|Year : 2016 | Volume
| Issue : 4 | Page : 126-131
Prognostic predictors of patients admitted in Intensive Care Unit through emergency ambulance services
Prasad A Rajhans1, Priya Yogesh Kulkarni2, Dhananjay S Kelkar1, Sameer A Jog1, Gouri Ranade1, Sonal Utpat1, Varsha Hande1
1 Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
2 Community Medicine, PIMS and RC, Sangli, Maharashtra, India
|Date of Web Publication||27-Dec-2016|
Priya Yogesh Kulkarni
Community Medicine, SMBT Medical College, Nashik, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Lot of progress has been made in emergency medical services (EMSs) in India in private and government sectors. Very few studies are done focusing the prognosis of patients utilizing EMSs. Aim: This study aimed to analyze the prognostic predictors of patients admitted in Intensive Care Unit (ICU) through EMSs. Materials and Methods: It was a hospital records-based study. EMS patients who were admitted in ICU were included in the study. Patients with a poor prognosis were defined as who died within 48 h of ICU admission, and patients who were stable and shifted to other wards after 48 h of ICU admission were defined to have a good prognosis. A person with medical background was trained to extract all the socioclinical information from hospital records from January 2013 to December 2014. Patients with incomplete records were excluded from the study. Data were entered in Microsoft Excel and imported in SPSS 15.0 software for analysis. Frequencies and proportions were enlisted. Associations were tested by Chi-squared test. Significant variables were entered in logistic regression model. Results: We included a total of 151 records in the study. Nearly 40.40% of the patients (61/151) had a poor prognosis while 59.60% (90/151) had a good prognosis. Baseline characteristics did not differ in both the groups (P > 0.294). In univariate analysis, breathlessness, anuria as purpose to call EMSs, severe condition as per Glasgow Coma Scale (GCS), and lifesaving interventions done during the transport were associated with a poor prognosis (P = 0.001, 0.029, <0.001, <0.001, and <0.001, respectively). Breathlessness as purpose of call and severe GCS of the patients were the independent predictors of poor prognosis after logistic regression analysis. Comorbidities were not associated with the poor prognosis. Conclusion: Assessment of GCS on call itself will help give highest priority to patients with severe condition and breathlessness, prescribe medicines before arrival of emergency team at the scene and to dispatch appropriate level of ambulance (advanced life support, basic life support, and specialty care transport) in resource-poor situations.
Keywords: Emergency medical services, Glasgow Coma Scale, Intensive Care Unit
|How to cite this article:|
Rajhans PA, Kulkarni PY, Kelkar DS, Jog SA, Ranade G, Utpat S, Hande V. Prognostic predictors of patients admitted in Intensive Care Unit through emergency ambulance services. Int J Health Syst Disaster Manage 2016;4:126-31
|How to cite this URL:|
Rajhans PA, Kulkarni PY, Kelkar DS, Jog SA, Ranade G, Utpat S, Hande V. Prognostic predictors of patients admitted in Intensive Care Unit through emergency ambulance services. Int J Health Syst Disaster Manage [serial online] 2016 [cited 2021 Mar 2];4:126-31. Available from: https://www.ijhsdm.org/text.asp?2016/4/4/126/196793
| Introduction|| |
India is facing ills of both developed and underdeveloped countries and rise in medical emergencies is one of them.  If emergency patients receive basic care from trained professionals and are transported to the nearest health-care facility within 15-20 min, they have the greatest chance of survival. Utilization of this "Golden hour" typifies the importance of emergency medical services (EMSs) all over the world. Appropriate management utilizing golden hour enhances survival, controls morbidity, and prevents disability. 
As, EMS is essential part of healthcare system, MCI has identified the need to develop emergency medicine (EM) residency training programs in India and it is now emerging as a new academic discipline. , It is essential to recognize the current scenario of EMSs to develop appropriate program along with identifying opportunities and challenges.
Few years ago, it was a difficult task to receive emergency care during the golden hour in India.  Efforts are being made to expand EMSs in India and to make it easily accessible from all the levels. One of its achievements is the establishment of "Dial 108 service," which is a nationwide initiative to support EMSs. 
It is based on the basic fundamental principle of EMS systems to have a common emergency communication number connected to responsive agencies. Since 2005, EMSs in India has been improved significantly, and in 19 states and two union territories, there is a specific emergency number to dial to get help of government EMSs. Effective transport component is also contributing to reduction in maternal and infant mortalities and will help achieve various Millennium Development Goals. 
