Huge improvements regarding their outcome were made in recent years for patients with trauma, stroke and STEMI. There is a lack of national databases and guidelines for MEP to reach comparable successes for this patient group. MEP are complex, have a low chance of survival, and they are frequent.
There are well established databases for patients with trauma (Danish Trauma Registry, TraumaRegister DGU), STEMI (Acute Coronary Syndrome STEMI (ACS) Registry) and stroke (SITS – Safe Implementation of Treatment in Stroke), with published studies illuminating their mortality and outcomes (13–16).
Similar databases for MEP are lacking, and only few studies have been published describing this patient group (4,5,7,17–21). The survival rates and base characteristics for patients with trauma, STEMI and suspected stroke at OUH match those published in international databases (13,14,16).
In this study, we were able to compare the outcome of all patients admitted by trigger teams to a level 1 university hospital. There are only 21 emergency hospitals in Denmark. OUH is the only hospital in a perimeter of 50 km, as well as the only level 1 hospital in the whole region. All patients fulfilling the inclusion criteria for the different trigger calls were admitted here and could not be transported to an alternate hospital. This makes comparison of the different patient groups possible and is one of the strengths of the study.
In concordance with earlier studies (18,21) we can show a high mortality rate for MEP, higher than for the patients received by the other trigger teams. This is also true when comparing patients with suspected stroke and MEP, who show approximately the same base statistics (i.e. age and gender). From our data, we cannot conclude the reason for this, but it probably partially reflects the improved care after the introduction of thrombolysis, and a therefore reduced mortality rate for stroke patients. It could also be a sign for a higher multimorbidity of MEP.
Looking at ICU admission, two groups of patients are sticking out, trauma patients and MEP. Both show a high percentage of ICU admission (37.1% and 26.8%, respectively), but more MEP die within 90 days after admission (13.2% and 31%, respectively).
Our results illustrate that we receive more MEP per 100,000 inhabitants than patients for the other trigger teams. In other studies, it was not possible to show this divergence, as there are usually multiple hospitals in the catchment areas, and there could be a distribution of the patients to different hospitals according to the suspected severity of their acute symptoms.
It is not surprising that the final discharge diagnosis for patients with trauma, suspected stroke and STEMI were limited to a narrow spectrum of the ICD10 catalogue. However, that is different for MEP. Here, we found a wide distribution of diagnoses, ranging through the entire ICD10 catalogue. The most common diagnosis groups were those describing respiratory and circulatory diseases. This shows the inhomogeneity of this patient group and illuminates the complexity of developing diagnostic and treatment guidelines for MEP that incorporate all possible aspects.
In 2014, a national register and a definition of MEP was requested in Germany (21), to better define the patient population and develop guidelines. In Germany, in 2016, a consensus document was published, with focus on patients arriving at the hospital with sepsis, amongst other diseases (23). Other MEP were not included in the study. An Australian study could show that MEP received by an ICU based trigger team had a shorter length of stay (24). Here, the setup did not include emergency physicians.
A study published in 2018 reviewed the outcome of MEP admitted in a similar set up as ours, with equally high mortality, but also a much higher ICU admission (25). This probably reflects different local setups and lack of international guidelines. In Denmark, only one study is published focusing on MEP (18).
MEP are heterogenic, and as there is no international agreement on their receival and treatment in the ED, their path through the ED differs from hospital to hospital. A review from 2017 concluded that it was not possible to suggest practice recommendations for MEP (22). Reason for this was the lack of sufficient data on MEP.
Our study has limitations. Some patients with cardiac arrest could have been coded as STEMI patients or MEP, thus raising the 7-day mortality. The study was composed as a single centre study and reflects the local setup for the trigger teams. We have no information on base values, Charlson comorbidity index, or lab findings to compare the different patient groups.