Repeated vital sign measurements in the emergency department predict patient deterioration within 72 hours: a prospective observational study

Abstract

BackgroundMore than one in five patients presenting to the emergency department (ED) with (suspected) infection or sepsis deteriorate within 72 h from admission. Surprisingly little is known about vital signs in relation to deterioration, especially in the ED. The aim of our study was to determine whether repeated vital sign measurements in the ED can differentiate between patients who will deteriorate within 72 h and patients who will not deteriorate.MethodsWe performed a prospective observational study in patients presenting with (suspected) infection or sepsis to the ED of our tertiary care teaching hospital. Vital signs (heart rate, mean arterial pressure (MAP), respiratory rate and body temperature) were measured in 30-min intervals during the first 3 h in the ED. Primary outcome was patient deterioration within 72 h from admission, defined as the development of acute kidney injury, liver failure, respiratory failure, intensive care unit admission or in-hospital mortality. We performed a logistic regression analysis using a base model including age, gender and comorbidities. Thereafter, we performed separate logistic regression analyses for each vital sign using the value at admission, the change over time and its variability. For each analysis, the odds ratios (OR) and area under the receiver operator curve (AUC) were calculated.ResultsIn total 106 (29.5%) of the 359 patients deteriorated within 72 h from admission. Within this timeframe, 18.3% of the patients with infection and 32.9% of the patients with sepsis at ED presentation deteriorated. Associated with deterioration were: age (OR: 1.02), history of diabetes (OR: 1.90), heart rate (OR: 1.01), MAP (OR: 0.96) and respiratory rate (OR: 1.05) at admission, changes over time of MAP (OR: 1.04) and respiratory rate (OR: 1.44) as well as the variability of the MAP (OR: 1.06). Repeated measurements of heart rate and body temperature were not associated with deterioration.ConclusionsRepeated vital sign measurements in the ED are better at identifying patients at risk for deterioration within 72 h from admission than single vital sign measurements at ED admission.

Development and Internal Validation of a Model Predicting Safe, Early Discharge Among Patients Presenting to the Emergency Department with an Infection.

“…[49] Liver failure was de ned as total bilirubin level > 34.2 µmol/L (2.0 mg/dL) and either a transaminase level or alkaline phosphatase above twice the normal limit. [11,50] Respiratory failure was de ned as the need for mechanical ventilation, either hypercapnia (PaCO2 > 6.5 kPa) or hypoxemia (PaO2 < 8.0 kPa) in the arterial blood gas analysis or either a SpO2 < 90% when breathing room air or < 95% with at least 2L/min of oxygen supplementation. [51]…”

“…Multiple studies have analyzed the value of repeated vital sign measurements on patient outcome. Available studies either analyzed individual vital sign measurements [63] or combined these measurements in scores like the qSOFA or MEWS [11,35,[64][65][66]. Three studies compared single with repeated vital sign or score measurements and demonstrated that repeated measurements are superior in predicting clinical course of infectious or septic patients in the ED.…”

“…Three studies compared single with repeated vital sign or score measurements and demonstrated that repeated measurements are superior in predicting clinical course of infectious or septic patients in the ED. [11,64,65] Several studies conclude that early changes in vital signs or scores are associated with patient outcomes like mortality or ICU admission. [11,35,[63][64][65][66] These studies show that, compared to patients with deteriorating vital signs, patients with vital sign normalization had a lower risk of mortality.…”

“…[5][6][7][8][9][10] Since not all patients with an infection will develop sepsis and only a minority will progress to severe sepsis requiring Intensive Care Unit (ICU) admission. [11][12][13][14][15] Further research should therefore focus on patient improvement, alongside deterioration, of patients presenting to the ED with an infection.…”

“…While clinical deterioration can, to a certain degree, be predicted with the use of clinical judgment, clinical scoring systems and repeated vital sign measurements, clinical improvement, on the other hand, cannot. [11,13,[16][17][18][19][20][21][22][23] Length of in-hospital stay of patients presenting to the ED with an infection varies, with an average of 1 to 7 days (range 0-38 days). [24][25][26] Which of these patients will develop sepsis and, in turn, need prolonged hospitalization, remains a complex and not well understood process.…”