title: Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms.
abstract: OBJECTIVE
  Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs.
  
  
  METHODS
  Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths.
  
  
  RESULTS
  A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates.
  
  
  CONCLUSIONS
  ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.
authors.affiliation: Division of Vascular Surgery, Stanford University, Stanford, Calif 94305-5642, USA. mwmell@stanford.edu
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Mell
authors.forename: Rachael A
authors.initials: RA
authors.lastname: Callcut
authors.forename: Fritz
authors.initials: F
authors.lastname: Bech
authors.forename: M Kit
authors.initials: MK
authors.lastname: Delgado
authors.forename: Kristan
authors.initials: K
authors.lastname: Staudenmayer
authors.forename: David A
authors.initials: DA
authors.lastname: Spain
authors.forename: Tina
authors.initials: T
authors.lastname: Hernandez-Boussard
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality* / Q000628:therapy; D001019:Aortic Rupture / Q000401:mortality* / Q000628:therapy; D016009:Chi-Square Distribution; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission / Q000706:statistics & numerical data; D012111:Residence Characteristics / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology