are managed annually in the ED of the

is associated with increasing complication rates, therefore, the “first-

University Hospital of Leipzig, a level 1 trauma centre. However,

pass intubation success” is an important concept in emergency airway

about 50% of patients suffering from non-traumatic acute problems

management [6, 7]. ED Airway registries exist in some countries (e.g.,

or emergencies. The out-of-hospital emergency care is provided by

Australia [8], North America [9, 10], Korea [11], Japan [12]), however

an EMS system staffed with paramedics and EMS physicians. In our

data on emergency airway management in German EDs are still

institution, all non-traumatic critically ill patients in the RR are treated

missing.

by a team of two nurses, one resident and one senior physician with emergency and intensive care competency. Patients fulfilling the non-

The aim of this study is to evaluate airway management in critically

trauma RR activation criteria according to Additional file 1: Table S1

ill patients in the resuscitation room (RR) of a German ED in order to

(in the Supplemental material) are admitted to the RR, the others are

describe incidence, devices, techniques, success and complication

treated in other regions of the ED as the observation unit or one of the

rates.

single cabins.

CLINICAL PAPER Study definition and data collection

The out-of-hospital airway management records were reviewed by the

All adult non-traumatic critically ill patients needing airway management

main investigator [airway management technique performed by EMS

in the ED RR were consecutively included. Paediatric and trauma

physicians including endotracheal intubation, supraglottic airway device

patients were excluded. For further analysis, data were documented

(SAD), cricothyroidotomy, success of airway management, use of

in a self-developed and implemented airway registry form. The airway

capnography].

registry form included the “Utstein airway core variables” established in the out-of-hospital airway management, as well as parameters

The ED airway management was recorded, including patient position

implemented in out-of-hospital and ED airway registries in North

[back-up head elevated (BUHE [20]) or supine position], immobilization,

America and Austria, as well as other out-of-hospital studies from

and airway device [Macintosh blade, video laryngoscope, SAD

Germany [4, 5, 8, 9, 13-16].

(laryngeal tube, laryngeal mask airway), cricothyroidotomy, tracheotomy tube]. The number of intubation attempts per patient was also recorded.

The OcEAN airway registry form was completed in the RR, any missing

An airway management attempt was defined as the insertion of the

data were followed up through interviews with the staff involved or from

airway device in the mouth (i.e., single passage of a laryngoscopy

the medical records.

blade behind the lips, insertion of SAD). Multiple intubation attempts were defined as more than one insertion attempt. Per our institutional

The OcEAN airway registry form included the patient’s characteristics

safety protocol, physicians had to handover the airway procedure to

(age, gender, weight, high, body mass index), out-of-hospital triage score

another physician after a second failed attempt at airway management.

using American Society of Anesthesiology (ASA) score [17] at hospital

Difficult airway characteristics were described using parameters of the

admission and National Advisory Committee of Aeronautics (NACA) score

LEMON law (look external, evaluate 3–3-2 rule, Mallampati score [21],

in order to stratify the patient cohort [18], as well as the chief complaint

obstruction, immobilisation). Degree of visualization of the vocal cords

leading to ED admission [cardiac arrest, unconsciousness (Glasgow

was described using Cormack/Lehane (C/L) grade [22, 23] as assessed

coma scale [19] < 9), respiratory failure, shock].

by direct or video laryngoscopy. The intubations’ difficulty scale (IDS)

RESUSCITATION TODAY - SUMMER 2019

Fig. 1 Study cohort: ED = emergency department, CINT = critically ill non-traumatic, RR = resuscitation room

CLINICAL PAPER Table 1 Patient’s characteristics out-of-hospital airway management (n = 150)

ED airway management (n = 136)

age (years), MV ± SD,

66 ± 16

65 ± 18

0.730

Median, min-max

69, 18–94

71, 20–89

Weight (kg), MV ± SD,

83 ± 27

81 ± 22

Median, min-max

80, 42–180

80, 40–150

Hight (cm), MV ± SD,

170 ± 32

170 ± 9

Epidemiology

0.403 0.992

Median, min-max

170, 150–190

170, 140–190

BMI (kg/m2), MV ± SD,

28 ± 8

28 ± 7

Median, min-max

28, 15–58

26, 16–59

Male Gender [n, (%)]

86 (57.3%)

82 (60.2%)

0.611

NACA (points), MV ± SD,

5.3 ± 0.8

4.8 ± 0.7

0.001

Median, min-max

5.5, 3–6

5, 3–6

ASA (points), MV ± SD,

3.5 ± 1.3

3.2 ± 0.9

Median, min-max

4, 1–6

3, 1–5

Cardiac arrest [n, (%)]

74 (49.3%)

9 (6.6%)

< 0.001

Unconsciousness [n, (%)]

50 (33.3%)

58 (42.6%)

0.105

Respiratory failure [n, (%)]

18 (12.0%)

50 (36.8%)

< 0.001

Hemodynamic instability [n, (%)]

8 (5.3%)

19 (14.0%)

0.01

0.419

0.007

Reason for airway management

was calculated for each patient [24]. A difficult intubation was defined as

In 150 (52.4%) patients, airway management was performed by EMS

one that requires more than two attempts or an IDS ≥5 points [24].

before and in 136 (47.6%) patients by ED staff after admission to the RR (Fig. 1). In 11 (7.3%) patients of the EMS group, the airway was secured

For ED airway management, intubation conditions (very good = glottis

with a laryngeal tube by paramedics. In 7 out of these 11 (63.6%) cases,

open, good = glottis open and less combative patient, poor = glottis

an EMS physician had changed the airway device into an endotracheal

nearly closed and combative patient, very bad = glottis closed) were

tube in the out-of-hospital setting. In 16 (10.7%) patients of the EMS

recorded. Moreover, any complication during RR airway management

group, the airway device had to be changed after RR admission due

was documented. Complications (e.g. oxygen desaturation,

to various reasons. The patient characteristics in the EMS and the RR

hypotension) were defined in accordance to Sakles et al. [6].

management group were comparable (Table 1). However, according to the out-of-hospital triage score, patients with out-of-hospital airway

RESUSCITATION TODAY - SUMMER 2019

Statistical analysis

management had a higher NACA (5.3 ± 0.8 vs. 4.8 ± 0.7, p = 0.001) and

Data were entered into Microsoft Excel 2014 (Microsoft, Germany) and

ASA score (3.5 ± 1.3 vs. 3.2 ± 0.9, p = 0.007) in comparison to patients

analysed using SPSS (IBM-Statistics, Version 20, IBM Inc., Armonk, NY,

with in-hospital airway management in the RR. The leading indication

USA). Descriptive statistics included number or percentages, mean

for airway management in the field and the RR setting differ significantly,

(SD), median and minimal to maximal value. Chi2-test or, as appropriate,

with cardiac arrest in the out-of-hospital setting and unconsciousness as

Fisher’s exact test were used to compare groups of binary data and

well as respiratory failure in the RR setting (Table 1).

to test for trends. For all analyses, actual P-values were reported and all tests were two-tailed. Statistically significant differences were

Patients with out-of-hospital airway management in the

considered at p < 0.05 level.

resuscitation room

Results

Patients who received airway management by EMS physicians (n = 150) underwent endotracheal intubation or laryngeal tube insertion in 90.7% (n = 136) and 9.3% (n = 14), respectively. Out of hospital capnography

During the 12-month study period, 34,303 patients were admitted to the

was used in 82.7%. Oesophageal intubation was detected in two cases

ED. 13,229 patients with 592 treated in the RR were excluded due to

(1.5%) of the out-of-hospital intubation group. In one of these patients

trauma as leading cause of admission. 21,074 patients were admitted

capnography had not been used in the field or during transport. Both

for non-traumatic emergencies, with 537 patients directly admitted to

patients were admitted with on-going cardiopulmonary resuscitation and

the RR (2.54%). After excluding five patients due to incomplete datasets,

ED physicians secured the airway within the first intubation attempt using

286 critically ill non-traumatic patients receiving airway management in

direct laryngoscopy (each C/L grade 1). In both cases, there were no

the RR were further investigated (53.8%).

predicted or occurred difficult airways using LEMON law and IDS score.

