Predictive value and interrater reliability of mental status and mobility assessment in the emergency department.

AIM: To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team. METHOD: Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team. RESULTS: 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility. CONCLUSION: Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Implementation of a fast triage score for patients arriving to a low resource hospital in Uganda.

Background: The Kitovu Fast Triage (KFT) score predicts imminent mortality from mental status, gait and either respiratory rate or oxygen status. As some non-life-threatening conditions require immediate attention, the South African Triage System (SATS) assigns arbitrary rankings of urgency for specific patient presentations. Aim: Establish the feasibility of determining and then comparing the KFT score and explicitly defined SATS urgency rankings. Methods: A computerized proforma used standardized methods of assessing and measuring mental status and gait, and respiratory rate and collected explicitly defined clinical presentations and SATS urgency rankings on 4,842 patients at the time of their arrival to the hospital. Results: 75 % of patients were awake and able to count the months backwards from December to September. Respiratory rates measured by a computer application had no clustering of values or digit preference; however, oximetry failed in 14 % of patients, making the score based on respiratory rate the most practical in our setting. Determining the SATS acuity ranking and both KFT scores usually took <90 s; the commonest complaints were pain, dyspnoea, and fever, which often occurred together; overall 3574 (73.8 %) patients had at least one of these symptoms as did 96.4 % of those with the highest KFT score based on respiratory rate. 12 % of patients with the lowest KFT score based on respiratory rate had one or more very urgent SATS rankings, 52 % of whom had non-severe chest pain. Only 5.7 % of patients complaining of fever had a temperature >38 °C. Conclusion: Whilst the KFT score based on respiratory rate could be rapidly determined in all patients, it identified some patients as low acuity who had very urgent SATS rankings. However, most of these patients had non-severe chest pain, which may not be a very urgent presentation in our setting as ischaemic heart disease remains uncommon in sub-Saharan Africa.

Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

The prediction of 24-h mortality by the respiratory rate and oxygenation index compared with National Early Warning Score in emergency department patients: an observational study.

BACKGROUND: The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h. AIM: The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital. METHODS: This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment. RESULTS: The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%. CONCLUSION: The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED.

Using Vital Signs to Place Acutely Ill Patients Quickly and Easily into Clinically Helpful Pathophysiologic Categories: Derivation and Validation of Eight Pathophysiologic Categories in Two Distinct Patient Populations of Acutely Ill Patients.

BACKGROUND: Early warning scores reliably identify patients at risk of imminent death, but do not provide insight into what may be wrong with the patient or what to do about it. OBJECTIVE: Our aim was to explore whether the Shock Index (SI), pulse pressure (PP), and ROX Index can place acutely ill medical patients in pathophysiologic categories that could indicate the interventions required. METHODS: A retrospective post-hoc analysis of previously obtained and reported clinical data for 45,784 acutely ill medical patients admitted to a major regional referral Canadian hospital between 2005 and 2010 and validated on 107,546 emergency admissions to four Dutch hospitals between 2017 and 2022. RESULTS: SI, PP, and ROX values divided patients into eight mutually exclusive physiologic categories. Mortality was highest in patient categories that included ROX Index value < 22, and a ROX Index value < 22 multiplied the risk of any other abnormality. Patients with a ROX Index value < 22, PP < 42 mm Hg, and SI > 0.7 had the highest mortality and accounted for 40% of deaths within 24 h of admission, whereas patients with a PP ≥ 42 mm Hg, SI ≤ 0.7, and ROX Index value ≥ 22 had the lowest risk of death. These results were the same in both the Canadian and Dutch patient cohorts. CONCLUSIONS: SI, PP, and ROX Index values can place acutely ill medical patients into eight mutually exclusive pathophysiologic categories with different mortality rates. Future studies will assess the interventions needed by these categories and their value in guiding treatment and disposition decisions.

The United Kingdom's National Early Warning Score: should everyone use it? A narrative review.

This review critiques the benefits and drawbacks of the United Kingdom's National Early Warning Score (NEWS). Potential developments for the future are considered, as well as the role for NEWS in an emergency department (ED). The ability of NEWS to predict death within 24 h has been well validated in multiple clinical settings. It provides a common language for the assessment of clinical severity and can be used to trigger clinical interventions. However, it should not be used as the only metric for risk stratification as its ability to predict mortality beyond 24 h is not reliable and greatly influenced by other factors. The main drawbacks of NEWS are that measuring it requires trained professionals, it is time consuming and prone to calculation error. NEWS is recommended for use in acute UK hospitals, where it is linked to an escalation policy that reflects postgraduate experience; patients with lower NEWS are first assessed by a junior clinician and those with higher scores by more senior staff. This policy was based on expert opinion that did not consider workload implications. Nevertheless, its implementation has been shown to improve the efficient recording of vital signs. How and who should respond to different NEWS levels is uncertain and may vary according to the clinical setting and resources available. In the ED, simple triage scores which are quicker and easier to use may be more appropriate determinants of acuity. However, any alternative to NEWS should be easier and cheaper to use and provide evidence of outcome improvement.

Characteristics and Subjective Evaluation of an Intelligent Empowering Agent for Health Person Empowerment.