Prior to these government efforts, some private agencies started EMSs in Chennai, Mumbai, Pune, etc. It was available only through private hospitals.  Deenanth Mangeshkar Hospital and Research Centre (DMHRC), Pune, Maharashtra, is one of the pioneering institutions to set up EMSs in Maharashtra as early as 1999 where the present study is carried out. It got 105 number to be dialed by emergencies. Intensivists from DMHRC have significantly contributed to the development of Maharashtra EMSs which was launched in 2014 by the Government of Maharashtra, India.  DMHRC is offering internship program for PG-diploma EMS students.  DMHRC has developed excellent network of EMSs in the catchment area. Ambulance personnel are well trained to assess and manage critical patients while transportation.
Increase in the awareness of existence of EMS system, emergency number to be dialed, and change in attitude toward emergencies by government and private institutions have been contributing to the success of EMSs in India.
Most EMSs use the Glasgow Coma Scale (GCS) in their rapid paramedical assessment of patients though it was originally derived for head injury patients to describe the level of consciousness. ,, It helps them to decide further management of emergency patients.  It measures patients' best eye, motor, and verbal responses. GCS grades condition of the patients as mild (14-15), moderate (9-13), or severe (3-8). As per the Canadian computed tomography head rule study, the Advanced Trauma Life Support (ATLS) recently modified this classification so that a GCS score of 13 would fall within the mild category (modified model). 
It is a widely used and accepted prognostic indicator for both traumatic and nontraumatic patients. GCS is validated for its inter-observer reliability, which improves with training and experience in different scenarios.  It is taken as an index of how patient is critical and to evaluate response to ongoing treatment. Studies show that prognosis/outcomes of emergency patients, mortality, or disability are related to GCS scores. ,
There are very few studies carried out to assess the prognosis, efficacy, and parameters of EMSs in private and government sectors of India which indeed is the need for further improvements in the existing EMS systems and to design EM residency training programs. In this study, we aimed to study the prognostic predictors of patients admitted to Intensive Care Unit (ICU) of DMHRC through its own EMSs. These ambulance personnel are trained to analyze and report the severity of patients' condition based on GCS.
| Materials and Methods|| |
DMHRC is a tertiary care hospital in Erandwane, Pune. The annual number of admissions through EMS ranges from 1000 to 1150, of which 30%-35% of the patients need to be admitted in ICU for further management, and the rest are transferred to respective wards directly or after observation for stable condition.
It was a hospital records-based study. Records of the EMS patients who were admitted in ICU between January 1, 2013, and December 31, 2014, were included in the study. Prior to the study, ethical approval was obtained from the Institutional Ethical Committee.
Patients with a poor prognosis were defined as who died within 48 h of ICU admission while patients who were stable and shifted to other wards after 48 h of ICU admission were defined to have a good prognosis. Data were extracted from dedicated EMSs and ICU database by a trained person with medical background. Incomplete records and records with errors in name and /or registration number that could not be traced were excluded from the study. In addition, the study patients who were transported to ICU of other hospitals, died at scene and did not need transportation, and discharged against medical advice from ICU were excluded from the study.
Data were entered in Microsoft Excel and imported in SPSS 15.0 software (SPSS Inc., Chicago, IL, USA) for further analysis. Frequencies and proportions were enlisted. Associations were tested by Chi-squared test. Significant variables were entered in logistic regression model.
Information from purpose of EMS call to final outcome of the patient while discharge was collected with special emphasis on the following variables:
- Age, gender, religion, and socioeconomic status
- Residence: Pune and out of Pune; urban/rural/urban slum
- Time required to reach at scene
- Approximate kilometers of scene to hospital
- Purpose of EMS call
- GCS grade at initial assessment by EMS
- Whether patient was alert, responding to verbal stimuli, responding to pain or unconscious (AVPU status) during initial examination at the scene.
- System involved
- Lifesaving procedures done at the scene and during transportation
- Final outcome while discharge.
If patient brought to ICU through EMS and died within 48 h of ICU admission.
If patient brought to ICU through EMS and was stable within 48 h of ICU admission and shifted to appropriate wards for further management.
Place from where call for EMS was received.
Glasgow Coma Scale
GCS score was calculated by summing up scores for eye, motor, and verbal responses of the patients. Maximum GCS score as 15 represents good general condition. It was categorized as 3-8: severe; 9-12: moderate; and ≥13: mild as per the modified ATLS model. 
lifesaving procedures include oxygen therapy, intravenous (IV) fluid resuscitation, state-of-the-art diagnostic evaluations, cardiopulmonary resuscitation (CPR), medication administration, and advanced airway procedures such as intubations.
Data were entered in Microsoft Excel spreadsheet and imported in SPSS 15.0 data editor for further analysis. Qualitative and dichotomous data were reported as the percent of n and they were compared with Pearson's Chi-square test/Fisher's exact test. Quantitative variables were expressed as mean (±SD). All variables with P < 0.05 in a primary univariate analysis were included in binary logistic regression model. P < 0.05 was considered statistically significant.
| Results|| |
During the study period, a total of 826 patients admitted in ICU of DMHRC through EMSs.