CLINICAL PAPER In the 14 patients with out-of-hospital inserted laryngeal tubes, we observed insufficient ventilation (e.g. airway leakage) in 8 cases (57.1%), in 75% without out-of-hospital use of capnography. During the RR period, all 14 patients with laryngeal tube were successfully intubated using direct vs. video laryngoscopy (42.9%, n = 6 vs. 57.1%, n = 8) within 1.3 ± 0.5 (Median: 1, min-max 1–2) vs. 1.9 ± 1.4 attempts (Median: 1.5, min-max 1–5), respectively. We did not observe a significant difference according to LEMON law (0.7 ± 0.5 vs. 0.6 ± 0.5 points) or IDS score (2.7 ± 0.5 vs. 2.0 ± 1.9) comparing direct vs. video laryngoscopy, while C/L grades were significantly different (2.3 ± 1.0 vs. 1.4 ± 0.5, p = 0.04). RR patients without out-of-hospital airway management In 136 patients, airway management was initiated first after RR admission. A tracheotomy tube change was necessary in 2 cases, both successful at the first attempt. The other patient had been intubated with first-pass, second-pass, and third-pass intubation success rates of 70.9% (n = 95), 14.9% (n = 20), and 0.8% (n = 1), respectively. Overall, 100% of the intubations were successful in mean after 1.3 ± 0.8 intubation attempts (Median: 1, min-max: 1–6). Multiple intubation attempts were needed in 39 cases (29.1%). The intubation procedure

Table 2 Difficult airway characteristics (n = 136) [n, (%)] anticipated difficult airway

Table 2 Difficult airway characteristics (n = 136) LEMON

0 points anticipated difficult airway LEMON ≥1 point LEMON IDS 0 points 0 points LEMON ≥1 point 1–5 points IDS ≥ 5 points 0 points Cormack/Lehane I 1–5 points II ≥ 5 points III Cormack/Lehane I IV II not documented III

*including 2 patients with tracheotomy tube exchange

not documented

32 (23.5%) [n, 85 32 51

(%)] (62.5%) (23.5%) (37.5%)

85 39 51 81

(62.5%) (28.8%) (37.5%) (59.6%)

16 (11.6%) 39 (28.8%) 59 (43.4%) 81 (59.6%) 40 (29.4%) 16 (11.6%) 23 (16.9%) 59 (43.4%) 4 (2.9%) 40 (29.4%) 10 (7.4%)* 23 (16.9%) 4 (2.9%) 10 (7.4%)*

was handed over to another physician in 14 cases (10.4%), as required

*including 2 (9.3%) patients(Table with tracheotomy tube exchange desaturation 4). The overall complication rate was 42.6%.

by the institutional ED safety protocol. In the cases handed over,

The complication rates (and mean number of intubations attempts)

1.2 ± 0.4 intubations attempts were required for successful intubation by

increased according to the C/L grade 1, 2, 3 and 4 as following 24%

the next provider (Median 1, min-max: 1–2).

(1.2 ± 0.5), 25% (1.2 ± 0.4), 24% (1.6 ± 0.8), and 75% (3.3 ± 2.2).

Direct laryngoscopy and video laryngoscopy was used in 69.9% (n = 94) and 30.1% (n = 40), respectively. Overall, the needed mean number of intubation attempts in the direct (macintosh blade) and video laryngoscopy (macintosh-like blade) group with 1.2 ± 0.5 vs. 1.2 ± 0.4 were comparable (p = 0.887). The percentage of anticipated difficult airways estimated by the acting physician was 23.5%. The prediction of difficult airways according to patients with at least one positive LEMON criterion and with an IDS ≥5 points was 37.5 and 11.6%. The difficult airway characteristics of the patients are presented in Table 2, and the difficulties contributed to problems during RR intubation procedures were shown in Table 3. BUHE and supine, as patient positioning for endotracheal intubation, were used in 50.7% (n = 68) and 44.8% (n = 60), respectively. In order to optimize the first intubation attempt, stylets, NBA, Jackson’s position, BURP, and suction units were used in 91.0% (n = 122), 82.1% (n = 110),

Discussion This prospective single centre study evaluated the out-of-hospital and ED initiated airway management in adult non-traumatic critically ill patients in an academic German ED during a one-year observational period. The primary goal was to evaluate the out-of-hospital airway management performed by EMS physicians at hospital arrival and to document the airway management in the RR setting in the ED in order to describe incidence, airway technique, success and complication rates. Several ED airway registries exist worldwide (e.g., Australia [8], North

Table [9, 3 Difficulties contributed to problems America 10], Korea [11], Japan [12]), however during data on emergency resuscitation room intubation procedures (n = 129)

[n, (%)]

Table 3 Difficulties contributed to problems during Secretion/blood resuscitation room intubation procedures (n = 129)

21 (16.3%)

Complications and adverse events were documented in 129 out of

Anatomy neck

0 (0.0%)

136 patients (94.9%). The most common complications and adverse

Malfunction equipment

0 (0.0%)

The mean number of needed intubation attempts correlated with the intubation condition categories “very good/good” and “bad/very bad” with 1.2 ± 0.5 vs. 2.2 ± 1.4 (p = 0.0001) and C/L grade 1/2 and 3/4 (1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002) (Fig. 2). First-pass success was associated with C/L 1, 2, 3 and 4 with 79.5, 77.5, 56.5, and 25.0%, respectively. Patient positioning in BUHE or supine did not affect the C/L grade (BUHE vs. supine: C/L grade 1/2: 78.1 vs. 79.3%; C/L grade 3/4: 21.9 vs. 20.7, p = 0.873). Direct laryngoscopy compared with video laryngoscopy did not lead to better C/L grade 1/2 (81.3 vs. 73.9%, p = 0.334).

RESUSCITATION TODAY - SUMMER 2019

Short neck Secretion/blood Immobilisation Reduced mouth opening Untrained personal Short neck Retrognathy Immobilisation Patient positioning Untrained personal Anatomy pharynx/larynx Retrognathy Foreign body Patient positioning Anatomy neck Anatomy pharynx/larynx Malfunction equipment Foreign body

12 (9.3%) [n, (%)] 9 (8.5%) 21 (16.3%) 7 (5.4%) 12 (9.3%) 7 (5.4%) 9 (8.5%) 4 (3.1%) 7 (5.4%) 3 (2.3%) 7 (5.4%) 3 (2.3%) 4 (3.1%) 1 (1.6%) 3 (2.3%) 0 (0.0%) 3 (2.3%) 0 (0.0%) 1 (1.6%)

70.9% (n = 95), 26.9% (n = 36), and 14.2% (n = 19).

Reduced mouth opening

events during RR airway management were hypotension (20.4%) and

CLINICAL PAPER

Fig. 2 Number of mean intubations attempts according to intubations conditions and Cormack/Lehane grade. MV = mean value, SD = standard deviation Fig. 2 Number of mean intubations attempts according to intubations conditions and Cormack/Lehane grade. MV = mean value, SD = standard deviation

airway management in German EDs are still missing. Thereby, the

As described in the study protocol only critically ill non-traumatic

introduction of an airway registry is an important issue for quality

patients were investigated in this study and patients with trauma were

assurance [25]. To our knowledge, this is the first study investigating RR

excluded. However, this study population may restrict the comparability

airway management in non- traumatic patients in a German ED setting.

of our results to other airway registries [8, 10, 32, 33].

In patients with out-of-hospital airway management admitted to the RR we

In the second part of this investigation, the observed sample size of

found a low incidence of oesophageal intubation with 1.5% in comparison

136 ED initiated airway procedures in our ED is comparable with those

to other studies that reported a rate of 5.1–6.7% in German physician-

in other large ED airway registries (including 50–90 cases per year)

staffed EMS [26, 27]. Interestingly, 9.3% of the admitted patients were treated with a laryngeal tube. According to institutional policy all 14 patients with SADs were intubated immediately after RR admission. In 57% of these SAD patients ventilation was insufficient at RR admission. Comparable complications and adverse events rates after out-of-hospital laryngeal tube insertion were also reported elsewhere [28, 29, 30]. One of the major concerns is that only 82.7% of patients received capnography in the out-of-hospital setting. Oesophageal intubations, as well as insufficient ventilation after insertion of a laryngeal tube would likely be recognized during the out-of-hospital airway management if capnography would solely have been used [28, 31]. RESUSCITATION TODAY - SUMMER 2019

Hypotension (decrease in SBP to < 90 mmHg)

16 of theses cases with insufficient ventilation and oxygenation needed immediate airway management after hospital arrival. The observed first-pass success rate of the 134 patients receiving invasive airway management after RR admission was 70.9%. These findings were in line with previous analysis of ED airway registry reporting a first-pass success range of 61–94% [7, 8, 10, 33, 34, 35]. However, the first-pass success rate in this study was lower than in the meta-analysis by Park et al. [36] founded 84% as an ED benchmark. The aim of improving first-pass success should be paramount since it is well known that in complications [6, 7, 12]. The overall airway management success in

26 (20.2%) 12 (9.3%)

oesphageal(decrease intubationin SBP to < 90 mmHg) Hypotension aspiration (decrease in oxygen saturation ≥ 10%) desaturation

(5.4%) 267(20.2%) (3.1%) 124(9.3%)

endobronchial intubation oesphageal intubation cardiac arrest aspiration

2 (1.6%) 7 (5.4%) 4 (3.1%) 4 (3.1%)

complicationsintubation endobronchial

55 (42.6%) 2 (1.6%)

SBP systolic blood pressure cardiac arrest

4 (3.1%)

complications

55 (42.6%)

SBP systolic blood pressure

airway management already performed by EMS physicians. However,

multiple intubation attempts are associated with significant increases

Table 4 Complications during airway management in resuscitation room (n = 129)

Table 4 Complications during airway management in desaturation (decrease in oxygen saturation ≥ 10%) resuscitation room (n = 129)

[10, 34]. In addition, we investigated RR patients with out-of-hospital

this investigation was 100% and comparable with the results of other airway registries and ED studies [7, 10, 32, 34]. Overall, the airway of all patients was secured using endotracheal intubation, excluding two patients with tracheostomy tube change (1.5%). Contrary to other investigations [10, 25, 32], fiberoptic intubation and cricothyroidotomy was not performed during the study period. However, with an anticipated incidence of cricothyroidotomy of 0.3%, it is likely only a question of time for this procedure to also be seen in our institution. The intubation procedure was performed in two-thirds of cases using direct laryngoscopy with Macintosh blades, and less often using C-MAC video laryngoscopes with Macintosh-like blades. Other investigations found a comparable rate of video laryngoscopy use in 39–48% [8, 34].

