“What Happened?” Recognizing and Preventing Acute Decompensation in the ED

Authors: Michael C. Perry, MD (EM Resident Physician/University of Texas at Austin Dell School of Medicine) and Janna Welch, MD (Assistant Residency Director, University of Texas at Austin Dell School of Medicine) // Edited by: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK)

The emergency department (ED) is a complicated place to work. A calm shift can easily develop into chaos in a short period of time. As emergency physicians, we may have no more than a few minutes to distinguish the sick patients from the well patients. Despite our best efforts, we may sometimes miss subtle clues and erroneously disregard truly sick patients. Also, on occasion, previously ‘stable’ patients can become unstable and may quickly become very sick in front of our eyes. These patients can be difficult to identify. They are challenges to physicians, nurses and the entire ED staff as they present a significant opportunity for a poor outcome.

However, is there a way we can identify these patients? Is there a way we can improve the care of those experiencing acute decompensation?

Clinical Scenarios

Case 1: A 49 year-old male presents to the ED with a chief complaint of syncope. He experienced an unwitnessed syncopal event at home this morning. His wife was in the next room but arrived immediately to his room after she heard him fall. The patient had no signs of trauma, was at his neurological baseline nearly immediately after the event, and his total loss of consciousness was less than one minute. His only preceding symptom was shortness of breath. The patient’s history is only relevant for 30 pack-year smoking history and his father with a myocardial infarction (MI) at age 55. Initial labs including troponin, EKG and head CT are all normal. Based on this data, you are reassured and are planning to discharge.

The nurse pages you overhead when the patient suddenly goes into cardiac arrest.

Case 2: A 66 year-old female with a past medical history (PMH) of hypertension and diabetes mellitus presents with a history of subjective fever and mild dry cough. Initial vital signs are a temperature of 98° Fahrenheit (F) (axillary), pulse of 91 beats per minute (bpm), respirations of 20 per minute, a BP 110/70 mmHg, and O 2 sat 98% on room air. She appears well and her physical exam is unremarkable. You order basic labs and a chest X-ray and plan to reassess her in a short while.

When you return to her room nearly two hours later on a busy shift, she has become lethargic, hypoxic and appears to be developing septic shock.

Case 3: A 23 year-old male is brought into the ED by emergency medical services (EMS) after a highway-speed motor vehicle collision. He was the restrained driver in a head-on collision and had to be extricated by the fire department. He responds only to painful stimuli with moaning, has a large scalp laceration and an obvious deformity to both lower extremities. His airway is patent and he is in no respiratory distress, but is intubated for a low Glasgow Coma Score (GCS). He is normotensive but tachycardic. Initial chest X-Ray shows good ET tube placement and a FAST exam of his abdomen is negative. The CT scanner is currently busy so the patient remains in the ED until the CT scanner becomes available.

10 minutes later, the patient goes into arrest as a missed pneumothorax expands with positive pressure ventilation (PPV).

Recognizing those at risk for decompensation

It is our job every day in the emergency department to rapidly recognize and treat emergent medical conditions. However, in the chaos of the ED, patients can sometimes unfortunately fall through the cracks.

Often, acute decompensation in the emergency department represents a failure of early recognition. If a patient is improperly triaged, they may be placed in the waiting room or an under-monitored setting where any deterioration may not be noticed. Furthermore, if the treating physician fails to recognize early warning signs, this risk may be compounded.

Therefore, scrutinize the triage note on each patient and carefully review vital signs, as these are often the only clues indicating possible deterioration.

Review of the Literature

In a single-center retrospective review of nearly 1400 patients, Henriksen et al attempted to identify risk factors for inpatient deterioration despite appearing well upon presentation. The researchers identified old age (defined in this study as age > 65 years) and previous do-not-resuscitate (DNR) orders as independent risk factors for deterioration. The authors also identified that aggressive monitoring of vital signs may help identify early deterioration and aid in early intervention. Though the scope of this study was not the emergency department, their findings are nonetheless relevant to our practice.

Given the relative difficulty in predicting which well-appearing patients will undergo clinical decline, several studies have attempted to create early warning scores for adult patients similar to the PEWS (Pediatric Early Warning Score). Most are small and a full discussion of findings is beyond the scope of this article. However, a common unifying factor is the need for attention to vital signs and effective triage. See below for full list of resources.

How We Can Do Better

Let’s review the cases above.

In case 1, the 49 year-old with syncope, the patient was well appearing at triage and placed in an unmonitored bed. His single EKG during the ED visit did not demonstrate the runs of ventricular tachycardia that were likely occurring throughout the morning. The triage nurse, and therefore the physician, demonstrated diagnostic anchoring. They presumed he was well and as a result, they minimized the workup and failed to monitor the patient.

In the 66 year-old female with evolving sepsis in case 2, borderline abnormal vital signs on initial assessment were present. Vital signs cannot be ignored, especially in the elderly who have compromised reserve in responding to the increased demand of sepsis on the heart and lungs.

In case 3, the trauma patient, the team assumed his initial resuscitation was adequate. After managing the airway and assessing for other injuries, they let their guard down and walked away for 10 minutes to attend to other patients. Assessment of the trauma patient is a dynamic process. Frequent reassessment, with repeat physical exam and E-Fast ultrasound, is the standard of care.

Whatever the cause – a missed myocardial infarction (MI), an expanding pneumothorax, or progressing severe sepsis – recognizing and preventing deterioration in the emergency department is wholly dependent upon vigilance and recognition. Conducting a careful history and physical exam and closely evaluating vital signs will help risk stratify patients toward an appropriately monitored setting.

Furthermore, frequent reassessment, either by physician or staff, is critical to ensuring that any change in patient status is caught and further deterioration prevented.

References and Further Reading

Henriksen, Daniel Pilsgaard, Mikkel Brabrand, and Annmarie Touborg Lassen. “Prognosis and Risk Factors for Deterioration in Patients Admitted to a Medical Emergency Department.” Ed. Paul Robert Cleary. PLoS ONE 9.4 (2014): e94649. PMC. Web. 15 June 2015.

“Predicting factors associated with clinical deterioration of sepsis patients with intermediate levels of serum lactate.” http://www.ncbi.nlm.nih.gov/pubmed/22683735

“Identifying Infected Emergency Department Patients Admitted to the Hospital Ward at Risk of Clinical Deterioration and Intensive Care Unit Transfer” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058807/

“Recognizing clinical deterioration in emergency department patients.” http://www.ncbi.nlm.nih.gov/pubmed/24815204

“Unreported clinical deterioration in emergency department patients: a point prevalence study.” http://www.ncbi.nlm.nih.gov/pubmed/25441535

“Novelty Detection for Identifying Deterioration in Emergency Department Patients” http://link.springer.com/chapter/10.1007%2F978-3-642-23878-9_27

“Designing a 3-Stage Patient Deterioration Warning System for Emergency Departments” http://cci.drexel.edu/hi/hi-kdd2014/morning_3.pdf

“Recognition and Management of Patients who are Clinically Deteriorating” http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf

“The Deteriorating patient” http://lifeinthefastlane.com/the-deteriorating-patient/