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Abnormal vital signs are strong predictors for intensive care unit admission and in-hospital mortality in adults triaged in the emergency department - a prospective cohort study.

https://arctichealth.org/en/permalink/ahliterature125355
Source
Scand J Trauma Resusc Emerg Med. 2012;20:28
Publication Type
Article
Date
2012
Author
Charlotte Barfod
Marlene Mauson Pankoke Lauritzen
Jakob Klim Danker
György Sölétormos
Jakob Lundager Forberg
Peter Anthony Berlac
Freddy Lippert
Lars Hyldborg Lundstrøm
Kristian Antonsen
Kai Henrik Wiborg Lange
Author Affiliation
Department of Anaesthesia and Intensive Care, Hillerød Hospital, Denmark. cbar@hih.regionh.dk
Source
Scand J Trauma Resusc Emerg Med. 2012;20:28
Date
2012
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Denmark
Emergency Service, Hospital - statistics & numerical data
Female
Hospital Mortality
Humans
Intensive Care Units - statistics & numerical data
Male
Middle Aged
Outcome and Process Assessment (Health Care)
Patient Admission - statistics & numerical data
Prognosis
Prospective Studies
Regression Analysis
Triage - methods - statistics & numerical data
Vital Signs
Young Adult
Abstract
Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.
The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.
The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients.
The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.
Notes
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PubMed ID
22490208 View in PubMed
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Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study.

https://arctichealth.org/en/permalink/ahliterature282154
Source
Scand J Gastroenterol. 2016 Aug;51(8):1000-6
Publication Type
Article
Date
Aug-2016
Author
Patricia Duch
Camilla Haahr
Morten Hylander Møller
Steffen J Rosenstock
Nicolai B Foss
Lars Hyldborg Lundstrøm
Nicolai Lohse
Source
Scand J Gastroenterol. 2016 Aug;51(8):1000-6
Date
Aug-2016
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Anesthesia
Cohort Studies
Denmark
Duodenoscopy
Emergencies
Endoscopy, Gastrointestinal
Female
Gastroscopy
Humans
Male
Middle Aged
Peptic Ulcer Hemorrhage - diagnosis - mortality
Registries
Abstract
Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care.
This population-based cohort study included all emergency EGDs for PUB in adults during 2012-2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model.
Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR?=?1.51 (95% CI?=?1.25-1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR?=?1.22 (95% CI?=?0.55-2.71). The prevalence of anaesthesia care varied between the hospitals, median?=?78.9% (range 6.9-98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity.
Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.
PubMed ID
27152958 View in PubMed
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Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study.

https://arctichealth.org/en/permalink/ahliterature275068
Source
Scand J Gastroenterol. 2016 Jan;51(1):121-8
Publication Type
Article
Date
Jan-2016
Author
Morten Vester-Andersen
Lars Hyldborg Lundstrøm
David Levarett Buck
Morten Hylander Møller
Source
Scand J Gastroenterol. 2016 Jan;51(1):121-8
Date
Jan-2016
Language
English
Publication Type
Article
Keywords
Abdomen - surgery
Aged
Aged, 80 and over
Cohort Studies
Denmark
Emergencies
Female
Hospitalization - statistics & numerical data
Humans
Laparoscopy - methods
Laparotomy - methods
Logistic Models
Male
Middle Aged
Odds Ratio
Outcome Assessment (Health Care)
Registries
Risk factors
Surgical Procedures, Operative - mortality
Time Factors
Abstract
In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general.
All in-patients aged = 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression.
A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding.
In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.
PubMed ID
26153059 View in PubMed
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Detailed statistical analysis plan for the difficult airway management (DIFFICAIR) trial.