CLINICAL PAPER It is anticipated that the incidence of video laryngoscopy assisted

Our study suffers from several limitations. At first, this study was

intubation will increase in the upcoming years [10, 33].

carried out at a single institution and so the results cannot be taken to be representative of all EDs in Germany, or other places in the

A difficult airway was anticipated in 23.5% of patients receiving RR

world. Nevertheless, this study provided detailed information about

airway management. One-third of airways were predicted as difficult

German RR airway management in critically ill non-traumatic patients

per LEMON law, and a moderate to severe intubation situation was

for the very first time. Furthermore, the study was observational in

observed in 11.6% per IDS. These findings were in the range with

nature, neither randomized nor controlled. The team leader was

data reported from other airway registries [33]. In line with previous

required to complete the airway registry form. Reporter bias is difficult

investigations, problems associated with difficulties during ED airway

to exclude, and there may be a tendency to document an improved

management were most often secretion or blood in the pharynx,

glottis visualisation and underreport complications. The self-developed

reduced mouth opening, short neck and immobilization [4]. In

emergency airway registry form was combined with the information

contrast to Khandelwal et al. [20] and Turner et al. [37], we did not

of medical charts, which has been reported to be beneficial [45]. The

find an association between C/L grade and BUHE or supine position

team leaders were instructed repeatedly and attempts to improve

in ED airway management. Hossfeld et al. [38] reported an improved

accuracy were made by interviewing the ED physicians and by

visualization using video laryngoscopes (with Macintosh-like blade)

reviewing the medical record.

compared to standard Macintosh laryngoscopes. However, in line with some investigations [39], we found similar C/L grade 1/2 using

Due to the fact that in Germany a multi-centre airway registry does not

video laryngoscopes in comparison to direct laryngoscopy with

exist, we suggest that this should be initiated in order to analyse the

standard Macintosh blade.

situation countrywide. Studies identified more than eleven emergency airway registries that sometimes widely differed concerning inclusion

Complications associated with the intubation procedures were

period, inclusion criteria, definition of complications and application of

observed in 42.6%. Other studies reported complication rates

newer methods of emergency airway management [47]. Comparability

between 10 and 29% [8, 32, 33, 34]. Differences in the reported

of the reported results and first-pass-success rates is only possible

complication rates are at least in part due to varying definitions

to a limited extent. Therefore, standardised reporting forms should

of complications in other airway registries. Hypotension was the

be used in order to make the results comparable. Using the data,

most common reported complication with 20%, which is in line with

benchmarking would be possible, with systematic investigation on

other investigations reporting an incidence of 7–18% [40, 41]. The

first-pass success, techniques, complications and adverse events.

incidence of immediately detected and corrected oesophageal

Moreover, the effect of new techniques in the ED setting concerning

intubations in 5.4% was in line with other ED studies [8, 34].

emergency airway management over the years will be detectable as

Immediate recognition of oesophageal intubation using capnography

described by Brown et al. [34]. Using these data, procedural and

is imperative to prevent hypoxemia [31]. In the RR, we used

structural optimisation of this important field will be possible.

capnography without exception. Desaturation occurred in this study with 9.3% and which is comparable to other out-of-hospital and ED airway registries (11–16%) [8, 33, 42].

Conclusions

As a limitation of this study, we need to mention that we performed

In conclusion, RR airway management of critically ill non-traumatic

but did not document specific procedures for preoxygenation

patients has substantial challenges. Our study results confirm that

(e.g., delayed sequence intubation using non-invasive ventilation

RR airway management is a high-risk procedure. We propose a

for preoxygenation [43]) or apnoeic oxygenation [44]. Including

nation-wide airway registry to better track outcomes of RR airway

these procedures to further study protocols seems to be necessary.

management in the future.

Moreover, the kind of laryngoscopy (video vs. direct laryngoscopy) Abbreviations

complication during ED airway management occurred in the present

AM: Airway management; ASA: American Society of Anaesthesiology;

investigation at a rate of 3.1%, which was comparable to other out-

BUHE: Back-up head elevated or supine position; C/L: Cormack/

of-hospital and ED investigations with a reported range between

Lehane score; CINT: Critically ill non-traumatic patients; ED:

1.5–4.4% [8, 34, 45].

Emergency department; EMS: Emergency medical service (in Germany with emergency doctors and emergency paramedics); IDS:

Rapid sequence induction using neuromuscular blocking agents was

Intubations’ difficulty scale; LEMON: Look external, evaluate 3–2-2

performed in 87.5% in the RR setting. These findings are in line with

rule, Malampati score, obstruction, immobilisation; NACA: National

other data from ED airway registries described percentages between

Advisory Committee of Aeronautics; OcEAN: Observation of airway

73 and 92% [10, 25, 32, 34]. However, there are other data from

management in Emergency Department; RR: Resuscitation room;

a Japanese ED airway registry stated a lower rate of RSI use with

SAD: Supraglottic airway device

only 20% [35]. Comparable with other investigations [34], the most frequent used neuromuscular blocking agent was rocuronium in 85%.

Acknowledgements Not applicable

Taking together, the game changer in out-of-hospital airway management are preoxygenation (e.g. delayed sequence intubation),

Funding

using of video laryngoscopy and muscle relaxation [43, 46].

This study was funded solely by departmental resources.

RESUSCITATION TODAY - SUMMER 2019

should be documented in further studies. Cardiac arrest as a major

CLINICAL PAPER Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Authors’ contributions MB and SNB contributed equally to the manuscript. MB, SNB, TH, AG and ARZ conceived the study, collected the data, and performed first and subsequent drafts. MB, SNB, MYD, AG, ARZ performed the statistical analysis of the data. SP reviewed and constructively criticised the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate The OcEAN study was approved by the ethical committee of the Medical Faculty of the University of Leipzig, Germany (265–1425,082,014). Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Michael Bernhard and Sönke N. Bax contributed equally to the

†

manuscript.. *Correspondence: soenke@bax-se.de; soenke.bax@ paracelsus-kliniken.de.1Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany. 2Emergency Department, University Hospital of Leipzig, Leipzig, Germany. 3Working group “Trauma and Resuscitation Room Management“, Task Force Emergency Medicine, German Society of Anaesthesiology and Intensiv care Medizin, Nürnberg, Germany. 4Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany. 5Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany. Department of Anaesthesiology and Intensive Care Medicine, University

Hospital of Leipzig, Leipzig, Germany. 7Emergency Department, Paracelsus Hospital of Henstedt-Ulzburg, Wilstedter Straße 134, D-24558 Henstedt-Ulzburg, Germany. References RESUSCITATION TODAY - SUMMER 2019

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37. Turner JS, Ellender TJ, Okonkwo ER, et al. Feasibility of upright patient positioning and intubation success rates at two academic emergency departments. Am J Emerg Med. 2017;35:986–92.

26. Gries A, Sikinger M, Hainer C, et al. Time in care of trauma patients in the air rescue service: implications for disposition? Anaesthesist. 2008;57:562–70.

38. Hossfeld B, Frey K, Doerges V, Lampl L, Helm M. Improvement in glottic visualisation by using the C-MAC PM video laryngoscope as a first-line device for out-of-hospital emergency tracheal intubation. Eur J Anaesthesiol. 2015;32:425–31.

27. Timmermann A, Russo SG, Eich C, et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg. 2007;104:619–23.

39. Carlson JN, Crofts J, Walls RM, Brown CA. Direct vs. video laryngoscopy for intubating adult patients with gastrointestinal bleeding. West J Emerg Med. 2015;16:1052–6.

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40. Newton A, Ratchford A, Khan I. Incidence of adverse events during prehospital rapid sequence intubation: a review of one year on the London helicopter emergency medical service. J Trauma. 2008;64:487–92.

