Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department

Abstract

Background: Emergency medical care for critically ill nontrauma patients (CINT) varies between different emergency departments (ED) and healthcare systems, while resuscitation of trauma patients is always performed within the ED. In many ED CINT are treated and stabilized while in many German smaller hospitals CINT are transferred directly to the intensive care unit (ICU) without performing critical care measures in the ED. Little is known about the resuscitation room management of CINT regarding patient characteristics and outcome although bigger hospitals perform ED resuscitation of CINT in routine care. Against this background we conducted this retrospective analysis of CINT treated by an ED resuscitation room concept in a German 756 bed teaching hospital.

Methods: The collective of CINT treated within the ED resuscitation room (1 October 2018 to 31 March 2019) was analyzed after ethical approval. After each resuscitation room operation, the team leader filled out a standardized paper-based questionnaire and qualified the patient as a resuscitation room patient this way. Only patients who underwent invasive procedures and were admitted to ICU or died in the ED were included. Patient characteristics, performed critical care measures, short-term outcomes and the comparison of admission characteristics between survivors and non-survivors were evaluated. Additionally, the accordance of ED admission diagnoses and discharge diagnoses were analyzed.

Results: Overall, 243 of 19,854 ED patients (1.22%) were treated in the resuscitation room. After exclusion of trauma patients, 193 (0.97%) CINT were included. Overall mortality was 29% (n = 56), 24‑h mortality was 13% (n = 25). Patient characteristics (vital signs, blood gas analysis) differed significantly between survivors and nonsurvivors except for respiratory rate and pain scale. An excerpt of conducted resuscitation room measures was as follows: arterial line n = 78 (40%); noninvasive ventilation n = 60 (31%); endotracheal intubation n = 56 (29%); cardiopulmonary resuscitation n = 19 (10%), central venous line n = 8 (4%). The number of conducted measures differed between survivors and nonsurvivors (median and interquartile range, IQR): 4 (IQR 2) vs. 4 (IQR 3) p = 0.0453. The length of ED stay was 148.2 ± 202.7 min until the patient was admitted to an ICU or died within the ED. ED admission diagnoses matched with hospital discharge diagnoses in 78%.

Conclusion: The observed mortality was high and was comparable to patient collectives with septic shock. Nonsurvivors showed significantly more impaired vital parameters and blood gas analysis parameters. Vital parameters together with blood gas analysis might enable ED risk stratification of CINT. Resuscitation room management enables immediate stabilization and diagnostic work-up of CINT even when no ICU bed is available. Furthermore, optimal allocation to specialized ICUs can probably be enabled more accurately after a first diagnostic work-up; however, although a first diagnostic work-up including laboratory tests and computed tomography in many cases was performed, ED admission and hospital discharge diagnoses matched only in 78%.

Keywords: Intubation; Non-invasive Ventilation; Resuscitation; Resuscitation room; Sepsis.