Empowerment is a process through which people acquire the necessary knowledge and self-awareness to understand their health conditions and treatment options, self-manage them, and make informed choices. Currently, few stand-alone applications for patient empowerment exist and people/patients often go on the Web to search for health information. Such information is mainly obtained through generic search engines and it is often overwhelming, too generic, and of poor quality. Intelligent Empowering Agents (IEA) can filter such information and assist the user in the understanding of health information about specific complaints or health in general. We have designed and developed a first prototype of an IEA that dialogues with the user in simple language, collects health information from the Web, and provides tailored, easily understood, and trusted information. It empowers users to create their own comprehensive and objective opinion on health matters that concern them. The paper describes the IEA main characteristics and presents the results of subjective tests carried out to assess the effectiveness of the IEA. Twenty-eight Master students in Digital Health filled an online survey presenting questions on usability, user experience and perceived value. Most respondents found the IEA easy to use and helpful. They also felt that it would improve communication with their doctors.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients.

Background: Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit. Methods: Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa. Results: Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%. Conclusion: In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

A prospective, internal validation of an emergency patient triage tool for use in a low resource setting.

Aim: Assess the performance of a simple triage disposition score based on mental status, mobility and either oxygen saturation or respiratory rate by three principal metrics: 24 h mortality, the need for hospital admission and the urgency ranking of patient presentations. Method: Prospective observational non-interventional study of consecutive patients presenting to the emergency and outpatient departments of a low-resource sub-Saharan hospital. Results: Out of 14,585 consecutive patients arriving to hospital 1,804 (12.4%) were admitted and 39 died (0.3%) within 24 hours. No patients with normal mental status or a stable independent gait died within 24 h, and 95% of those who did had an oxygen saturation <94%. The c statistic of the score for death within 24 hours was >0.95 and not significantly changed if respiratory rate replaced oxygen saturation as a score component, or mental status was assessed subjectively or objectively. However, an objective measure of mental status significantly reduced the c statistic for hospital admission from 0.970 SE 0.003 to 0.956 SE 0.004, p 0.002. The score attributed a higher acuity rating than the South African Triage System urgency ranking of presentations to 11.1% of patients and a lower acuity rating to 1.3%. However, 53% of the patients given a higher acuity rating were subsequently admitted to hospital and 6.1% of them died. Conclusion: The score identified patients who subsequently required hospital admission and who were likely to die within 24 hours.

Are changes in vital signs, mobility, and mental status while in hospital measures of the quality of care?

INTRODUCTION: Little is known of the changes in patients' health condition while in hospital in low-resource settings. The aim of this exploratory study is to examine dependency of patients on hospital admission and discharge in a low-resource sub-Saharan hospital. METHODS: We carried out a retrospective observational study of changes in the health condition, as reflected by their mental status, mobility and vital signs, of 5,888 consecutive patients between hospital admission and discharge. RESULTS: Mental status, mobility and vital signs were normal in 25% of patients on hospital admission and 30% of patients at discharge. Although very few patients with normal mental status, mobility and vital signs on admission died in hospital, the condition of 40% of them deteriorated. CONCLUSION: No comparative data on changes in health condition between hospital admission and discharge have been published. Our proposed health condition categories identify changes that may matter most to patients and should be considered as a standard metric of hospital care.

A systematic review of the discrimination and absolute mortality predicted by the National Early Warning Scores according to different cut-off values and prediction windows.

BACKGROUND: Although early warning scores were intended to simply identify patients in need of life-saving interventions, prediction has become their commonest metric. This review examined variation in the ability of the National Early Warning Scores (NEWS) in adult patients to predict absolute mortality at different times and cut-offs values. METHOD: Following PRISMA guidelines, all studies reporting NEWS and NEWS2 providing enough information to fulfil the review's aims were included. RESULTS: From 121 papers identified, the average area under the Receiver Operating Characteristic curve (AUC) for mortality declined from 0.90 at 24-hours to 0.76 at 30-days. Studies with a low overall mortality had a higher AUC for 24-hour mortality, as did general ward patients compared to patients seen earlier in their treatment. 24-hour mortality increased from 1.8% for a NEWS ≥3 to 7.8% for NEWS ≥7. Although 24-hour mortality for NEWS <3 was only 0.07% these deaths accounted for 9% of all deaths within 24-hours; for NEWS <7 24-hour mortality was 0.23%, which accounted for 44% of all 24-hour deaths. Within 30-days of a NEWS recording 22% of all deaths occurred in patients with a NEWS <3, 52% in patients with a NEWS <5, and 75% in patient with a NEWS <7. CONCLUSION: NEWS reliably identifies patients most and least likely to die within 24-hours, which is what it was designed to do. However, many patients identified to have a low risk of imminent death die within 30-days. NEWS mortality predictions beyond 24-hours are unreliable.

Prediction of admission to a low-resource sub-Saharan hospital by mental status, mobility and oxygen saturation recorded on arrival: a prospective observational study.

BACKGROUND: The decision to admit patients to hospital in low-resource settings have been poorly investigated. AIM: We aimed to determine the association of a disposition score determined on arrival with the decision subsequently made to admit or discharge the patient. The score awarded one point for altered mental status, one point for impaired mobility and one point for low oxygen saturation. METHODS: The mental status, mobility and oxygen saturation on arrival of 5,334 consecutive patients attending a combined emergency and outpatient department in a low-resource Ugandan hospital were recorded. Admission decisions were subsequently made independently by clinicians unaware to the score. RESULTS: Most patients (n=3,876; 73%) had a disposition score of zero and only 25 of these patients (0.6%) were subsequently admitted. A total of 646 (12.1%) patients were admitted. Only 301 (5.6%) patients had a score of 3 points and 263 (87.4%) of these were admitted. The C statistic for the discrimination of the score for admission was 0.953 (95% confidence interval 0.941-0.964). CONCLUSION: In a low-resource setting, a simple score based on mental status, mobility and oxygen saturation identified outpatient and emergency department patients most and least likely to be subsequently admitted to hospital with a high degree of discrimination.