29. Bernhard M, Hossfeld B, Kumle B, Becker TK, Böttiger BW, Birkholz T. Don’t forget to ventilate during cardiopulmonary resuscitation with mechanical chest compression devices. Eur J Anaesthesiol. 2016;33:553–6.

41. Rognas L, Hansen TM, Kirkegaard H, Tonnesen E. Pre-hospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med. 2013;21:58.

30. Schalk R, Seeger FH, Mutlak H, et al. Complications associated with the prehospital use of laryngeal tubes – a systematic analysis of risk factors and strategies for prevention. Resuscitation. 2014;85:1629–32.

42. Helm M, Kremers G, Lampl L, Hossfeld B. Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists. Acta Anaesthesiol Scand. 2013;57:199–205.

31. Von Goedecke A, Herff H, Paal P, Dörges V, Wenzel V. Field airway management disasters. Anesth Analg. 2007;104:481–3.

43. Weingart SD, Trueger S, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015;65:349–55.

32. Walls RM, et al. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med. 2011;41:347–54. 33. Fogg T, Alkhouri H, Vassiliadis J. The Royal North Shore Hospital Emergency Department airway registry: closing the audit loop. Emerg Med Australisia. 2016;28:27–33. 34. Brown CA, et al. Techniques, success and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65:363–70. 35. Hasegawa K, et al. Emergency airway management in Japan: interim analysis of a multi-center prospective observational study. Resuscitation. 2012;83:428–33. 36. Park L, Zeng I, Brainard A. Systematic review and meta-analysis of first-pass success rate in emergency department intubation: creating a benchmark for emergency airway care. Emerg Med Austral. 2017;29:40–8.

44. Oliveira LE, Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Ann Emerg Med. 2017;70:483–94. 45. Bloomer R, Burns BJ, Ware S. Improving documentation in prehospital rapid sequence induction: investigating the use of a dedicated airway registry form. Emerg Med J. 2013;30:324–6. 46. Hossfeld B, Bein B, Böttiger BW, Bohn A, Fischer M, Gräsner JT, Hinkelbein J, Kill C, Lott C, Popp E, Rössler M, Schaumberg A, Wenzel A, Bernhard M. Recommended practice for out-of-hospital emergency anaesthesia in adults. Statement from the out-of-hospital emergency Anaesthesia working Group of the Emergency Medicine Research Group of the German Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2016;33:881–97. 47. Girrbach FF, Hilbig F, Michael M, Bernhard M. Systematic analysis of airway registries in emergency medicine. Anaesthesist. 2018;67:664–73.

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RESUSCITATION TODAY - SUMMER 2019

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CLINICAL PAPER

REPEATED VITAL SIGN MEASUREMENTS IN THE EMERGENCY DEPARTMENT PREDICT PATIENT DETERIORATION WITHIN 72 HOURS: A PROSPECTIVE OBSERVATIONAL STUDY Vincent M. Quinten1* , Matijs van Meurs2,3, Tycho J. Olgers1, Judith M. Vonk4, Jack J. M. Ligtenberg1 and Jan C. ter Maaten1 Reproduced with permission from the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. (2018) 26:57 doi: 10.1186/s13049-018-0525-y

Abstract Background More than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate. Methods We performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its

variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated. Results In total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration. Conclusions Repeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission. Keywords: Accident & emergency medicine; Patient deterioration; Sepsis; Vital signs

Background Glasgow coma scale (GCS) are associated with intensive care unit

(ED) with (suspected) infection or sepsis deteriorate within 72 h from

(ICU) admission [9, 11]. For all other vital signs, insufficient evidence

admission, despite treatment [1]. Recent advances in research have

is available [9, 11]. The few available studies mostly studied vital

improved our understanding of the pathophysiology of sepsis [2]. The

signs used in triage systems or vital signs obtained at the time of ED

adoption of surviving sepsis campaign (SSC) guidelines, increased

admission [9, 12]. Almost one third of the medical patients who arrive at

awareness and early goal-directed therapy dramatically reduced sepsis-

the ED with normal vital signs show signs of deterioration in vital signs

related mortality over the past two decades [3, 4]. However, one of the

within 24 h [13]. Our pilot study in the ED showed that vital signs change

main challenges for the physician in the ED remains to determine the

significantly during the patientâ&#x20AC;&#x2122;s stay in the ED [7]. However, surprisingly

risk of deterioration for the individual patient [2]. The numerous sepsis-

little is known on how to monitor and identify deteriorating patients in the

related biomarkers lack sensitivity and specificity for deterioration and

emergency department [13]. The latest SSC guidelines recommend a

are not readily available in the ED [5, 6, 7]. Despite the relative ease of

thorough re-evaluation of routinely measured vital signs as parameter

measurement, surprisingly little is known about vital signs in relation

for response to treatment [4]. Therefore, the aim of the current study

to clinical outcomes, especially in the ED setting [8, 9, 10, 11]. There

was to determine whether repeated vital sign measurements during

is limited evidence that oxygen saturation and consciousness level

the patientâ&#x20AC;&#x2122;s stay in the ED can distinguish between patients who will

at ED arrival are associated with mortality, and that heart rate and

deteriorate within 72 h from admission and patients who will not.

RESUSCITATION TODAY - SUMMER 2019

More than one in five patients presenting to the emergency department

CLINICAL PAPER Methods Study design and setting This study is a predefined prospective observational study, part of the Sepsis Clinical Pathway Database (SCPD) project in our emergency department (ED). The SCPD project is a prospective cohort study of medical patients presenting to the ED with fever and/or suspected infection or sepsis. Data was collected in the ED of the University Medical Center Groningen in The Netherlands, an academic tertiary

oxygen supplementation [7]. The protocol did not change during the inclusion period and was not influenced by the patient’s participation in the study. For patients arriving at the ED with EMS and (suspected) sepsis, treatment with fluid resuscitation and supplementary oxygen was started in the ambulance by EMS personnel according to the nationwide EMS guidelines for sepsis in The Netherlands [14]. The average time from EMS dispatch call to ED arrival is 40 min in The Netherlands, but actual dispatch times in this study were not measured [14]. Pre-hospital start of treatment was not influenced by the patient’s participation in the

care teaching hospital with over 30,000 ED visits annually.

study.

This study was carried out in accordance with the Declaration of

Endpoints and definitions

Helsinki, the Dutch Agreement on Medical Treatment Act and the Dutch Personal Data Protection Act. The Institutional Review Board of the University Medical Center Groningen ruled that the Dutch Medical Research Involving Human Subjects Act is not applicable for this study and granted a waiver (METc 2015/164). All participants provided written

The primary endpoint was patient deterioration within 72 h from ED admission. We defined patient deterioration as the development of organ dysfunction, ICU admission or death during the patient’s stay in the hospital. For organ dysfunction, we distinguished between acute kidney failure (AKI), liver failure and respiratory failure. AKI was defined

informed consent.

using the Kidney Disease Improving Global Outcomes (KDIGO) criteria

Study population

48 h or 1.5 times the baseline (known or presumed to have occurred

Data was collected between March 2016 and February 2017. Consecutive medical patients visiting the ED between 8 a.m. and 23 p.m. were screened for eligibility. Inclusion criteria were: (1) age of 18 years or older, (2) fever (> = 38 °C) or suspected infection or sepsis, (3) able to provide written informed consent. The clinical suspicion of infection or sepsis was judged by the coordinating internist acute medicine on duty. He/she handles all medical patient announcements from general practitioners or the emergency medical services (EMS),

as an increase in serum creatinine by 26.5 μmol/L (0.3 mg/dL) within within the prior 7 days) [15]. Liver failure was defined as total bilirubin level > 34.2 μmol/L (2.0 mg/dL) and either alkaline phosphatase or a transaminase level above twice the normal limit [16]. Respiratory failure was defined as the need for mechanical ventilation, or either hypoxemia (PaO2 < 8.0 kPa) or hypercapnia (PaCO2 > 6.5 kPa) in the arterial blood gas analysis, or a peripheral oxygen saturation < 90% when breathing ambient air or < 95% with at least 2 L/min of oxygen supplementation [17]. In-hospital mortality was defined as all-cause mortality during the

and medical patients that enter the ED without previous announcement.

patient’s stay in the hospital. The Sepsis-2 criteria (2001 international

The judgement was based on information provided over the phone

sepsis definitions conference) were used to define sepsis, severe

during the announcement, information obtained at triage and

sepsis or septic shock, i.e. two or more systemic inflammatory response

immediately after ED admission of the patient. Only patients with at least

syndrome criteria and suspected/confirmed infection [18].

three repeated vital sign measurements during their first 3 h in the ED were included in the final analysis.

