A pre-hospital risk score predicts critical illness in non-trauma patients transported by ambulance to a Dutch tertiary referral hospital

Abstract

Background Early pre-hospital identification of critically ill patients reduces morbidity and mortality. To identify critically ill non-traumatic and non-cardiac arrest patients, a pre-hospital risk stratification tool was previously developed in the United States. The aim of this study was to investigate the accuracy of this tool in a Dutch Emergency Department. Methods This retrospective study included all patients of 18 years and older transported by ambulance to the Emergency Department of a tertiary referral hospital between January 1st 2017 and December 31st 2017. Documentation of pre-hospital vital parameters had to be available. The tool included a full set of vital parameters, which were categorized by predetermined thresholds. Study outcome was the accuracy of the tool in predicting critical illness, defined as admittance to the Intensive Care Unit for delivery of vital organ support or death within 28 days. Accuracy of the risk stratification tool was measured with the Area Under the Receiver Operating Characteristics (AUROC) curve. Results Nearly 3000 patients were included in the study, of whom 356 patients (12.2%) developed critical illness. We observed moderate discrimination of the pre-hospital risk score with an AUROC of 0.74 (95%-CI 0.71–0.77). Using a threshold of 3 to identify critical illness, we observed a sensitivity of 45.0% (95%-CI 44.8–45.2) and a specificity of 86.0% (95%-CI 85.9–86.0). Conclusion These data show that this pre-hospital risk stratification tool is a moderately effective tool to predict which patients are likely to become critically ill in a Dutch non-trauma and non-cardiac arrest population.

Recognition of Critically Ill Patients by Acute Healthcare Providers: A Multicenter Observational Study*

“…This higher occurrence might be explained by the selection of the most severe and ill patients in our level one trauma center. The occurrence of critical illness as stated in this study is in concordance with a study done by the same study group in 2017 (10).…”

“…Our primary hypothesis was that the specificity of medical caregivers would be significantly higher (20%), whereas sensitivity would be noninferior compared with MEWS greater than or equal to 3. Prior research in our centers reported an occurrence of critical illness in around 15% of all patients brought to the ED by EMS (10). Based on these findings, a loss to follow-up of 10%, alpha of 0.05, and a power of 80%, 193 medical judgments were needed to answer our primary outcome.…”

“…EMS nurses had a median experience of 10 years (IQR, 4-20), in which longer experience correlated significantly with the correct prediction of 3-day critical illness (p < 0.001). The ED nurses had a median experience of 5 years (IQR, [3][4][5][6][7][8][9][10][11][12], and the physicians had a median experience of 5 years (IQR, 3-11) both with no significant correlation with the correct prediction of 3-day critical illness (p = 0.499 and p = 0.237, respectively).…”

Performance of early warning and risk stratification scores versus clinical judgement in the acute setting: a systematic review

“…Attempts to achieve earlier identification of the clinically deteriorating patient led to the introduction of Early Warning Scores (EWS) risk-stratification models 10 11. EWS are used to recognise the early signs of clinical deterioration by assessing various physiological variables (eg, BP, HR, oxygen saturation, RR, level of consciousness and temperature).…”

Effect of Designating Emergency Medical Centers for Critical Care on Emergency Medical Service Systems during the COVID-19 Pandemic: A Retrospective Observational Study

“…Time-sensitive disease groups were defined as those with out-of-hospital cardiac arrest, ACS, or acute stroke. We also tried to classify the critical cases, but that was difficult based on a prehospital evaluation [27]. We, therefore, used SI and mental change as indicators for ill patients.…”