IntroductionEarly risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting.MethodWe included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin).ResultsDuring a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender.ConclusionsCombination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes.Trial registrationClinicalTrials.gov NCT01768494. Registered January 9, 2013.

Study design: Retrospective study of 432 patients admitted to our institution with a spinal injury over a 5-year period. Objectives:To present epidemiological data relating to this spinal population, reporting specifically on delayed admission and length of hospitalisation. Setting: Royal National Orthopaedic Hospital, Stanmore, UK. Methods: A total of 432 traumatic spinal injuries admitted between March 1998 and March 2003 were analysed with respect to age, gender, mechanism of injury, level of bony injury, neurological level (complete, incomplete and intact), Injury Severity Score (ISS), date of injury, referral and admission independently and length of hospitalisation. The delays between injury and referral (43 days) and between referral and admission (47 days) were correlated to the length of hospitalisation. A detailed analysis of the cause of delay at both junctures was undertaken.Results: There were 322 males (average age, 38.6 years) and 110 females (average age, 41.8 years) in our study. Classification of neurological severity disclosed 108 complete injuries, 115 incomplete and 209 intact. The average time between injury and referral was 5.5 days (range 0-94), and between referral and admission was 10.7 days (range 0-130). A total of 161 patients (37%) experienced a delay between injury and referral, of whom 59 (37%) were subsequently also delayed to admission. The principal reason for delay between injury and referral was the treatment of concurrent injuries. Even patients with complete injuries (15/43) experienced delayed referral. In all, 112 patients (26%) experienced a delay between referral and admission. Principal reasons included the provision of beds (Intensive care, acute and rehabilitation) and physiological stabilisation of other injuries particularly thoracic trauma. Conclusions: Provision of beds remains the most common preventable reason for delay between referral and admission and is associated with increased hospitalisation. Early liaison with a designated spinal injuries unit, particularly those with cord injury remains vitally important.

In this large and heterogenous medical ED patient cohort, admission PCT was a strong and independent outcome predictor for 30-day mortality across different medical diagnoses independent of underlying infection. PCT may help to improve risk stratification in unselected medical ED patients.

ObjectivesThe National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM).DesignSecondary analysis of a multinational, observational study (TRIAGE study, March 2013–October 2014).SettingThree tertiary care centres in France, Switzerland and the USA.ParticipantsA total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data.Main outcome measuresThe primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination.ResultsOf the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006).ConclusionNEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population.Trial registration number NCT01768494; Post-results.