Statistical analysis Continuous data were reported as median with interquartile range (IQR)

Data collection

and analysed using the Mann-Whitney U test. Categorical data were

The data collected in the SCPD project includes socio-demographic

summarized as counts with percentages and analysed using the Chi-

information, patient history, prescription drug usage, comorbidity,

square test.

treatment parameters, results from routine blood analysis,

RESUSCITATION TODAY - SUMMER 2019

questionnaires about activities of daily living, follow-up during the

For each vital sign and for each patient, we used the repeated

patient’s stay in the hospital and registration of various endpoints. The

measurements to estimate the linear change and variability over

data was collected by trained members of our research staff during

time. Linear change over time was estimated using individual linear

the patient’s stay in the ED and combined with data from the patient’s

regression analysis separately for each vital sign (heart rate, respiratory

medical record for follow-up during the patient’s stay in the hospital.

rate, mean arterial pressure and temperature) with the time of the measurement (in minutes) as independent variable. The resulting

For the current study, next to the data collected for all patients included

regression estimates for time, indicate the linear change per minute

in the SCPD project, we repeatedly measured vital signs in 30-min

for each patient and each vital sign. The variability of each vital sign

intervals during the patient’s stay in de ED. These vital signs included

was calculated as the difference between the highest and lowest value

heart rate, respiratory rate and blood pressure, measured using a

during the first 3 h in the ED.

Philips MP30 or MX550 bed-side patient monitor (Philips IntelliVue System with Multi-Measurement Module; Philips, Eindhoven, The

To analyse the added value of the linear change and variability over time

Netherlands). Furthermore, the body temperature was measured using

of each vital sign as predictors for patient deterioration within 72 h, we

an electronic tympanic ear thermometer (Genius 2; Mountainside

performed multiple logistic regression analysis. First, we constructed a

Medical Equipment, Marcy, New York, USA).

base model containing age, gender and comorbidity. The added value of each vital sign to the base model was assessed using the following

All patients received treatment for infection or sepsis as per our

logistic regression analyses: (1) base model + vital sign value at

hospital’s standardized protocol at the treating physician’s discretion.

admission, (2) base model + vital sign value at admission + change of

This protocol included intravenous antibiotics, fluid resuscitation and

the vital sign during the first 3 h in the ED and (3) base model + vital

CLINICAL PAPER

Fig. 1 Flow chart of patient recruitment. Consecutive adult medical patients visiting the emergency department of the University Medical Center Groningen between March 2016 and February 2017 were screened for eligibility

were included in the final analysis. Of the 359 patients, 106 (29,5%)

in the ED. For each model, the area under the receiver operator curve

patients deteriorated within 72 h from admission (Table 1). Patients

(AUC) was calculated using the predicted probabilities.

with cardiac disease (p = 0.004), COPD (p = 0.047) or diabetes (p = 0.002), deteriorated more often compared to patients without these

All statistical analyses were performed using IBM SPSS Statistics for

comorbidities. Malignancy (28.4%) and organ transplant (26.7%) were

Windows V.23.0 (IBM Corp, Armonk, New York, USA). A two-tailed

the most frequent comorbidities (Table 2).

p-value of < 0.05 was considered significant. Patient deterioration

Results

Signs of organ failure were observed in 21.2% of the patients at ED admission (Table 3). An additional 6.1% of the patients deteriorated in the first 24 h after admission. The increase in respiratory failure

Patient characteristics

(+ 4.2%) was the largest contributor to this deterioration. In the first 48

During the study period 366 patients met the inclusion criteria (Fig.

h after admission, 3.1% of the patients deteriorated to multiple organ

1). Seven patients were excluded because they had less than three

failure. Most deterioration took place within the first 72 h from admission

repeated vital sign measurements in the emergency department

(+ 8.3%), with only a small increase (+ 1.7%) during the rest of the

(ED) during the first 3 h from admission. The remaining 359 patients

hospitalization.

RESUSCITATION TODAY - SUMMER 2019

sign value at admission + variability of the vital sign during the first 3 h

CLINICAL PAPER Table 1 Patient characteristics Overall

Not deteriorated

Deteriorated

p Value

359 (100)

253 (70.5)

106 (29.5)

–

Age [median (IQR)]

63 (49; 71)

60 (47; 70)

66 (56; 74)

.001*

Male [n (% of the group)]

222 (61.8)

149 (58.9)

73 (68.9)

.076

Number of comorbidities [median (IQR)]

1 (0; 2)

1 (1; 2)

.001*

Cardiac disease [n (% of the group)]

66 (18.4)

37 (14.6)

29 (27.4)

.004*

COPD [n (% of the group)]

23 (6.4)

12 (4.7)

11 (10.4)

.047*

Diabetes [n (%of the group)]

63 (17.5)

34 (13.4)

29 (27.4)

.002*

Chronic kidney disease [n (% of the group)]

43 (12.0)

26 (10.3)

17 (16.0)

.125

Number of patients [n (%)] Demographics

Comorbidity

Chronic liver disease [n (% of the group)]

30 (8.4)

19 (7.5)

11 (10.4)

.370

Organ transplant [n (% of the group)]

96 (26.7)

64 (25.3)

32 (30.2)

.339

Malignancy [n (% of the group)]

102 (28.4)

77 (30.4)

25 (23.6)

.189

None of the above [n (% of the group)]

98 (27.3)

81 (32.0)

17 (16.0)

.002*

Infection [n (% of overall)]

82 (22.8)

67 (81.7)

15 (18.3)

.011*

Sepsis [n (% of overall)]

277 (77.2)

186 (67.1)

91 (32.9)

.011*

Heart rate (bpm) [median (IQR)]

95 (83.0; 110.0)

95.0 (82.0; 110.0)

95.5 (83.0; 110.0)

.262

Mean arterial pressure (mmHg) [median (IQR)]

91.7 (83.3; 102.9)

94.3 (86.3; 103.3)

85.8 (73.4; 97.3)

<.001*

Respiratory rate (/min) [median (IQR)]

19.0 (16.0; 24.0)

18.0 (16.0; 23.3)

20.0 (17.0; 25.0)

.031*

Body temperature (°C) [median (IQR)]

37.8 (37.0; 38.6)

38.0 (37.0; 38.8)

.564

−1.10 (−2.89; 0.00)

−1.14 (− 2.89; 0.00)

−0.90 (− 2.93; − 0.01)

.810

Disease severity

Vital signs at ED admission

Vital sign change Heart rate (bpm) [median (IQR)] Mean arterial pressure (mmHg) [median (IQR)]

− 0.97 (− 2.86; 0.57)

−0.91 (− 2.71; 0.50)

−1.18 (− 3.04; 0.84)

.833

Respiratory rate (/min) [median (IQR)]

− 0.07 (− 0.61; 0.58)

−0.09 (− 0.69; 0.61)

−0.07 (− 0.45; 0.56)

.427

Body temperature (°C) [median (IQR)]

−0.05 (− 0.17; 0.06)

−0.04 (− 0.17; 0.07)

.997

Heart rate (bpm) [median (IQR)]

12.0 (7.0; 20.0)

12.0 (7.0; 19.5)

12.0 (7.0; 20.5)

.740

Mean arterial pressure (mmHg) [median (IQR)]

15.3 (9.7; 21.7)

14.0 (8.9; 19.5)

18.2 (12.6; 27.5)

<.001*

Respiratory rate (/min) [median (IQR)]

5.0 (2.0; 8.0)

4.0 (2.0; 7.0)

6.0 (3.0; 9.8)

.001*

Body temperature (°C) [median (IQR)]

0.7 (0.2; 1.1)

0.7 (0.4; 1.1)

0.7 (0.4; 1.2)

.512

4.7 (0.7; 7.9)

3.6 (0.2; 6.2)

6.7 (4.1; 11.3)

<.001*

28-day [n (% of the group)]

17 (4.7)

4 (1.6)

13 (12.3)

<.001*

6-month [n (% of the group)]

44 (12.3)

24 (9.5)

20 (18.9)

.013*

Vital sign variability

Hospital admission Length of stay (days) [median (IQR)] Mortality

RESUSCITATION TODAY - SUMMER 2019

COPD: chronic obstructive pulmonary disease; ED: emergency department; IQR: interquartile range

In the patients who presented with infection, 14.6% had signs of organ

admission, an additional 6.9% of the patients with sepsis

failure at ED admission (Table 3). An additional 3.7% of the patients

deteriorated, mostly due to respiratory failure (+ 5%). An additional

with infection deteriorated in the first 24 h after admission. Two patients

1.8% of the patients deteriorated to multiple organ failure and after

(2.4%) required ICU admission and one patient (1.2%) developed

48 h another 1.8% of the patients had developed multiple organ

multiple organ failure. In the remainder of the first 72 h, no additional

failure. After 72 h, one patient had multiple organ failure in all three

patients deteriorated.

organ systems. During the rest of the hospitalization, only 1% of the patients deteriorated additionally. In the remainder of this

Of the patients with sepsis, 23.1% had signs of organ failure at ED

article we use the first 72 h of admission as timeframe for patient

admission (Table 3). Most of them had AKI (14.1%). In the first 24 h after

deterioration.

