The Diagnoses and Outcomes of Emergency Patients With an Elevated D-Dimer Over the Next 90 Days.

BACKGROUND: It is not known what diagnoses are associated with an elevated D-dimer in unselected patients attending emergency departments (ED), nor have their associated outcomes been determined. METHODS: This was a prospective observational study of 1612 unselected patients attending a Danish ED, with 100% follow-up for 90 days after presentation. RESULTS: The 765 (47%) ED patients with an elevated D-dimer level (ie, ≥ 0.5 mg/L) were more likely to be admitted to hospital (P <.0001), re-present to health services (P = .02), and die within 90 days (8.1% of patients, P <.0001). Only 10 patients with a normal D-dimer level (1.2%) died within 90 days. Five had chronic obstructive pulmonary disease and infection, and 5 had cancer (4 of whom also had infection). Venous thromboembolism, infection, neoplasia, anemia, heart failure, and unspecified soft tissue disorders were significantly associated with an elevated D-dimer level. Of the 72 patients with venous thromboembolism, 20 also had infection, 8 had cancer, and 4 had anemia. None of the patients with heart failure, stroke, or acute myocardial infarction with a normal D-dimer level died within 90 days. CONCLUSIONS: In this study, nearly half of all patients attending the ED had an elevated D-dimer level, and these patients were more likely to be admitted to hospital and to re-present to health services or die within 90 days. In this unselected ED patient population, elevated D-dimer levels were found to not only be significantly associated with venous thromboembolism, but to also be associated with infection, cancer, heart failure, and anemia.

A simple prognostic score predicts one-year mortality of alert and calm emergency department patients: A prospective two-center observational study.

STUDY OBJECTIVE: To derive and validate a prognostic score to predict 1-year mortality using vital signs, mobility and other variables that are readily available at the bedside at no additional cost. METHODS: Post hoc analysis of two independent prospective observational studies in two emergency departments, one in Denmark and the other in Switzerland. PARTICIPANTS: Alert and calm emergency department patients. MEASUREMENTS: The prediction of mortality from presentation to 365 days by vital signs, mobility and other variables that are readily available at the bedside at no additional cost. RESULTS: One thousand six hundred and eighteen alert and calm patients were in the Danish cohort and 1331 in the Swiss cohort. Logistic regression identified age >68 years, abnormal vital signs, impaired mobility and the decision to admit as significant predictors of 365-day mortality. A simple prognostic score awarded one point to each of these predictors. Less than two of these predictors were present in 45.6% of patients, and only 0.4% of these patients died within a year. If two or more of these predictors were present, 365-day mortality increased exponentially. CONCLUSION: Age >68 years, the decision for hospital admission, any vital sign abnormality at presentation and impaired mobility at presentation are equally powerful predictors of 1-year mortality in alert and calm emergency department patients. If validated by others these predictors could be used to discharge patients with confidence since nearly half of these patients had less than two predictors and none of them died within 30 days. However, when two or more predictors were present 365-day mortality increased exponentially.

Mobility Identifies Acutely Ill Patients at Low Risk of In-Hospital Mortality: A Prospective Multicenter Study.

BACKGROUND: A retrospective study has reported that impaired mobility on presentation (IMOP) enhanced the ability of vital signs to predict mortality in acutely ill patients. This study was designed to further examine the association between IMOP and in-hospital mortality. METHODS: Prospective observational study of three different cohorts of acutely ill patients admitted to hospitals in Esbjerg, Denmark (998 patients), Basel, Switzerland (743 patients), and Kitovu, Uganda (1,622 patients). RESULTS: There were significant differences in age, sex, length of stay, proportion of medical and surgical patients, and in-hospital mortality between the three cohorts. Yet in all three cohorts a National Early Warning Score (NEWS) ≥ 3 when first recorded and IMOP increased the risk of in-hospital mortality to approximately the same extent. IMOP and NEWS ≥ 3 when first recorded were, therefore, used for risk categorization: patients with a NEWS < 3 when first recorded and normal mobility on presentation had the lowest in-hospital mortality risk and those with NEWS ≥ 3 when first recorded and IMOP had the highest risk. The number of these low risk patients ranged from 26% in Kitovu to 42% in Esbjerg, and their in-hospital mortality rates did not significantly differ in all three cohorts, ranging from 0.2% in Esbjerg to 0.4% in Basel. CONCLUSIONS: In this prospective multicenter study IMOP enhanced the risk categorization of acutely ill patients from very different clinical settings. The combination normal mobility on presentation and first recorded NEWS identified a substantial proportion of patients in all cohorts with a low risk of dying while in hospital. TRIAL REGISTRY: The Esbjerg data were collected as part of a trial registered with the US National Library of Medicine (ClinicalTrials.gov; No.: NCT03108807; URL: www.clinicaltrials.gov).