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Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department

Kurzzeitergebnisse und Charakteristik der Schockraumversorgung kritisch kranker nichttraumatologischer Patienten

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Abstract

Background

Emergency medical care for critically ill nontrauma patients (CINT) varies between different emergency departments (ED) and healthcare systems, while resuscitation of trauma patients is always performed within the ED. In many ED CINT are treated and stabilized while in many German smaller hospitals CINT are transferred directly to the intensive care unit (ICU) without performing critical care measures in the ED. Little is known about the resuscitation room management of CINT regarding patient characteristics and outcome although bigger hospitals perform ED resuscitation of CINT in routine care. Against this background we conducted this retrospective analysis of CINT treated by an ED resuscitation room concept in a German 756 bed teaching hospital.

Methods

The collective of CINT treated within the ED resuscitation room (1 October 2018 to 31 March 2019) was analyzed after ethical approval. After each resuscitation room operation, the team leader filled out a standardized paper-based questionnaire and qualified the patient as a resuscitation room patient this way. Only patients who underwent invasive procedures and were admitted to ICU or died in the ED were included. Patient characteristics, performed critical care measures, short-term outcomes and the comparison of admission characteristics between survivors and non-survivors were evaluated. Additionally, the accordance of ED admission diagnoses and discharge diagnoses were analyzed.

Results

Overall, 243 of 19,854 ED patients (1.22%) were treated in the resuscitation room. After exclusion of trauma patients, 193 (0.97%) CINT were included. Overall mortality was 29% (n = 56), 24‑h mortality was 13% (n = 25). Patient characteristics (vital signs, blood gas analysis) differed significantly between survivors and nonsurvivors except for respiratory rate and pain scale. An excerpt of conducted resuscitation room measures was as follows: arterial line n = 78 (40%); noninvasive ventilation n = 60 (31%); endotracheal intubation n = 56 (29%); cardiopulmonary resuscitation n = 19 (10%), central venous line n = 8 (4%). The number of conducted measures differed between survivors and nonsurvivors (median and interquartile range, IQR): 4 (IQR 2) vs. 4 (IQR 3) p = 0.0453. The length of ED stay was 148.2 ± 202.7 min until the patient was admitted to an ICU or died within the ED. ED admission diagnoses matched with hospital discharge diagnoses in 78%.

Conclusion

The observed mortality was high and was comparable to patient collectives with septic shock. Nonsurvivors showed significantly more impaired vital parameters and blood gas analysis parameters. Vital parameters together with blood gas analysis might enable ED risk stratification of CINT. Resuscitation room management enables immediate stabilization and diagnostic work-up of CINT even when no ICU bed is available. Furthermore, optimal allocation to specialized ICUs can probably be enabled more accurately after a first diagnostic work-up; however, although a first diagnostic work-up including laboratory tests and computed tomography in many cases was performed, ED admission and hospital discharge diagnoses matched only in 78%.

Zusammenfassung

Einleitung

Die Notfallversorgung für kritische Kranke ist in verschiedenen Gesundheitssystemen heterogen organisiert. Während Traumapatienten immer im Schockraum übergeben und stabilisiert werden, erfolgt speziell in der deutschen Grund- und Regelversorgung bei kritisch kranken Nicht-Traumapatienten häufig eine direkte Aufnahme auf die Intensivstation durch den Rettungsdienst. In dieser retrospektiven Studie wurde daher die Schockraumversorgung nichttraumatologischer Patienten in einem 756-Betten-Lehrkrankenhaus analysiert.

Methode

Schockraumversorgungen kritisch Kranker (01.10.2018 bis 31.03.2019) wurden in Bezug auf Patientencharakteristika, durchgeführte Schockraummaßnahmen und Krankenhaussterblichkeit analysiert. Ferner sollten die Aufnahmecharakteristika zwischen Überlebenden und Nichtüberlebenden evaluiert werden. Aufnahme- und Entlassungsdiagnosen sollten vergleichend ausgewertet werden.

Ergebnisse

Es wurden 243/19.854 Patienten (1,22 %) im Untersuchungszeitraum als Schockraumpatienten behandelt. Nach Ausschluss von Traumapatienten konnten 193 (0,97 %) kritisch kranke nichttraumatologische Patienten eingeschlossen werden. Die Gesamtsterblichkeit lag bei 29 % (n = 56), die 24-h-Sterblichkeit bei 13 % (n = 25). Es wurden im Mittel 4,24 Schockraummaßnahmen (z. B. Intubation, Zentraler Venenkatheter) durchgeführt mit einer Versorgungsdauer in der Notaufnahme von 148 ± 203 min. Die Aufnahmeparameter von Überlebenden und Nichtüberlebenden unterschieden sich signifikant mit Ausnahme von Atemfrequenz und Schmerzskala. Durchgeführte Schockraummaßnahmen bei Überlebenden vs. Nichtüberlebenden: Median 4 (IQR 2) vs. 4 (IQR 3), p = 0,0453. Krankenhausaufnahme- und Entlassungsdiagnosen stimmten in 78 % der Fälle überein.

Schlussfolgerung

Bei insgesamt hoher Krankenhaussterblichkeit zeigten sich signifikant schlechtere Vital- und Blutgasanalyseparameter bei Aufnahme für das Subkollektiv der Nichtüberlebenden. Ein möglicher Score aus Vital- und Blutgaswerten könnte folglich eine zukünftige Risikostratifizierung für nichttraumatologische Schockraumpatienten ermöglichen. Die nichttraumatologische Schockraumversorgung ermöglicht eine sofortige notfallmedizinische Versorgung und genaue Patientenallokation zu spezialisierten Intensivstationen. Nichtsdestotrotz stimmten Krankenhausaufnahme- und Entlassungsdiagnosen in 78 % überein.

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Funding

The study was performed and funded solely by departmental resources.

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Authors and Affiliations

  1. Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany

    Jessika Stefanie Kreß, Marc Rüppel &  Sebastian Bergrath

  2. Lehrstuhl für Anästhesiologie, Medizinische Fakultät RWTH Aachen, Uniklinik RWTH Aachen, Aachen, Germany

    Jessika Stefanie Kreß &  Sebastian Bergrath

  3. Klinik für Kardiologie, Elektrophysiologie und internistische Intensivmedizin, Kliniken Maria Hilf, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany

    Hendrik Haake & Jürgen vom Dahl

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  1. Jessika Stefanie Kreß
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  4. Jürgen vom Dahl
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Corresponding author

Correspondence to Sebastian Bergrath.

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Conflict of interest

H. Haake reports personal fees from Berlin Chemie, Novartis, Bayer Chemie and Maquet all outside the submitted work. J.S. Kreß, M. Rüppel, J. vom Dahl and S. Bergrath declare that they have no competing interests.

Due to the process that only routine data were collected, and all data analyses were performed in a pseudonymized way, the ethics committee (University hospital Aachen, Germany) waived personal consent by patients or ED personnel (EK051/20).

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Kreß, J.S., Rüppel, M., Haake, H. et al. Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department. Anaesthesist 71, 30–37 (2022). https://doi.org/10.1007/s00101-021-00953-4

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  • DOI: https://doi.org/10.1007/s00101-021-00953-4

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