CLINICAL PAPER Table 2 Study population comorbidity matrix N = 359

Cardiac disease

COPD

Diabetes

Chronic Kidney Disease

Chronic Liver Disease

Organ Transplant

7Chronic Kidney Disease

9Chronic Liver Disease

17 Organ Transplant

11 Malignancy

29 16

417

130

411

96 17

21 11

4102

Cardiac disease

COPD 23 Table 2 Study population comorbidity matrix Diabetes N = 359 Cardiac disease COPD Chronic Kidney Disease Cardiac disease

Chronic COPD Liver Disease

63 Diabetes

43 13

Organ Transplant Diabetes

Malignancy Chronic Kidney Disease Chronic Liver Disease Organ Transplant

Malignancy

AgeMalignancy and diabetes associated with higher risk of deterioration

102 was of deterioration (Table 4, Fig. 2). A higher MAP at ED admission

The logistic regression base model for patient deterioration including

associated with a lower risk of deterioration (OR: 0.96/mmHg; model

age, gender and comorbidities yielded an AUC of 0.679 (Table 4). A

MAP-M1; AUC .746). The body temperature at ED admission was not

higher age (odds ratio (OR): 1.02 / year) and a history of diabetes (OR:

independently associated with deterioration (model BT-M1; AUC .680).

1.90) were associated with a higher risk of patient deterioration. Gender and comorbidities other than diabetes were not independent predictors

Repeated vital sign measurements improve the prediction of

of deterioration.

deterioration Next to the vital signs at ED admission, the change and variability

Vital signs at ED admission are associated with deterioration

of the repeated vital signs measurements in the first 3 h in the

Patients who deteriorated had a lower MAP (p < 0.001) and a higher

ED were entered into the base model together with the vital signs

respiratory frequency (p = 0.03) at ED admission (Table 1). The base

at ED admission (Table 4, Fig. 2). An increase in MAP over time

model extended with the patient’s vital signs at ED admission, showed

was associated with a lower risk of deterioration (OR: 0.873/unit

that both a higher heart rate (OR: 1.01/beat per minute; model HR-

increase; model MAP-M2; AUC .758). An increase in respiratory

M1; AUC .683) and a higher respiratory rate (OR: 1.05/respiration per

rate over time was associated with a higher risk of deterioration

Table 3 Patient deterioration outcomes in different timeframes during the patient’s stay in-hospital and divided by infection and (OR: 1.441/unit increase; model RR-M2; AUC .686). The changes in sepsis on emergency department presentation

minute; model RR-M1; AUC .663) were associated with a higher risk

Acute Liver Respiratory Organ failure ICU InDeteriorated Kidney failure failure admission hospital Single Multiple Injury mortality Table 3 Patient deterioration outcomes in different timeframes during the patient’s stay in-hospital and divided by infection and

sepsis emergency Total (Non = 359, 100.0%) department presentation 24 h after ED admission

Acute 45 (12.5%) Kidney 51 (14.2%) Injury

Liver 21 (5.8%) failure 22 (6.1%)

Respiratory 14 (3.9%) failure 29 (8.1%)

Organ failure 4 (1.1%) 72 (20.1%) Single Multiple 82 (22.8%) 10 (2.8%)

–ICU admission 16 (4.5%)

–Inhospital 1mortality (0.3%)

98 (27.3%)

48 (N h after ED100.0%) admission Total = 359,

57 (15.9%)

23 (6.4%)

33 (9.2%)

83 (23.1%)

18 (5.0%)

1 (0.3%)

102 (28.4%)

At ED admission

15 (4.2%)

Deteriorated 76 (21.2%)

60 45 (16.7%) (12.5%)

23 21 (6.4%) (5.8%)

35 14 (9.7%) (3.9%)

87 72 (24.2%) (20.1%)

15 (4.2%) 4 (1.1%)

–18 (5.0%)

–3 (0.8%)

106(21.2%) (29.5%) 76

Until hospital discharge 24 h after ED admission

70 (14.2%) (19.5%) 51

26 (6.1%) (7.2%) 22

43 (8.1%) (12.0%) 29

87 (22.8%) (24.2%) 82

24 (2.8%) (6.7%)xx 10

22 (4.5%) (6.1%) 16

(3.3%) 112(0.3%)

112(27.3%) (31.2%) 98

Infection (N =ED 82,admission 22.8%) 48 h after

57 (15.9%)

23 (6.4%)

33 (9.2%)

83 (23.1%)

15 (4.2%)

18 (5.0%)

1 (0.3%)

102 (28.4%)

At ED admission 72 h after ED admission

6 (7.3%) 60 (16.7%)

4 (4.9%) 23 (6.4%)

3 (3.7%) 35 (9.7%)

11 (24.2%) (13.4%) 87

1 (1.2%) 15 (4.2%) x

–18 (5.0%)

–3 (0.8%)

12 106(14.6%) (29.5%)

24 h after ED admission Until hospital discharge

770(8.5%) (19.5%)

426(4.9%) (7.2%)

443(4.9%) (12.0%)

11 87 (13.4%) (24.2%)

224(2.4%) (6.7%)xx

222(2.4%) (6.1%)

012(0.0%) (3.3%)

15 112(18.3%) (31.2%)

48 h after Infection (N =ED 82,admission 22.8%)

7 (8.5%)

4 (4.9%)

5 (6.1%)

12 (14.6%)

2 (2.4%)

0 (0.0%)

15 (18.3%)

72 h after ED admission At ED admission

76 (8.5%) (7.3%)

4 (4.9%)

53 (6.1%) (3.7%)

12 11 (14.6%) (13.4%)

21 (2.4%) (1.2%)

2– (2.4%)

0– (0.0%)

15 12 (18.3%) (14.6%)

Until hospital discharge 24 h after ED admission

10 (12.2%) 7 (8.5%)

64 (7.3%) (4.9%)

14 11 (17.1%) (13.4%)

(4.9%) 24 (2.4%)

(6.7%) 23 (2.4%)

(1.2%) 01 (0.0%)

18 (18.3%) (22.0%) 15

Sepsis = 277, 48 h(Nafter ED 77.2%) admission

7 (8.5%)

4 (4.9%)

5 (6.1%)

12 (14.6%)

2 (2.4%)

0 (0.0%)

15 (18.3%)

At admission 72 ED h after ED admission

(14.1%) 739(8.5%)

(6.1%) 417(4.9%)

(4.0%) 511(6.1%)

61 (14.6%) (22.0%) 12

(1.1%) 23 (2.4%)

–2 (2.4%)

–0 (0.0%)

64 15 (23.1%) (18.3%)

24 h after ED admission Until hospital discharge

44 10 (15.9%) (12.2%)

18 (6.5%) 6 (7.3%)

25 (9.0%) 6 (7.3%)

71 14 (25.6%) (17.1%)

84 (2.9%) (4.9%)

14 (5.1%) 3 (6.7%)

1 (0.4%) (1.2%)

83 18 (30.0%) (22.0%)

48 h(Nafter ED 77.2%) admission Sepsis = 277,

50 (18.1%)

19 (6.9%)

28 (10.1%)

71 (25.6%)

13 (4.7%)

16 (5.8%)

1 (0.4%)

87 (31.4%)

72 h after ED admission At ED admission

53 39 (19.1%) (14.1%)

19 17 (6.9%) (6.1%)

30 11 (10.8%) (4.0%)

75 61 (27.1%) (22.0%)

13 (4.7%) 3 (1.1%)

–16 (5.8%)

–3 (1.1%)

91 (23.1%) (32.9%) 64

Until hospital discharge 24 h after ED admission

60 (15.9%) (21.7%) 44

20 (6.5%) (7.2%) 18

37 (9.0%) (13.4%) 25

73 (25.6%) (26.4%) 71

(7.2%) xx 820(2.9%)

19 (5.1%) (6.9%) 14

(4.0%) 111(0.4%)

94 (30.0%) (33.9%) 83

ED:48 emergency one patient19 with all three organ systems failing; of which four patient with all organ systems failing 87 (31.4%) h after EDdepartment; admission of which 50 (18.1%) (6.9%) 28 (10.1%) 71 (25.6%) 13 (4.7%) 16three (5.8%) 1 (0.4%)

72 h after ED admission

53 (19.1%)

19 (6.9%)

30 (10.8%)

75 (27.1%)

13 (4.7%)x

16 (5.8%)

3 (1.1%)

91 (32.9%)

Until hospital discharge

60 (21.7%)

20 (7.2%)

37 (13.4%)

73 (26.4%)

20 (7.2%) xx

19 (6.9%)

11 (4.0%)

94 (33.9%)

ED: emergency department; x of which one patient with all three organ systems failing;

RESUSCITATION TODAY - SUMMER 2019

72 h after ED admission At ED admission

of which four patient with all three organ systems failing

CLINICAL PAPER Table 4 Logistic regression models for deterioration within 72 h from admission based on repeated vital sign measurements with a 30-min interval during the first 3 h of ED admission Sig.

