Duration of Mechanical Ventilation in the Emergency Department.

INTRODUCTION: Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). METHODS: This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. RESULTS: We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. CONCLUSION: In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.

Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients.

BACKGROUND: Little is known about the diagnostic accuracy of systemic inflammatory response syndrome (SIRS) criteria for critical illness among emergency department (ED) patients with and without infection. Our objective was to assess the diagnostic accuracy of SIRS criteria for critical illness in ED patients. METHODS: This was a retrospective cohort study of ED patients at an urban academic hospital. Standardized chart abstraction was performed on a random sample of all adult ED medical patients admitted to the hospital during a 1-year period, excluding repeat visits, transfers, ED deaths, and primary surgical or psychiatric admissions. The binary composite outcome of critical illness was defined as 24 hours or longer in intensive care or inhospital death. Presumed infection was defined as receiving antibiotics within 48 hours of admission. Systemic inflammatory response syndrome criteria were calculated using ED triage vital signs and initial white blood cell count. RESULTS: We studied 1152 patients; 39% had SIRS, 27% had presumed infection, and 23% had critical illness (2% had inhospital mortality, and 22% had ≥24 hours in intensive care). Of patients with SIRS, 38% had presumed infection. Of patients without SIRS, 21% had presumed infection. The sensitivity of SIRS criteria for critical illness was 52% (95% confidence interval [CI], 46%-58%) in all patients, 66% (95% CI, 56%-75%) in patients with presumed infection, and 43% (95% CI, 36%-51%) in patients without presumed infection. CONCLUSIONS: Systemic inflammatory response syndrome at ED triage, as currently defined, has poor sensitivity for critical illness in medical patients admitted from the ED.

Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS).

OBJECTIVE: To prospectively and externally validate the Mortality in Emergency Department Sepsis (MEDS) score as a predictor of 28-day mortality in patients who present to the emergency department with a systemic inflammatory response syndrome. DESIGN: Multicentered prospective cohort study. SETTING: Emergency departments at the University of Colorado Hospital and Denver Health Medical Center in Denver, CO, and Albert Einstein Medical Center and the Hospital of the University of Pennsylvania in Philadelphia, PA. SUBJECTS: Adult patients who presented to the emergency department, who met criteria for systemic inflammatory response syndrome, and who were admitted to the hospital. MEASUREMENTS: The MEDS score was calculated by recording the presence of terminal illness, tachypnea or hypoxemia, septic shock, platelet count <150,000 cells/mm3, band count as a percentage of total white blood cell count >5%, age >65 yrs, lower respiratory infection, nursing home residence, and altered mental status. OUTCOME: Mortality within 28 days or discharged alive from the hospital. RESULTS: In all, 385 patients were enrolled between 18 and 100 yrs of age. The overall mortality was 9%. As in the original article, the MEDS score was categorized into five groups: very low, low, moderate, high, and very high for 28-day mortality. Mortality rates for each group were 0.6% (95% confidence interval [CI], 0%-3%), 5% (95% CI, 1%-13%), 19% (95% CI, 11%-29%), 32% (95% CI, 15%-54%), and 40% (95% CI, 12%-74%), respectively. The MEDS score had an area under the receiver operating characteristic curve of 0.88 (95% CI, 0.83-0.92). CONCLUSIONS: The MEDS score accurately predicts 28-day mortality in patients who present to the emergency department with systemic inflammatory response syndrome and who are admitted to the hospital.