Construct validity of acute morbidity as a novel outcome for emergency patients

Schmid, Fabrizia; Malinovska, Alexandra; Weigel, Karin; Bosia, Tito; Nickel, Christian H.; Bingisser, Roland

doi:10.1371/journal.pone.0207906

Cited by 5 publications

(7 citation statements)

References 27 publications

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“…Two recent studies of patients presenting at the ED with multiple symptoms showed increased resource requirements and hospitalizations, but no evidence of adverse outcomes, such as acute morbidity or mortality [ 4 , 5 ]. The situation is different for emergency patients who present to the ED with atypical or nonspecific symptoms.…”

Section: Introductionmentioning

confidence: 99%

The presentational flow chart “unwell adult” of the Manchester Triage System—Curse or blessing?

Brutschin

Kogej

Schacher³

et al. 2021

PLoS ONE

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Background The presentational flow chart “unwell adult” of the Manchester Triage System (MTS) occupies a special role in this triage system, defined as the nonspecific presentation of an emergency patient. Current scientific studies show that a considerable proportion of emergency room patients present with so-called "nonspecific complaints". The aim of the present study is to investigate in detail the initial assessment of emergency patients triaged according to the presentational flow chart "unwell adult". Methods Monocentric, retrospective observational study. Results Data on 14,636 emergency department visits between March 12th and August 12th, 2019 were included. During the observation period, the presentational flow chart "unwell adult" was used 1,143 times and it was the third most frequently used presentational flow chart. Patients triaged with this flow chart often had unspecific complaints upon admission to the emergency department. Patients triaged with the “unwell adult” chart were often classified with a lower triage level. Notably, patients who died in hospital during the observation period frequently received low triage levels. The AUC for the MTS flow chart “unwell adult” and hospitalization in general for older patients (age ≥ 65 years) was 0.639 (95% CI 0.578–0.701), and 0.730 (95% CI 0.714–0.746) in patients triaged with more specific charts. The AUC for the MTS flow chart “unwell adult” and admission to ICU for older patients (age ≥65 years) was 0.631 (95% CI 0.547–0.715) and 0.807 (95% CI 0.790–0.824) for patients triaged with more specific flow charts. Comparison of the predictive ability of the MTS for in-hospital mortality in the group triaged with the presentational flow chart “unwell adult” revealed an AUC of 0.682 (95% CI 0.595–0.769) vs. 0.834 (95% CI 0.799–0.869) in the other presentational flow charts. Conclusion The presentational flow chart "unwell adult" is frequently used by triage nurses for initial assessment of patients. Patient characteristics assessed with the presentational flow chart "unwell adult" differ significantly from those assessed with MTS presentational flow charts for more specific symptoms. The quality of the initial assessment in terms of a well-functioning triage priority assessment tool is less accurate than the performance of the MTS described in the literature.

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Section: Introductionmentioning

confidence: 99%

The presentational flow chart “unwell adult” of the Manchester Triage System—Curse or blessing?

Brutschin

Kogej

Schacher³

et al. 2021

PLoS ONE

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“…Acute morbidity was defined as any potentially life-threatening condition or any condition requiring early intervention to prevent disability, deterioration, or death [ 4 , 13 , 14 ]. It was assessed based on chart reviews by two physicians and, in case of disagreement, a senior physician who served as a referee.…”

Section: Methodsmentioning

confidence: 99%

“…A patient was categorized as acutely morbid, if their chart included one or more of the following events: administration of antibiotics, virostatics, antifungals, immunosuppressives, diuretics, anticoagulants, antihypertensives, and procoagulants; the need for invasive interventions, or prolonged monitoring; new neurological deficits, or seizures; fractures, or self-harm. A more complete definition of acute morbidity can be found elsewhere [ 14 ].…”

Section: Methodsmentioning

confidence: 99%

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

et al. 2020

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Background Generalized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians’ disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians’ DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI. Methods Prospective observational study between 2013–2015 (analysis in 2018–2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations. Findings Compared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3–6 vs. median = 3; IQR = 2–5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it. Conclusions The use of physicians’ disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians’ prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients’ clinical state at triage and how this can be improved and used in simple decision aids.

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“…This may in part be explained by the fact that no protocols exist for nonspecific complaints, but also by the wide range of underlying disease in nonspecific presentation, which favours the probability of a mismatch [89]. Therefore, in a nonspecific presentation, other concepts were developed for risk stratification, such as the frameworks of "acute morbidity" [74] or "acuity" [45,48]. Both can support risk stratification in a phase in which diagnoses are still unclear.…”

Section: Advances Due To Symptom-oriented Research At Work-upmentioning

confidence: 99%

“…Research on patients presenting with multiple symptoms showed an increased demand for resources and hospitalisation, but no evidence of adverse outcomes such as acute morbidity [74] or mortality [43]. Interestingly, certain combinations of symptoms, such as weakness and fatigue [75], may predict adverse outcomes -a strong indication that systematically assessing symptoms at triage may add prognostic information.…”

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confidence: 99%

The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

Bingisser

Nickel

2019

Swiss Med Wkly

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As a result of the ever-increasing use of imaging and clinical chemistry, symptom-oriented research has lost ground in many areas of clinical medicine. In emergency medicine, the importance of symptom-oriented research is obvious, as the three major tasks (triage, work-up and disposition) are still under-investigated. Scientific progress is closely linked to the analysis of readily available information, such as the patients' symptoms.A decade ago, there were more questions than answers. Therefore, we describe the state of the evidence and the importance of symptoms for decisions at triage, during work-up and for disposition. Recent advances in each field focusing on symptoms as predictors of outcome and/or diagnosis are shown. Finally, future directions of research regarding novel triage tools, efficient work-up and evidence-based disposition are discussed. Symptom-oriented research has been a driver for medical progress for centuries, and re-focusing on patient-centred clinical research will strengthen this field in the future in order to support smarter medicine.

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Construct validity of acute morbidity as a novel outcome for emergency patients

Cited by 5 publications

References 27 publications

The presentational flow chart “unwell adult” of the Manchester Triage System—Curse or blessing?

The presentational flow chart “unwell adult” of the Manchester Triage System—Curse or blessing?

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

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