title: The TRIAGE-ProADM Score for an Early Risk Stratification of Medical Patients in the Emergency Department - Development Based on a Multi-National, Prospective, Observational Study.
abstract: BACKGROUND
  The inflammatory biomarker pro-adrenomedullin (ProADM) provides additional prognostic information for the risk stratification of general medical emergency department (ED) patients. The aim of this analysis was to develop a triage algorithm for improved prognostication and later use in an interventional trial.
  
  
  METHODS
  We used data from the multi-national, prospective, observational TRIAGE trial including consecutive medical ED patients from Switzerland, France and the United States. We investigated triage effects when adding ProADM at two established cut-offs to a five-level ED triage score with respect to adverse clinical outcome.
  
  
  RESULTS
  Mortality in the 6586 ED patients showed a step-wise, 25-fold increase from 0.6% to 4.5% and 15.4%, respectively, at the two ProADM cut-offs (≤0.75nmol/L, >0.75-1.5nmol/L, >1.5nmol/L, p ANOVA <0.0001). Risk stratification by combining ProADM within cut-off groups and the triage score resulted in the identification of 1662 patients (25.2% of the population) at a very low risk of mortality (0.3%, n = 5) and 425 patients (6.5% of the population) at very high risk of mortality (19.3%, n = 82). Risk estimation by using ProADM and the triage score from a logistic regression model allowed for a more accurate risk estimation in the whole population with a classification of 3255 patients (49.4% of the population) in the low risk group (0.3% mortality, n = 9) and 1673 (25.4% of the population) in the high-risk group (15.1% mortality, n = 252).
  
  
  CONCLUSIONS
  Within this large international multicenter study, a combined triage score based on ProADM and established triage scores allowed a more accurate mortality risk discrimination. The TRIAGE-ProADM score improved identification of both patients at the highest risk of mortality who may benefit from early therapeutic interventions (rule in), and low risk patients where deferred treatment without negatively affecting outcome may be possible (rule out).
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Alexander
authors.identifier: http://orcid.org/0000-0002-7549-5648
authors.initials: A
authors.lastname: Kutz
authors.affiliation: Emergency Department, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.|Sorbonne Universités UPMC-Univ Paris06, UMRS INSERM 1166, IHUC ICAN, Paris, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Hausfater
authors.affiliation: Morton Plant Hospital, Clearwater, FL, United States of America.
authors.forename: Devendra
authors.initials: D
authors.lastname: Amin
authors.affiliation: Morton Plant Hospital, Clearwater, FL, United States of America.
authors.forename: Adina
authors.initials: A
authors.lastname: Amin
authors.affiliation: Emergency Department, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
authors.forename: Pauline
authors.initials: P
authors.lastname: Canavaggio
authors.affiliation: Emergency Department, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Sauvin
authors.affiliation: Biochemistry Department, Hôpital Pitié-Salpêtrière and Univ-Paris Descartes, Paris, France.
authors.forename: Maguy
authors.initials: M
authors.lastname: Bernard
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Antoinette
authors.initials: A
authors.lastname: Conca
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Haubitz
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Tristan
authors.initials: T
authors.lastname: Struja
authors.affiliation: Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Andreas
authors.initials: A
authors.lastname: Huber
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Beat
authors.initials: B
authors.lastname: Mueller
authors.affiliation: Division of General and Emergency Medicine; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Schuetz
mesh_terms: D053607:Adrenomedullin / Q000097:blood*; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood*; D002318:Cardiovascular Diseases / Q000097:blood / Q000175:diagnosis*; D004636:Emergency Service, Hospital; D005260:Female; D005767:Gastrointestinal Diseases / Q000097:blood / Q000175:diagnosis*; D006801:Humans; D007239:Infections / Q000097:blood / Q000175:diagnosis*; D007390:International Agencies; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000097:blood / Q000175:diagnosis*; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D014218:Triage / Q000379:methods*
chemical_list: D015415:Biomarkers; D053607:Adrenomedullin