Admission of patients with chest pain and/or breathlessness from the emergency department in relation to risk assessment and copeptin levels – an observational study
Background: One of the most critical decisions that emergency department (ED) physicians make is the discharge versus admission of patients. We aimed to study the association of the decision in the ED to admit patients with chest pain and/or breathlessness to a ward with risk assessment using the Rapid Emergency Triage and Treatment System (RETTS), the National Early Warning Score (NEWS), and plasma levels of the biomarkers copeptin, midregional proadrenomedulin (MR-proADM), and midregional proatrial natriuretic peptide (MR-proANP).
Methods: Patients presenting at the ED with chest pain and/or breathlessness with less than one week onset were enrolled. Patients were triaged according to RETTS. NEWS was calculated from the vital signs retrospectively.
Results: Three hundred and thirty-four patients (167 males), mean age 63.8 ± 16.8 years, were included. Of which, 210 (62.8%) patients complained of chest pain, 65 (19.5%) of breathlessness, and 59 (17.7%) of both. Of these, 176 (52.7%) patients were admitted to a ward, and 158 (47.3%) patients were discharged from the ED. In binary logistic models, age, gender, vital signs (O2 saturation and heart rate), NEWS class, and copeptin were associated with admission to a ward from the ED. In receiver-operating-characteristics (ROC) analysis, copeptin had an incremental predictive value compared to NEWS alone (P = 0.002).
Conclusions: Emergency physicians’ decisions to admit patients with chest pain and/or breathlessness from the ED to a ward are related to age, O2 saturation, heart rate, NEWS category, and copeptin. As an independent predictive marker for admission, early analysis of copeptin might be beneficial when improving patient pathways at the ED.
2. Mockel M, Searle J, Muller R, Slagman A, Storchmann H, Oestereich P, et al. Chief complaints in medical emergencies: do they relate to underlying disease and outcome? The Charite Emergency Medicine Study (CHARITEM). Eur J Emerg Med 2013;20:103–8. doi: 10.1097/MEJ.0b013e328351e609
3. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011;342:d2983. doi: 10.1136/bmj.d2983
4. Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Medicine 2013;61(6):605–11.e6. doi: 10.1016/j.annemergmed.2012.10.026
5. Calder LA, Arnason T, Vaillancourt C, Perry JJ, Stiell IG, Forster AJ. How do emergency physicians make discharge decisions? Emerg Med J 2015;32(1):9–14. doi: 10.1136/emermed-2013-202421
6. Wireklint SC, Elmqvist C, Parenti N, Goransson KE. A descriptive study of registered nurses’ application of the triage scale RETTS(c); a Swedish reliability study. Int Emerg Nurs 2018;38:21–8. doi: 10.1016/j.ienj.2017.12.003
7. Ruge T, Malmer G, Wachtler C, Ekelund U, Westerlund E, Svensson P, et al. Age is associated with increased mortality in the RETTS-A triage scale. BMC Geriatr 2019;19(1):139. doi: 10.1186/s12877-019-1157-4
8. Bilben B, Grandal L, Sovik S. National Early Warning Score (NEWS) as an emergency department predictor of disease severity and 90-day survival in the acutely dyspneic patient - A prospective observational study. Scand J Trauma Resusc Emerg Med. 2016;24:80. doi: 10.1186/s13049-016-0273-9
9. Mitsunaga T, Hasegawa I, Uzura M, Okuno K, Otani K, Ohtaki Y, et al. Comparison of the National Early Warning Score (NEWS) and the Modified Early Warning Score (MEWS) for predicting admission and in-hospital mortality in elderly patients in the pre-hospital setting and in the emergency department. PeerJ. 2019;7:e6947. doi: 10.7717/peerj.6947
10. Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation. 2013;84(4):465–70. doi: 10.1016/j.resuscitation.2012.12.016
11. Spangfors M, Arvidsson L, Karlsson V, Samuelson K. The National Early Warning Score: translation, testing and prediction in a Swedish setting. Intensive Crit Care Nurs. 2016;37:62–7. doi: 10.1016/j.iccn.2016.05.007
12. Spangfors M, Bunkenborg G, Molt M, Samuelson K. The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs: a retrospective medical record review study. J Clin Nurs. 2019;28(7–8):1216–22. doi: 10.1111/jocn.14728
13. Williams B, Alberti G, Ball C, Ball D, Binks R, Durham L.National Early Warning Score (NEWS), Standardising the assessment of acute-illness severity in the NHS. London: Royal College of Physicians; 2012.
