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Background: Several early warning scores have been designed to optimize acute care by identifying patients at risk of deterioration. Methods: In this post hoc dual center study, we analyzed the performance of six clinical scores (the Goodacre score, Groarke, Worthing Physiological Score, Rapid Acute Physiology Score, Rapid Emergency Medicine Score, United Kingdom National Early Warning Score. The primary outcome is 30-day all-cause mortality after inclusion and data were obtained from previous studies performed at two different emergency departments on two continents (Denmark, Europe, and Hong Kong, Asia). Results: We included 2952 people; 1482 (50.2%) were male, mean age (standard deviation) was 65.7 (18.3) years, and 109 (3.7%) died within 30 days. Mortality rate increased steadily with increasing scores for all six scoring systems in Hong Kong while this was less obvious in Denmark. In all patients, Rapid Acute Physiology Score had the lowest discriminatory power while National Early Warning Score had the highest. National Early Warning Score performed best in Hong Kong while Worthing performed marginally better in Denmark. Discussion: Surprisingly, the performance of the scoring systems varied considerably, but were largely unaffected by location, and none of them performed close to what clinicians would normally require for predicting 30-day all-cause mortality Conclusion: All scores performed similarly across both centers, with poor prediction of 30-day all-cause mortality. Based on these findings, we believe that clinical scores must be supplemented by either biochemical values or global markers of physiological reserve to reflect reality and to be of true value. [ABSTRACT FROM AUTHOR]

Background: Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong's Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department. Methods: In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients' triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into <5 and ⩾5 years emergency department experience. All nurses independently rated all 295 scenarios, blinded to clinical outcomes. Results: The percentage agreement between the real emergency department patients' triage category and the expert panel's assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively. Conclusion: The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended. [ABSTRACT FROM AUTHOR]

We aim to compare the prognostic value of Quick Sepsis-Related Organ Failure Assessment (qSOFA) and the previous Systemic Inflammatory Response Syndrome (SIRS) criteria, the National Early Warning Score (NEWS) and along with their combinations in the emergency department (ED). This single-centre prospective study recruited a convenience sample of unselected ED patients triaged as category 2 (Emergency) and 3 (Urgent). Receiver Operating Characteristic analyses were performed to determine the Area Under the Curve (AUC), along with sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for the various scores. Of 1253 patients recruited, overall 30-day mortality was 5.7%. The prognostic value for prediction of 30-day mortality, with AUCs for qSOFA ≥2, SIRS ≥2, NEWS ≥5, qSIRS (qSOFA + SIRS) ≥2 and NSIRS (NEWS + SIRS) ≥5 of 0.56 (95%CI 0.53–0.58), 0.61 (95%CI 0.58–0.64), 0.61 (95%CI 0.58–0.64), 0.64 (95%CI 0.62–0.67) and 0.61 (95%CI 0.58–0.63), respectively. Using pairwise comparisons of ROC curves, NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality. Among unselected emergency and urgent ED patients, the prognostic value for NEWS and qSIRS were greater than qSOFA, Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. NEWS ≥5 and qSIRS ≥2 were better than qSOFA ≥2 at predicting 30-day mortality in ED patients. Combinations of qSOFA and SIRS could improve the predictive value for 30-day mortality for ED patients. [ABSTRACT FROM AUTHOR]

