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This systematic review and meta-analysis showed traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared to those that are intubated in the hospital setting.

Study Objectives: Advanced heart failure (HF) is characterized by recurrent symptom exacerbations and elevated risk of mortality after an ED visit. While emergency physicians have proven adept at treating the presenting symptoms of HF, oftentimes the opportunity to facilitate connection with much needed palliative care or advanced care planning services is missed and holistic management suffers. Emergency physicians lack an accurate prognostic tool to help identify advanced HF patients at elevated risk of mortality who may benefit from referral to palliative care. The "Surprise Question" (SQ) has emerged as a simple prognostic tool, based on emergency physicians' gestalt, that can aid in the identification of ED patients at risk for 1-year mortality. In this study, we aim to evaluate factors associated with the SQ in patients with advanced HF presenting to the ED.Methods: Observational study of consecutive patients presenting to a single, urban academic hospital ED between 11/1/2016-2/1/2017. Any patient whose symptoms were suspected by the ED team to be secondary to heart failure were enrolled. Demographic data and clinical variables were collected from the electronic medical records. The attending physician responsible for care of each patient was asked to respond to the question "Would you be surprised if this patient died in the next 12 months?" Emergency physicians responded "No" if they would not be surprised if the patient died. Bivariate analysis of all variables was performed using Wilcox sum and chi square analysis. Standard deviations and 95% confidence interval (CI) were calculated.Results: 194 patients were identified and data was available for 95% of observations (n¼186). Emergency physicians responded "no" in 53% of cases (n¼99). The mean age among the "no" group was 78.7 vs. 69.2 in the "yes" group (p < 0.05). There was no statistically significant difference between the two groups in the presenting vital signs, creatinine, or ejection fraction. Troponin and BNP elevation was twice as likely among the "no" group, as was frequent ED visits (24/99 vs 12/87). The only co-morbidity with statistically significant difference between the groups was anemia (34.7% vs. 12.5%; p < 0.05).Conclusions: The SQ is a simple, single-question tool based on provider gestalt used to aid prognostication of 1-year mortality among patients with advanced illness. In an observational cohort, emergency physicians stated that they "would not be surprised" if 53% of their HF patients died in the next 12 months. Factors associated with predicting 1-year mortality included advanced age, history of anemia, and presence of elevated cardiac biomarkers. Future studies should evaluate the prognostic accuracy of the SQ for HF patients presenting to the ED.