Odds Ratio (95% CI)

Model statistics Cox & Snell R2

Base model for deterioration within 72 h from admission Age

.012*

1.022 (1.005; 1.039)

Gender (0 = male, 1 = female)

.502

0.839 (0.502; 1.402)

Cardiac disease

.158

1.544 (0.845; 2.820)

COPD

.159

1.906 (0.777; 4.676)

Diabetes

.035*

1.902 (1.048; 3.454)

Chronic kidney disease

.308

1.475 (0.699; 3.111)

Chronic liver disease

.345

1.493 (0.650; 3.429)

Organ transplant

.245

1.408 (0.791; 2.509)

Malignancy

.450

0.807 (0.463; 1.407)

AUC (95% CI)

.080

.679 (.619; .739)

359 (100%)

Base model with heart rate HR-M1.

Heart rate at admission

.042*

1.013 (1.000; 1.025)

.091

.683 (.623; .742)

359 (100%)

HR-M2.

Heart rate at admission

.035*

1.015 (1.001; 1.030)

.091

.684 (.624; .743)

358 (99.7%)

Heart rate change

.463

1.039 (0.938; 1.151)

Heart rate at admission

.062

1.013 (0.999; 1.027)

.091

.683 (.624; .743)

359 (100%)

Heart rate variability

.884

0.998 (0.977; 1.021)

<.001*

0.955 (0.937; 0.972)

.156

.746 (.688; .804)

357 (99.4%)

.176

.758 (.701; .815)

355 (98.9%)

.223

.800 (.750; .850)

357 (99.4%)

HR-M3.

Base model with mean arterial pressure MAP-M1. MAP-M2. MAP-M3.

MAP at admission MAP at admission

<.001*

0.940 (0.920; 0.961)

MAP change

.003*

0.873 (0.798; 0.954)

MAP at admission

<.001*

0.941 (0.922; 0.960)

MAP variability

<.001*

1.060 (1.037; 1.084)

Base model with respiratory rate RR-M1.

Respiratory rate at admission

.042*

1.048 (1.002; 1.097)

.075

.663 (.592; .735)

267 (74.4%)

RR-M2.

Respiratory rate at admission

.004*

1.086 (1.027; 1.148)

.096

.686 (.617; .755) b

242 (67.4%)

Respiratory rate change

.018*

1.441 (1.063; 1.952)

RR-M3.

Respiratory rate at admission

.144

1.022 (0.988; 1.071)

.087

.676 (.605; .746) b

267 (74.4%)

Respiratory rate variability

.063

1.067 (0.996; 1.142)

Base model with body temperature

RESUSCITATION TODAY - SUMMER 2019

BT-M1.

Body temperature at admission

.607

1.059 (0.845; 1.319)

.083

.680 (.619; .741)

355 (98.9%)

BT-M2.

Body temperature at admission

.880

1.020 (0.786; 1.324)

.080

.681 (.619; .743)

342 (95.3%)

Body temperature change

.677

0.720 (0.153; 3.385)

BT-M3.

Body temperature at admission

.962

0.994 (0.790; 1.252)

.090

.683 (.622; .745)

355 (98.9%)

Body temperature variability

.097

1.389 (0.942; 2.049)

AUC: area under the receiver operating curve; CI: confidence interval; COPD: Chronic Obstructive Pulmonary Disease; HR: Heart rate, MAP: mean arterial pressure; RR: respiratory rate; BT: body temperature; Sig.: statistical significance; * significant result (p < 0.05) a Missing or observations that were constant within the measured time period are excluded from the regression model; b the AUC of the base model only including patients with respiratory rate at admission was .638

heart rate and temperature were not independently associated with deterioration. Next to the vital signs at ED admission and change over time, a higher

Discussion The aim of our study was to determine whether repeated vital sign measurements in the ED can identify patients with sepsis or infection

variability in MAP (i.e. a higher range) was significantly associated with a

that will deteriorate within 72 h. We found an increase in MAP over time

higher risk of deterioration (OR: 1.06/mmHg; model MAP-M3; AUC .800;

was associated with a lower risk of deterioration, and a higher variability

Table 4, Fig. 2). The variability of the other vital signs was not associated

of the MAP or increase in respiratory rate over time, in combination with

with the risk of deterioration.

their respective values at ED admission, were associated with patient

CLINICAL PAPER

deterioration. Inclusion of repeated MAP measurements resulted in the largest AUC (.800), whereas repeated respiratory rate measurements only slightly improved the predictive capabilities of the logistic regression model over the base model. Repeated measurements of heart rate and body temperature were not associated with patient deterioration.

associated with patient deterioration in ED patients with infection or sepsis. This suggests that keeping a close eye on the MAP during the patients stay in the ED is important. Our study shows that this not only applies to patients with septic shock (only 1.9% of our population), as recommended by the surviving sepsis campaign (SSC) guidelines, but for all patients with sepsis or infection [4].

Our results indicate that changes and variability of the MAP are

Apart from our earlier pilot study, little is known about repeated vital

RESUSCITATION TODAY - SUMMER 2019

Fig. 2 Receiver operating curves of the logistic regression models for patient deterioration using various repeated vital sign measurements in 30-min intervals during the first three hours of the patientâ&#x20AC;&#x2122;s stay in the emergency department. The base model includes age, gender and comorbidities. Model M1 contains the base model combined with the value of the vital sign at admission, model M2 contains model M1 combined with the change of the vital sign over time, model M3 contains model M1 combined with the variability of the vital. A) the ROC curve for the base model combined with heart rate (HR). B) the ROC curve for the base model combined with mean arterial pressure (MAP). C) the ROC curve for the base model combined with respiratory rate (RR). * Base model only including patients with respiratory rate at admission (AUC .638). D) the ROC curve for the base model combined with body temperature (BT)

CLINICAL PAPER sign measurements in patients with infection or sepsis during their

thereafter three times per day. Deterioration of the MEWS score triggers

stay in the ED in relation to clinical outcomes, patient deterioration and

an early response team. Further research is needed to clarify whether

(early) signs of organ failure. Our pilot study showed that vital signs

repeated vital sign measurements in combination with repeated early

changed significantly during the patient’s stay in the ED, but did not

warning scores are useful in the detection of patient deterioration in

analyse patient deterioration [7]. Henriksen et al... retrospectively found

patients with sepsis or infection.

a deterioration of vital signs from the normal to abnormal range within 4–13 h after arrival in 31% of patients in the general ED population,

We have shown that almost 30% of the patients presenting to the ED

leading to a four times higher 30-day mortality risk [13]. The available

with suspected infection or sepsis deteriorated within 72 h of admission

studies on vital signs in the ED mostly use only single measurements,

and over 28% of the patients showed signs of (multiple) organ failure

mainly at triage [9, 12]. Furthermore, these were often retrospective

despite treatment. Our results show that 18.3% of the patients with

studies in contrast to our study. Finally, they often included the general

infection, 32.9% of the patients with sepsis and in total 29.5% of the

ED population and thus a more heterogeneous population. The

patients deteriorated within 72 h (Table 4). Glickman et al. showed

endpoints and cut-off values differ from study to study, most studies

that almost 23% of patients with uncomplicated sepsis progress

used mortality endpoints, several studies had ICU admission as an

to severe sepsis or septic shock within 72 h from admission [1].

endpoint and only a few studies included organ failure [8, 11, 13,

Although a direct comparison cannot be made because of a different

19, 20, 21, 22]. The single measurements, heterogeneous patient

population and different endpoints, these results clearly show that

populations and different endpoints make a direct comparison of those

a large part of the patients with infection deteriorate in the first days

results with our study’s results impossible. Coslovsky et al aimed to

in the hospital and develop (severe) sepsis. Therefore, we question

develop a prediction model for in-hospital mortality using a model with

whether the introduction of the recent Sepsis-3 definitions, in which

age, prolonged capillary refill, blood pressure, mechanical ventilation,

infection or uncomplicated sepsis are no longer part of the sepsis

oxygen saturation index, GSC and the APACHEII diagnostic category

severity spectrum, will lead to better patient care [28]. We would like to

in a cohort that contained 15% patients with infection among which

emphasise that it is important to properly monitor and treat all patients

7.3% with sepsis. Their model had an AUC of 0.92, although, it should

with infection or sepsis in the ED. Since sepsis-related mortality has

be noted that their model was based on a heterogeneous patient

dramatically reduced over the past two decades, we believe that early

population, single measurements and a combination of multiple vital

detection or prevention of organ failure is where the future focus of

signs [23]. Yamamoto et al. found an association between low body

infection/sepsis research should be, since there is a lot to gain [29].

temperature (< 36 °C) at ED admission and higher 30 day in-hospital mortality risk in patients with suspected sepsis [24]. In our study, we did

The 30-min measurement interval in the current study was arbitrarily

not find an association between body temperature and deterioration.

