Coma of unknown origin in the emergency department: implementation of an in-house management routine

Autor: Martin Möckel, Wolf U. Schmidt, Tobias Lindner, Christoph J. Ploner, Mischa Braun, Michael Römer
Rok vydání: 2016
Předmět:
Male
Emergency Medical Services
Diagnostic algorithm
600 Technik
Medizin
angewandte Wissenschaften::610 Medizin und Gesundheit
Critical Care and Intensive Care Medicine
Workflow
0302 clinical medicine
Germany
Emergency medical services
Coma
Original Research
Outcome
Aged
80 and over
Middle Aged
Survival Rate
Transportation of Patients
Emergency Medicine
Female
Brain diseases
Medical emergency
Neurosurgery
medicine.symptom
Algorithms
Adult
medicine.medical_specialty
Adolescent
Young Adult
03 medical and health sciences
medicine
Humans
Non traumatic coma
Aged
Retrospective Studies
business.industry
Neurological emergencies
Reproducibility of Results
030208 emergency & critical care medicine
Retrospective cohort study
Emergency department
medicine.disease
Triage
Emergency medicine
Wounds and Injuries
business
Trauma surgery
030217 neurology & neurosurgery
Standard operating procedure
Follow-Up Studies
Zdroj: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
ISSN: 1757-7241
DOI: 10.1186/s13049-016-0250-3
Popis: Background Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines. Methods We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in- house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed “coma alarm”). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP. Results During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1–4), then fluctuated between 84 and 94 % (months 5–24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro- ICUs. Discussion Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible. Conclusions Our SOP may provide an appropriate tool for efficient management of patients with non- traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.
Databáze: OpenAIRE
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