Coma of unknown origin in the emergency department: implementation of an in-house management routine.
BACKGROUND
Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines.


METHODS
We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed "coma alarm"). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP.


RESULTS
During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1-4), then fluctuated between 84 and 94 % (months 5-24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro-ICUs.


CONCLUSIONS
Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible.


CONCLUSIONS
Our SOP may provide an appropriate tool for efficient management of patients with non-traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.
Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.|Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Mischa
M
Braun
Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. wolf.schmidt@charite.de.|Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany. wolf.schmidt@charite.de.
Wolf Ulrich
WU
Schmidt
Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.
Martin
M
Möckel
Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.
Michael
M
Römer
Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
Christoph J
CJ
Ploner
Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.
Tobias
T
Lindner
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D003128:Coma / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014187:Transportation of Patients; D014218:Triage / Q000379:methods*; D014947:Wounds and Injuries / Q000175:diagnosis*; D055815:Young Adult
Brain diseases; Diagnostic algorithm; Neurological emergencies; Non traumatic coma; Outcome; Workflow