Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department.
BACKGROUND
The survival of patients admitted to an emergency department is determined by the severity of acute illness and the quality of care provided. The high number and the wide spectrum of severity of illness of admitted patients make an immediate assessment of all patients unrealistic. The aim of this study is to evaluate a scoring system based on readily available physiological parameters immediately after admission to an emergency department (ED) for the purpose of identification of at-risk patients.


METHODS
This prospective observational cohort study includes 4,388 consecutive adult patients admitted via the ED of a 960-bed tertiary referral hospital over a period of six months. Occurrence of each of seven potential vital sign abnormalities (threat to airway, abnormal respiratory rate, oxygen saturation, systolic blood pressure, heart rate, low Glasgow Coma Scale and seizures) was collected and added up to generate the vital sign score (VSS). VSSinitial was defined as the VSS in the first 15 minutes after admission, VSSmax as the maximum VSS throughout the stay in ED. Occurrence of single vital sign abnormalities in the first 15 minutes and VSSinitial and VSSmax were evaluated as potential predictors of hospital mortality.


RESULTS
Logistic regression analysis identified all evaluated single vital sign abnormalities except seizures and abnormal respiratory rate to be independent predictors of hospital mortality. Increasing VSSinitial and VSSmax were significantly correlated to hospital mortality (odds ratio (OR) 2.80, 95% confidence interval (CI) 2.50 to 3.14, P < 0.0001 for VSSinitial; OR 2.36, 95% CI 2.15 to 2.60, P < 0.0001 for VSSmax). The predictive power of VSS was highest if collected in the first 15 minutes after ED admission (log rank Chi-square 468.1, P < 0.0001 for VSSinitial;,log rank Chi square 361.5, P < 0.0001 for VSSmax).


CONCLUSIONS
Vital sign abnormalities and VSS collected in the first minutes after ED admission can identify patients at risk of an unfavourable outcome.
Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, 3010 Bern, Switzerland. tobias.merz@insel.ch
Tobias M
TM
Merz
Reto
R
Etter
Ludger
L
Mende
Daniel
D
Barthelmes
Jan
J
Wiegand
Luca
L
Martinolli
Jukka
J
Takala
D000328:Adult; D000368:Aged; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D017052:Hospital Mortality; D006801:Humans; D008875:Middle Aged; D010343:Patient Admission; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods; D012720:Severity of Illness Index; D055986:Vital Signs / Q000502:physiology*
Adv Health Sci Educ Theory Pract. 2008 Nov;13(4):503-20
17364221
Lancet. 1996 Nov 16;348(9038):1324-5
8918270
Ann Emerg Med. 2000 Jan;35(1):63-8
10613941
Intensive Care Med. 2002 Nov;28(11):1629-34
12415452
Med J Aust. 2003 Sep 15;179(6):283-7
12964909
N Engl J Med. 1995 Dec 14;333(24):1581-7
7477192
Resuscitation. 2004 Aug;62(2):137-41
15294398
N Engl J Med. 2001 Nov 8;345(19):1368-77
11794169
Emerg Med J. 2006 Nov;23(11):841-5
17057134
Qual Saf Health Care. 2004 Aug;13(4):251-4
15289626
Anaesthesia. 2003 Sep;58(9):882-5
12911362
Crit Care Med. 2005 May;33(5):974-8
15891323
Crit Care Resusc. 2004 Dec;6(4):261-7
16556104
QJM. 2001 Oct;94(10):521-6
11588210
Crit Care Med. 1989 May;17(5):418-22
2707011
Resuscitation. 2006 Jan;68(1):11-25
16153768
Acad Emerg Med. 2000 Dec;7(12):1354-61
11099425
Med J Aust. 2000 Sep;173(5):236-40
11130346
Ann Emerg Med. 1991 Mar;20(3):287-92
1996824
Lancet. 2005 Jun 18-24;365(9477):2091-7
15964445
J Clin Nurs. 2005 Oct;14(9):1067-74
16164524
Minerva Anestesiol. 2002 Jan-Feb;68(1-2):25-35
11877558
BMJ. 1998 Jun 20;316(7148):1853-8
9632403
Intern Med J. 2001 Aug;31(6):343-8
11529588
Emerg Med J. 2004 Nov;21(6):698-9
15496696
Circulation. 2005 Dec 13;112(24 Suppl):IV1-203
16314375
Emerg Med J. 2008 Dec;25(12):803-6
19033494
Crit Care Med. 1985 Oct;13(10):818-29
3928249
Anaesthesia. 1999 Sep;54(9):853-60
10460556
Intensive Care Med. 2004 Jul;30(7):1398-404
15112033
Circulation. 2004 Mar 16;109(10):1223-5
15007008
Anaesth Intensive Care. 1995 Apr;23(2):183-6
7793590
Am J Emerg Med. 1987 Jul;5(4):278-82
3593492
J Adv Nurs. 2001 Aug;35(4):550-61
11529955
Air Med J. 1994 Mar;13(3):91-5
10132620
Intensive Care Med. 1996 Jul;22(7):707-10
8844239
Anaesthesia. 1999 Jun;54(6):529-34
10403864
Crit Care Med. 2008 Mar;36(3):775-81
18209673
Crit Care Med. 2004 Apr;32(4):916-21
15071378
JAMA. 1993 Dec 22-29;270(24):2957-63
8254858
BMJ. 2002 Feb 16;324(7334):387-90
11850367
Resuscitation. 2004 Jun;61(3):257-63
15172703
Br Med J (Clin Res Ed). 1985 Aug 17;291(6493):432-4
3926230