14. Royal College of Physicians. National Early Warning Score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP; 2017.
15. Sbiti-Rohr D, Kutz A, Christ-Crain M, Thomann R, Zimmerli W, Hoess C, et al. The National Early Warning Score (NEWS) for outcome prediction in emergency department patients with community-acquired pneumonia: results from a 6-year prospective cohort study. BMJ Open. 2016;6(9):e011021. doi: 10.1136/bmjopen-2015-011021
16. Maier C, Clodi M, Neuhold S, Resl M, Elhenicky M, Prager R, et al. Endothelial markers may link kidney function to cardiovascular events in type 2 diabetes. Diabetes Care. 2009;32(10):1890–5. doi: 10.2337/dc08-2168
17. Enhörning S, Hedblad B, Nilsson PM, Engström G, Melander O. Copeptin is an independent predictor of diabetic heart disease and death. Am Heart J. 2015;169(4):549–56.e1. doi: 10.1016/j.ahj.2014.11.020
18. Landman GW, Van Dijk PR, Drion I, Van Hateren KJ, Struck J, Groenier KH, et al. Midregional fragment of proadrenomedullin, new-onset albuminuria, and cardiovascular and all-cause mortality in patients with type 2 diabetes (ZODIAC-30). Diabetes Care. 2014;37(3):839–45. doi: 10.2337/dc13-1852
19. Mellbin LG, Ryden L, Brismar K, Morgenthaler NG, Ohrvik J, Catrina SB. Copeptin, IGFBP-1, and cardiovascular prognosis in patients with type 2 diabetes and acute myocardial infarction: a report from the DIGAMI 2 trial. Diabetes Care. 2010;33(7):1604–6. doi: 10.2337/dc10-0088
20. Van Hateren KJ, Landman GW, Kleefstra N, Groenier KH, Struck J, Navis GJ, et al. The midregional fragment of pro-A-type natriuretic peptide, blood pressure, and mortality in a prospective cohort study of patients with type 2 diabetes (ZODIAC-25). Diabetes Care. 2013;36(5):1347–52. doi: 10.2337/dc12-0428
21. Reichlin T, Hochholzer W, Stelzig C, Laule K, Freidank H, Morgenthaler NG, et al. Incremental value of copeptin for rapid rule out of acute myocardial infarction. J Am Coll Cardiol. 2009;54(1):60–8. doi: 10.1016/j.jacc.2009.01.076
22. Idzikowska K, Zielińska M. Midregional pro-atrial natriuretic peptide, an important member of the natriuretic peptide family: potential role in diagnosis and prognosis of cardiovascular disease. J Int Med Res. 2018;46(8):3017–29. doi: 10.1016/j.jacc.2010.02.025
23. Maisel A, Mueller C, Nowak R, Peacock WF, Landsberg JW, Ponikowski P, et al. Mid-region pro-hormone markers for diagnosis and prognosis in acute dyspnea: results from the BACH (Biomarkers in Acute Heart Failure) trial. J Am Coll Cardiol. 2010;55(19):2062–76. doi: 10.1016/j.jacc.2010.02.025
24. Miller WL, Hartman KA, Grill DE, Struck J, Bergmann A, Jaffe AS. Serial measurements of midregion proANP and copeptin in ambulatory patients with heart failure: incremental prognostic value of novel biomarkers in heart failure. Heart. 2012;98(5):389–94. doi: 10.1136/heartjnl-2011-300823
25. Khan SQ, O’Brien RJ, Struck J, Quinn P, Morgenthaler N, Squire I, et al. Prognostic value of midregional pro-adrenomedullin in patients with acute myocardial infarction: the LAMP (Leicester Acute Myocardial Infarction Peptide) study. J Am Coll Cardiol. 2007;49(14):1525–32. doi: 10.1016/j.jacc.2006.12.038