Background: Overutilisation of the Accident and Emergency Department is an increasingly serious healthcare challenge. Online symptom checkers could help alleviate this challenge by allowing patients to self-triage before visiting the Accident and Emergency Department. Objectives: This study aimed to assess the triage accuracy of online symptom checkers, which would help determine the potential roles of symptom checkers in an Accident and Emergency Department setting. Methods: A total of 100 random Accident and Emergency Department records were sampled from the Queen Mary Hospital in Hong Kong. The inclusion criteria were patients over the age of 18 attending the Queen Mary Hospital Accident and Emergency Department in 2016. Symptom checkers by Drugs.com and FamilyDoctor were selected as representative tools. One triage recommendation was generated by each symptom checker for each case record. Each symptom checker's triage accuracy was then evaluated using a few outcome measures: overall sensitivity, sensitivity for emergency cases and specificity for non-emergency cases, when compared with the triage categories assigned by the triage nurses. Results: The results showed that Drugs.com had a higher overall triage accuracy than FamilyDoctor (74% and 50%, respectively), but both checkers are inadequately sensitive to emergency cases (70% and 45%, respectively) with low negative predictive values (43% and 24%, respectively). Conclusion: In their current states, symptom checkers are not yet suitable as alternatives to Accident and Emergency Department triage protocols due to their low overall sensitivities and negative predictive values. However, symptom checkers might serve as useful Accident and Emergency Department adjuncts in other ways, such as to provide more information prior to a patient's arrival to streamline the triage and preparation process at the Accident and Emergency Department. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to investigate plasma concentrations of miR-124-3p and miR-16 as prognostic markers in emergency department patients with acute stroke. Design and methods Plasma concentrations of miR-124-3p and miR-16 of 84 stroke patients (presenting to the emergency department within 24 h from onset of symptoms) were determined by RT-qPCR. The primary outcome measure was 3-month mortality and the secondary outcome measure was post-stroke modified Rankin Score (mRS). Results Twelve patients (14.3%) died within 3 months of hospital admission and forty-one (48.8%) patients as achieved a 3-month mRS > 2. Median plasma miR-124-3p concentrations were elevated in patients who died compared to patients who survived ( p = 0.0052), and its levels were found to be higher in patients with a 3-month mRS > 2 compared with patients with mRS ≤ 2 ( p = 0.0312). Higher plasma miR-16 concentrations were observed in patients who survived than in patients who died ( p = 0.0394), while its concentrations were lower in patients achieving mRS > 2 than in patients with mRS ≤ 2 ( p = 0.0124). For a subgroup of cases presenting to the emergency department within 6 h from time of symptom onset (n = 36), plasma miR-124-3p concentrations predicted 3-month mortality with an area under the ROC curve of 0.87 (95%CI: 0.72–0.96). Conclusions Plasma miR-124-3p and miR-16 are molecular markers which could be useful for the early prediction of mortality and mRS. [ABSTRACT FROM AUTHOR]

Objective We aim to investigate whether prehospital Modified Early Warning Score (MEWS) can identify non-trauma patients requiring life-saving intervention (LSI) within 4 h of presentation to the ED. Methods It was a prospective study of non-trauma ED patients by ambulance who were 16 years or older from 1 to 27 November 2013. Prehospital MEWS was calculated according to vital signs measured by the ambulance crew. Data on patients' demographics, triage category, LSI within 4 h of ED presentation and 24 h mortality were retrieved. LSI was defined as emergency interventions to airway, breathing and circulation, emergency procedures and medications administered. The performance of prehospital MEWS was analysed with sensitivity, specificity, predictive values (PV), likelihood ratios (LR) and the receiver operating characteristic curve. Results Recruited during the study period were 1493 patients. The median age was 78 years. Of the patients, 49.9% belonged to critical, emergent or urgent triage categories. LSI was required in 321 patients (21.5%). Thirteen died within 24 h of ED presentation. The area under the receiver operating characteristic curve of prehospital MEWS relating to LSI was 0.72 (95% confidence interval 0.69 to 0.75). The sensitivity, specificity, positive PV, negative PV, positive LR and negative LR were 0.57, 0.76, 0.40, 0.87, 2.43 and 0.56, respectively, when prehospital MEWS ≥3 was chosen as the cut-off value. Conclusions Prehospital MEWS is useful in identifying non-trauma patients requiring LSI within 4 h of ED presentation. This may in turn enhance the triage accuracy in the ED in addition to clinical assessment. [ABSTRACT FROM AUTHOR]