chosen, since there is no standard on how often vital signs should

Furthermore, it should be noted that the in-hospital mortality in our

be measured in the ED and only little research has been conducted

study (3.3%) is much lower than in the study of Yamamoto (9.6%). In

on this topic. Descriptive studies in the general ED population have

summary, available studies did not specifically investigate ED patients

shown that the time between two measurements is between 67 and

with infection or sepsis, mostly used single vital sign measurements (at

130 min and that a higher illness severity results in more frequent

triage) and primarily had mortality or ICU admission endpoints.

measurements [10, 30]. We believe that these measurement intervals are not representative for patients with infection or sepsis, however,

RESUSCITATION TODAY - SUMMER 2019

Early warning scores (EWS), like the national early warning score

there are no specific guidelines on how often vital signs should be

(NEWS) and many variants and related scores, are increasingly

measured in these patients [13]. The 30-min measurement interval in

being used throughout healthcare. These EWS commonly contain

our study was much more frequent than the median intervals reported

a combination of various vital sign parameters, supplemented with

by Johnson and Lambe [10, 30]. A higher measurement frequency

laboratory values or other items, where each item is scored at certain

might provide even more information about deterioration, although this

thresholds. Early warning scores are mostly used as ‘track-and-trigger’

might lead to a higher burden on the patient and staff. Therefore, we

systems to trigger the nurse to call the physician or a rapid response

recommend continuous measurement of vital signs on a beat-to-beat

team, or to predict a high risk of mortality or ICU admission [25, 26].

level, preferably automated with the use of bed-side patients monitors

The many different EWS and patient populations, in which they have

or wearable devices [3]. Our next step, as a follow-up of this study,

been validated, make it difficult to compare their performance. However,

is to shorten the measurement interval to a beat-to-beat interval with

a recent review by Nannan Panday et al. showed that the NEWS score

heart rate variability (HRV) measured using bed-side patient monitors

was the best to predict mortality or ICU admission in the general

in the SepsiVit study [3]. As we have shown, a substantial number of

ED population and the modified early warning score was the best in

patients deteriorate in the first days from admission. In the currently

patients with suspected infection or sepsis [25]. Their performance

running SepsiVit study, we will extend the measurements beyond the

(AUC) was in the same range as we found for our repeated blood

boundaries of the ED towards the nursing wards during the first 48 h

pressure measurements (MAP). However, it should be noted that

of hospitalization. During this period, we will investigate whether the

we used only a single vital sign repeated measurement and had a

combination of HRV with monitoring on the nursing wards can provide

composite outcome of patient deterioration, which included signs of

an early warning of patient deterioration. Such an early warning could

organ dysfunction. Another recent study by Kivipuro et al. showed that

provide a possible opportunity for intervention in the future.

the NEWS score was significantly higher before ICU admission when a patient was transferred from the ward to the ICU, compared to the

Strengths and limitations

NEWS score of the same patient at the ED [27]. In our hospital, modified

To the best of our knowledge this is the first study that prospectively

early warning scores (MEWS) are taken at admission to the ward and

investigated the relation between repeated vital sign measurements

CLINICAL PAPER and patient deterioration in the ED in patients with infection or sepsis.

MAP and respiratory rate are associated with patient deterioration. Since

We did not only use the common mortality and ICU admission

almost one third of patients presenting with infection or sepsis to the ED

endpoints, but also included signs of organ failure in our composite

deteriorate within 72 h, repeated vital sign measurements may be an

patient deterioration endpoint. Vital signs can be easily measured

important way to guarantee early identification of deterioration.

with equipment readily available in every ED. The repeated vital sign measurements in our study were obtained specifically by a trained

Abbreviations

member of our research staff, which minimized the amount of missing

AKI: Acute kidney injury; AUC: Area under the receiver operator curve;

data. However, in spite of the prospective study design, 92 (25%)

BT: Body temperature; COPD: Chronic obstructive pulmonary disease;

respiratory rate measurements were not recorded at triage by the

ED: Emergency department; GCS: Glasgow coma score; HR: Heart

triage nurse. It is well-known that respiratory rate is the most frequently

rate; HRV: Heart rate variability; ICU: Intensive care unit; KDIGO: Kidney

missing vital sign, unfortunately our study is no exception [31]. These

disease improving global outcomes; MAP: Mean arterial pressure;

missing respiratory rate measurements at triage limit the power of our

METc: Institutional review board; OR: Odds ratio; RR: Respiratory rate;

logistic regression models that include respiratory rate (RR-Mx; Table 4).

SBP: Systolic blood pressure; SCPD: Sepsis clinical pathway database;

Another limitation of our study is that it is a single centre study in an

USA: United States of America

SpO2: Peripheral oxygen saturation; SSC: Surviving sepsis campaign;

academic tertiary care teaching hospital. This may limit the generalizability to other patient populations, especially since our population contains

Acknowledgements

a high number of patients with a history of organ transplantation (Table

The authors thank the nurses and physicians in our emergency

2). However, a history of organ transplantation was not independently

department for their assistance during the acquisition of the data. We

associated with patient deterioration in our models (Table 4). Therefore,

thank the members of the Sepsis Research Team in our emergency

we believe that the specific patient population did not have a substantial

department for their efforts in collecting the data.

influence on our results. We did not design the study to analyse combinations of multiple vital signs in our models, since we were

Availability of data and material

interested in identifying which repeated vital sign measurements are

The datasets used and/or analysed during the current study are

helpful in predicting patient deterioration and not in the best combination

available from the corresponding author on reasonable request.

of vital signs. We acknowledge that a combination of repeated vital signs may provide even more information in future studies, perhaps in

Funding

combination with repeated early warning scores.

This study is funded by the emergency department of the University Medical Center Groningen. VMQ received a MD-PhD scholarship from

Clinical implications

the University of Groningen, University Medical Center Groningen for his

We have shown that more than one in four patients presenting to the ED

PhD research.

with suspected infection or sepsis deteriorated within 72 h of admission and showed signs of organ failure. These were not exclusively patients

Authorsâ&#x20AC;&#x2122; contributions

with sepsis at admission, but one in five patients that presented to the

VMQ drafted the study design, assisted with data acquisition, carried

ED with infection only. Although the organ failure generally did not result

out data analysis and drafted the manuscript. MvM participated in the

in mortality, organ failure may even be preventable or treatable. Our

study design, assisted with data interpretation and critically revised

results show that repeated vital sign measurements (especially blood

the manuscript. TJO participated in the study design, assisted with

pressure) at the ED is a predictor of patient deterioration and might

data acquisition, and critically revised the manuscript. JMV carried out

result in a reduction of organ failure related morbidity. It is thus important

data analysis, assisted with data interpretation and critically revised the

to reassess patient at the ED frequently, including measurement of vital signs, as is done on the wards with early warning scores [29]. Although it is known that patient deterioration is often preceded by changes in vital signs several hours before the event, these signs are conducting a subsequent study (SepsiVit study) with 48 h of continuous vital sign measurements at the ED and on the general wards to test the hypothesis that repeated vital sign measurements at the general ward (with high frequency) is better in the prediction of patient deterioration than the currently used systems [3]. Until this information from the SepsiVit study becomes available, we assess patients at the ED frequently, including repeated vital sign measurements.

interpretation and critically revised the manuscript. JCtM participated in the study design, assisted with data interpretation, critically revised the manuscript and has given final approval of the version to be published. Ethics approval and consent to participate This study was carried out in accordance to the Declaration of Helsinki, the Dutch Agreement on Medical Treatment Act and the Dutch Personal Data Protection Act. The Institutional Review Board of the University Medical Center Groningen ruled that the Dutch Medical Research Involving Human Subjects Act is not applicable for this study and granted a waiver (METc 2015/164). All participants provided written informed consent.

Conclusions

Consent for publication Not applicable.

Repeated measurement of vital signs in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single

Competing interests

vital sign measurements at ED admission. Repeated measurements of

The authors declare that they have no competing interests.

RESUSCITATION TODAY - SUMMER 2019

frequently missed on general wards [25, 27, 32]. At this moment, we are

manuscript. JJML participated in the study design, assisted with data

CLINICAL PAPER Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Correspondence: v.m.quinten@umcg.nl 1Department of Emergency

10. Lambe KR, Currey JR, Considine J. Frequency of vital sign assessment and clinical deterioration in an Australian emergency department. Australas. Emerg. Nurs. J. [Internet]. Elsevier; 2016 [cited 2017 Oct 16];19:217–222. Available from: http://www.sciencedirect.com/science/article/pii/ S1574626716300398?via%3Dihub

Medicine, University of Groningen, University Medical Center Groningen, HPC TA10, PO Box 30001, 9700 RB Groningen, The Netherlands. Department of Critical Care, University of Groningen, University

Medical Center Groningen, Groningen, The Netherlands. 3Department of Pathology and Medical Biology, Medical Biology section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 4Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

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