https://arctichealth.org/en/permalink/ahliterature260658
Source
Trials. 2014;15:173
Publication Type
Article
Date
2014
Author
Anders Kehlet Nørskov
Lars Hyldborg Lundstrøm
Charlotte Vallentin Rosenstock
Jørn Wetterslev
Source
Trials. 2014;15:173
Date
2014
Language
English
Publication Type
Article
Keywords
Clinical Protocols
Data Interpretation, Statistical
Decision Support Techniques
Denmark
Humans
Intubation, Intratracheal - adverse effects - methods - statistics & numerical data
Laryngoscopy - adverse effects - statistics & numerical data
Models, Statistical
Preoperative Care - adverse effects - methods - statistics & numerical data
Research Design - statistics & numerical data
Risk assessment
Risk factors
Abstract
Preoperative airway assessment in Denmark is based on a non-specific clinical assessment left to the discretion of the responsible anesthesiologist. The DIFFICAIR trial compares the effect of using a systematic and consistent airway assessment versus a non-specific clinical assessment on the frequency of unanticipated difficult airway management.To prevent outcome bias and selective reporting, we hereby present a detailed statistical analysis plan as an amendment (update) to the previously published protocol for the DIFFICAIR trial.
The DIFFICAIR trial is a stratified, parallel group, cluster (cluster?=?department) randomized multicenter trial involving 28 departments of anesthesia in Denmark randomized to airway assessment either by the Simplified Airway Risk Index (SARI) or by a usual non-specific assessment. Data from patients' preoperative airway assessment are registered in the Danish Anesthesia Database. An objective score for intubation grading the severity, that is the severity of the intubations, as well as the frequency of unanticipated difficult intubation, is measured for each group.Primary outcome measures are the fraction of unanticipated difficult and easy intubations.The database is programmed so that the registration of the SARI is mandatory for the intervention group but invisible to controls.Data recruitment was commenced in October 2012 and ended in ultimo December 2013.
We intend to increase the transparency of the data analyses regarding the DIFFICAIR trial by an a priori publication of a statistical analysis plan.
ClinicalTrials.gov: NCT01718561.
Notes
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PubMed ID
24885548 View in PubMed
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The formation and design of the 'Acute Admission Database'- a database including a prospective, observational cohort of 6279 patients triaged in the emergency department in a larger Danish hospital.

https://arctichealth.org/en/permalink/ahliterature125354
Source
Scand J Trauma Resusc Emerg Med. 2012;20:29
Publication Type
Article
Date
2012
Author
Charlotte Barfod
Marlene Mauson Pankoke Lauritzen
Jakob Klim Danker
György Sölétormos
Peter Anthony Berlac
Freddy Lippert
Lars Hyldborg Lundstrøm
Kristian Antonsen
Kai Henrik Wiborg Lange
Author Affiliation
Department of Anaesthesia and Intensive Care, Hillerød Hospital, Hillerød, Denmark. cbar@hih.regionh.dk
Source
Scand J Trauma Resusc Emerg Med. 2012;20:29
Date
2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Databases, Factual
Denmark
Emergency Service, Hospital - statistics & numerical data
Female
Hospital Mortality
Humans
Intensive Care Units - statistics & numerical data
Length of Stay - statistics & numerical data
Male
Middle Aged
Outcome Assessment (Health Care)
Patient Admission - statistics & numerical data
Patient Discharge - statistics & numerical data
Prospective Studies
Severity of Illness Index
Triage - statistics & numerical data
Abstract
Management and care of the acutely ill patient has improved over the last years due to introduction of systematic assessment and accelerated treatment protocols. We have, however, sparse knowledge of the association between patient status at admission to hospital and patient outcome. A likely explanation is the difficulty in retrieving all relevant information from one database. The objective of this article was 1) to describe the formation and design of the 'Acute Admission Database', and 2) to characterize the cohort included.
All adult patients triaged at the Emergency Department at Hillerød Hospital and admitted either to the observationary unit or to a general ward in-hospital were prospectively included during a period of 22 weeks. The triage system used was a Danish adaptation of the Swedish triage system, ADAPT. Data from 3 different data sources was merged using a unique identifier, the Central Personal Registry number; 1) Data from patient admission; time and date, vital signs, presenting complaint and triage category, 2) Blood sample results taken at admission, including a venous acid-base status, and 3) Outcome measures, e.g. length of stay, admission to Intensive Care Unit, and mortality within 7 and 28 days after admission.
In primary triage, patients were categorized as red (4.4%), orange (25.2%), yellow (38.7%) and green (31.7%). Abnormal vital signs were present at admission in 25% of the patients, most often temperature (10.5%), saturation of peripheral oxygen (9.2%), Glasgow Coma Score (6.6%) and respiratory rate (4.8%). A venous acid-base status was obtained in 43% of all patients. The majority (78%) had a pH within the normal range (7.35-7.45), 15% had acidosis (pH 7.45). Median length of stay was 2 days (range 1-123). The proportion of patients admitted to Intensive Care Unit was 1.6% (95% CI 1.2-2.0), 1.8% (95% CI 1.5-2.2) died within 7 days, and 4.2% (95% CI 3.7-4.7) died within 28 days after admission.
Despite challenges of data registration, we succeeded in creating a database of adequate size and data quality. Future studies will focus on the association between patient status at admission and patient outcome, e.g. admission to Intensive Care Unit or in-hospital mortality.
Notes
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PubMed ID
22490233 View in PubMed
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Incidence of unanticipated difficult airway using an objective airway score versus a standard clinical airway assessment: the DIFFICAIR trial - trial protocol for a cluster randomized clinical trial.