26. Carter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014;46(2):106–15. doi: 10.1111/jnu.12055
27. Searle J, Slagman A, Stockburger M, Vollert JO, Müller C, Muller R, et al. Use of copeptin in emergency patients with cardiac chief complaints. Eur Heart Journal Acute Cardiovasc Care. 2015;4(5):393–402. doi: 10.1177/2048872614554197
28. Zuur-Telgen M, VanderValk P, Van der Palen J, Kerstjens HA, Brusse-Keizer M. Stable State Proadrenomedullin Level in COPD Patients: a validation study. Copd. 2017;14(2):219–27. doi: 10.1080/15412555.2016.1250254
29. Hong W, Earnest A, Sultana P, Koh Z, Shahidah N, Ong ME. How accurate are vital signs in predicting clinical outcomes in critically ill emergency department patients. Eur J Emerg Med. 2013;20(1):27–32. doi: 10.1097/MEJ.0b013e32834fdcf3
30. Mower WR, Myers G, Nicklin EL, Kearin KT, Baraff LJ, Sachs C. Pulse oximetry as a fifth vital sign in emergency geriatric assessment. Acad Emerg Med. 1998;5(9):858–65. doi: 10.1111/j.1553-2712.1998.tb02813.x
31. Bui AL, Grau-Sepulveda MV, Hernandez AF, Peterson ED, Yancy CW, Bhatt DL, et al. Admission heart rate and in-hospital outcomes in patients hospitalized for heart failure in sinus rhythm and in atrial fibrillation. Am Heart J. 2013;165(4):567–74.e6. doi: 10.1016/j.ahj.2013.01.007
32. Ljunggren M, Castrén M, Nordberg M, Kurland L. The association between vital signs and mortality in a retrospective cohort study of an unselected emergency department population. Scand J Trauma Resusc Emerg Med. 2016;24:21. doi: 10.1186/s13049-016-0213-8
33. Lee YS, Choi JW, Park YH, Chung C, Park DI, Lee JE, et al. Evaluation of the efficacy of the National Early Warning Score in predicting in-hospital mortality via the risk stratification. J Crit Care. 2018;47:222–6. doi: 10.1016/j.jcrc.2018.07.011
34. Corfield AR, Lees F, Zealley I, Houston G, Dickie S, Ward K, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emerg Med J. 2014;31(6):482–7. doi: 10.1136/emermed-2012-202186
35. Eckart A, Hauser SI, Kutz A, Haubitz S, Hausfater P, Amin D, et al. Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study. BMJ Open. 2019;9(1):e024636. doi: 10.1136/bmjopen-2018-024636
36. Nickel CH, Bingisser R, Morgenthaler NG. The role of copeptin as a diagnostic and prognostic biomarker for risk stratification in the emergency department. BMC Med. 2012;10:7. doi: 10.1186/1741-7015-10-7
37. Schuetz P, Hausfater P, Amin D, Amin A, Haubitz S, Faessler L, et al. Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study. Crit Care. 2015;19:377. doi: 10.1186/s13054-015-1098-z
38. Christenson J, Innes G, McKnight D, Thompson CR, Wong H, Yu E, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006;47(1):1–10. doi: 10.1016/j.annemergmed.2005.08.007
39. Farmer SA, Higginson IJ. Chest pain: physician perceptions and decision-making in a London emergency department. Ann Emerg Med. 2006;48(1):77–85. doi: 10.1016/j.annemergmed.2005.12.002
40. Boufous S, Kelleher PW, Pain CH, Dann LM, Ieraci S, Jalaludin BB, et al. Impact of a chest-pain guideline on clinical decision-making. Med J Aust. 2003;178(8):375–80. doi: 10.5694/j.1326-5377.2003.tb05253.x
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