Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single‐center, case–control study

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Abstract

Aim

The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department ( ED) discharge.

Methods

We undertook a case–control study using the ED database of the Nagano Municipal Hospital (Nagano, Japan) from January 2012 to December 2013. We selected adult patients with medical conditions who revisited the ED with deterioration within 2 days of ED discharge (deterioration group). The deterioration group was compared with a control group.

Results

During the study period, 15,724 adult medical patients were discharged from the ED. Of these, 170 patients revisited the ED because of clinical deterioration within 2 days. Among the initial vital signs, respiratory rate was less frequently recorded than other vital signs ( P < 0.001 versus all other vital signs in each group). The frequency of recording each vital sign did not differ significantly between the groups. Overall, patients in the deterioration group had significantly higher respiratory rates than those in the control group (21 ± 5/min versus 18 ± 5/min, respectively; P = 0.002). A binary logistic regression analysis revealed that respiratory rate was an independent risk factor for clinical deterioration (unadjusted odds ratio, 1.15; 95% confidence interval, 1.04−1.26; adjusted odds ratio, 1.15; 95% confidence interval, 1.01−1.29).

Conclusions

An increased respiratory rate is a predictor of early clinical deterioration after ED discharge. Vital signs, especially respiratory rate, should be carefully evaluated when making decisions about patient disposition in the ED.

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Most cited references 17

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Clinical antecedents to in-hospital cardiopulmonary arrest.

Roland Schein, Nelson Hazday, María Fernanda Peña … (1990)

While the outcome of in-hospital cardiopulmonary arrest has been studied extensively, the clinical antecedents of arrest are less well defined. We studied a group of consecutive general hospital ward patients developing cardiopulmonary arrest. Prospectively determined definitions of underlying pathophysiology, severity of underlying disease, patient complaints, and clinical observations were used to determine common clinical features. Sixty-four patients arrested 161 +/- 26 hours following hospital admission. Pathophysiologic alterations preceding arrest were classified as respiratory in 24 patients (38 percent), metabolic in 7 (11 percent), cardiac in 6 (9 percent), neurologic in 4 (6 percent), multiple in 17 (27 percent), and unclassified in 6 (9 percent). Patients with multiple disturbances had mainly respiratory (39 percent) and metabolic (44 percent) disorders. Fifty-four patients (84 percent) had documented observations of clinical deterioration or new complaints within eight hours of arrest. Seventy percent of all patients had either deterioration of respiratory or mental function observed during this time. Routine laboratory tests obtained before arrest showed no consistent abnormalities, but vital signs showed a mean respiratory rate of 29 +/- 1 breaths per minute. The prognoses of patients' underlying diseases were classified as ultimately fatal in 26 (41 percent), nonfatal in 23 (36 percent), and rapidly fatal in 15 (23 percent). Five patients (8 percent) survived to hospital discharge. Patients developing arrest on the general hospital ward services have predominantly respiratory and metabolic derangements immediately preceding their arrests. Their underlying diseases are generally not rapidly fatal. Arrest is frequently preceded by a clinical deterioration involving either respiratory or mental function. These features and the high mortality associated with arrest suggest that efforts to predict and prevent arrest might prove beneficial.

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Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study.

Geromy G. Moore, Philip Bernard, K. Anderson … (2002)

To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. 300 bed tertiary referral teaching hospital. All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. Incidence and outcome of unexpected cardiac arrest. The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.

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A prospective before-and-after trial of a medical emergency team.

Geoffrey Gutteridge, Reece Hart, Helen Opdam … (2003)

To determine the effect on cardiac arrests and overall hospital mortality of an intensive care-based medical emergency team. Prospective before-and-after trial in a tertiary referral hospital. Consecutive patients admitted to hospital during a 4-month "before" period (May-August 1999) (n = 21 090) and a 4-month intervention period (November 2000 -February 2001) (n = 20 921). Number of cardiac arrests, number of patients dying after cardiac arrest, number of postcardiac-arrest bed-days and overall number of in-hospital deaths. There were 63 cardiac arrests in the "before" period and 22 in the intervention period (relative risk reduction, RRR: 65%; P < 0.001). Thirty-seven deaths were attributed to cardiac arrests in the "before" period and 16 in the intervention period (RRR: 56%; P = 0.005). Survivors of cardiac arrest in the "before" period required 163 ICU bed-days versus 33 in the intervention period (RRR: 80%; P < 0.001), and 1353 hospital bed-days versus 159 in the intervention period (RRR: 88%; P < 0.001). There were 302 deaths in the "before" period and 222 in the intervention period (RRR: 26%; P = 0.004). The incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based medical emergency team.

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Author and article information

Contributors

Katsunori Mochizuki: kmochizuki@shinshu-u.ac.jp

Journal

Journal ID (nlm-ta): Acute Med Surg

Journal ID (iso-abbrev): Acute Med Surg

Journal ID (doi): 10.1002/(ISSN)2052-8817

Journal ID (publisher-id): AMS2

Title: Acute Medicine & Surgery

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Electronic): 2052-8817

Publication date (Electronic): 10 November 2016

Publication date Collection: April 2017

Volume: 4

Issue: 2 ( doiID: 10.1002/ams2.2017.4.issue-2 )

Pages: 172-178

Affiliations

[ ¹ ] Department of Emergency and Critical Care Medicine Shinshu University School of Medicine Matsumoto Japan

[ ² ] Department of Emergency Medicine Nagano Municipal Hospital Nagano Japan

Author notes

[*] [* ]Corresponding: Katsunori Mochizuki, MD, PhD, Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, 3‐1‐1 Asahi, Matsumoto 390‐8621, Japan. E‐mail: kmochizuki@ 123456shinshu-u.ac.jp .

Article

Publisher ID: AMS2252

DOI: 10.1002/ams2.252

PMC ID: 5667270

PubMed ID: 29123857

SO-VID: d985c9a7-b1fa-4cc1-862f-15b4922fd538

License:

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date received : 02 August 2016

Date accepted : 07 September 2016

Page count

Figures: 1, Tables: 3, Pages: 7, Words: 4233

Custom metadata

source-schema-version-number 2.0

component-id ams2252

cover-date April 2017

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.2.1 mode:remove_FC converted:02.11.2017

Keywords: deterioration,emergency department,predictor,respiratory rate,vital sign

Data availability:

Keywords: deterioration, emergency department, predictor, respiratory rate, vital sign

Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single‐center, case–control study

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Abstract

Aim

Methods

Results

Conclusions

Related collections

European Respiratory Society: COVID-19

Most cited references 17

Clinical antecedents to in-hospital cardiopulmonary arrest.

Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study.

A prospective before-and-after trial of a medical emergency team.

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