https://arctichealth.org/en/permalink/ahliterature106529
Source
Trials. 2013;14:347
Publication Type
Article
Date
2013
Author
Anders Kehlet Nørskov
Charlotte Valentin Rosenstock
Jørn Wetterslev
Lars Hyldborg Lundstrøm
Author Affiliation
Department of Anaesthesiology, Copenhagen University Hospital, Nordsjælland Hospital, 3400, Hillerød, Denmark. anderskehlet@hotmail.com.
Source
Trials. 2013;14:347
Date
2013
Language
English
Publication Type
Article
Keywords
Clinical Protocols
Decision Support Techniques
Denmark
Humans
Intubation, Intratracheal - adverse effects - instrumentation
Laryngeal Masks
Laryngoscopy - adverse effects - instrumentation
Multivariate Analysis
Preoperative Care
Research Design
Respiration, Artificial - adverse effects - instrumentation
Risk assessment
Risk factors
Abstract
Pre-operative airway assessment in Denmark is based on a non-specific clinical assessment. Systematic, evidence-based and consistent airway assessment may reduce the incidence of unanticipated difficult airway management. By assessing multiple predictors for difficult airway management, the predictive value of the assessment increases. The Simplified Airway Risk Index (SARI) is a multivariate risk score for predicting difficult intubation.This study aims to compare the use of the SARI with a non-specified clinical airway assessment on predicting difficult intubation. Further, to compare the examination and registration of predictors for difficult mask ventilation with a non-specified clinical airway assessment on prediction of difficult mask ventilation.
We cluster-randomized 28 Danish departments of anaesthesia to airway assessment either by the SARI or by usual non-specific assessment. Data from patients' pre-operative airway assessment are registered in the Danish Anaesthesia Database. Objective scores for intubation and mask ventilation grade the severity of airway managements. The accuracy of predicting difficult intubation and mask ventilation is measured for each group. The primary outcome measure is the fraction of unanticipated difficult and easy intubation.The fraction of unanticipated difficult intubation in Denmark is 1.87%. With a stratified randomization, type 1 error risk of 5% and a power of 80%, 30 departments are required to detect or reject a 30% relative risk reduction equalling a number needed to treat of 180. Sample size estimation is adjusted for the study design and based on standards for randomization on cluster-level. With an average cluster size of 2,500 patients, 70,000 patients will be enrolled over a 1-year trial period. The database is programmed so that registration of the SARI and predictors for difficult mask ventilation are mandatory for the intervention group but invisible to controls.
It is innovative to use a national clinical database as the basis for a randomized clinical trial. The method can serve as a precedent for implementation of evidence-based recommendations and database registration.The trial will forward understanding of how to predict and reduce unanticipated difficult airways and how to produce evidence-based recommendations for airway assessment and clinical database development.
(NCT01718561).
Notes
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PubMed ID
24152537 View in PubMed
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6 records – page 1 of 1.