Nearly 33.8% of the patients shifted to other hospitals, 0.86% after observation and 6.36% shifted directly to wards as they were stable, and 13.5% of the study patients died at the scene before/after arriving at EMSs [Figure 1].
|Figure 1: Distribution of emergency medical services patients in total during the study period|
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Highest proportion, i.e., 37.5% (310/826) was shifted to ICU [Figure 1], DMHRC, for further management [Table 1]. Out of them, 19.68% (61/310) of the patients had a poor prognosis as per the definition used in the study, i.e., they died within 48 h of ICU admission and 29.03% (90/310) of the patients were stable within 48 h of ICU admission and shifted to appropriate wards and labeled to have a good prognosis.
Other patients admitted to ICU during the study period were not included in the study.
Mean age of the patients was 63.83 (±18.446) years. Nearly 34.4% (52/151) of the patients were < 60 years old. Almost 66.9% (101/151) of the patients were males and 33.1% (50/151) were females. Majority, i.e., 98.7% (149/151) were Hindus. Nearly 5.3% of the study patients did not belong to Pune, and the remaining 94.7% (143/151) were residents of Pune or nearby rural area in the Pune district and majority (96%) were from urban area of Pune. Mean time for arrival of ambulance services at the scene was 25.59 min. Baseline characteristics did not differ in both the groups, i.e., patients with poor and good prognosis (P > 0.294) [Table 1].
Purpose to call emergency medical services
Maximum calls were for altered level of consciousness, i.e., 35.71% (54/151) followed by chest pain and/or palpitations and sweating, i.e., 23.18% (35/151) and breathlessness, i.e., 21.19% (32/151). In univariate analysis, breathlessness and genitourinary tract-related chief complaint of anuria as purpose to call EMS were associated with the poor prognosis [Table 2]. There was significantly less mortality within 48 h of ICU admission among patients with seizures.
|Table 2: Purpose to call emergency medical services for the study patients |
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Majority of comorbidities noticed were diabetes mellitus among 37.70% (23/61) and 38.89% (35/90); hypertension in 40.98% (25/61) and 40.98% (47/90); other cardiovascular system-related diseases among 27.87% (17/61) and 17.78% (16/90) patients with poor prognosis and good prognosis, respectively. No comorbidity was associated with poor prognosis (P > 0.05).
Prognosis based on initial assessment of the patient
Nearly 82.14% (23/28) of the study patients with severe GCS had poor prognosis. Severe GCS was highly significantly associated with mortality in ICU within 48 h (P < 0.001). Similarly, according to AVPU status of the patient, unconsciousness, and patients responding to only pain stimuli had significantly more poor prognosis (P < 0.001) [Table 3].
|Table 3: Prognosis based on initial assessment of the patient based on Glasgow Coma Scale and consciousness according to alert, voice, pain, unresponsive status |
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Prognosis based on interventions done by emergency medical services while transport
Nearly 29.14% (44/151) of the study patients required oxygen inhalation, 45.03% (68/151) required airway insertion, 4.64% (7/151) required intubation, and three study patients required CPR. All of these interventions were associated with poor prognosis (<0.05) [Table 4].
|Table 4: Prognosis based on interventions done by emergency medical services while transport |
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Other interventions such as IV fluid replacement, gastric lavage, catheterization, and insertion were not associated with poor prognosis.
Logistic regression analysis
All the variables that were significantly associated with poor prognosis with P < 0.05 were entered in binary logistic regression model.
Logistic regression analysis revealed breathlessness as purpose of call and severe GCS of the patients as predictors of poor prognosis of the patients calling EMS and then admitted to ICU [Table 4].
| Discussion|| |
This study focuses on prognosis of ICU admissions brought to the hospital through its own EMS system. It did not take into account patients brought by relatives or by other EMS systems. It helped to assess some parameters of hospital's EMS system also.
Breathlessness and severe condition according to GCS remained predictors of poor prognosis for patients admitted to ICU through EMS [Table 5] though univariate analysis showed that anuria and lifesaving procedures done during EMS transport were also associated with poor prognosis.
|Table 5: Logistic regression analysis including all significant variables |
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Breathlessness because of any cause, if not treated on time, has a severe impact on prognosis. Although prognosis depends on the severity of the underlying disease, the required medications can be started even earlier than arrival of EMS. There is a need to handle such calls differently such as prescribing some medicines on phone call itself till EMSs reach at the scene.
Rest 28.13% (9/32) had breathlessness were diagnosed with other definitive diagnoses like infectious disease, anemia, cancer, Gastriointenstinal or genitourinary system related or miscellaneous.
In 1992, it was estimated that 1400 people worldwide were dying each day from severe sepsis,  the true figure is likely to be much higher due to underreporting which is now-a-days on increase. Deaths due to sepsis and septic shock can be minimized by interventions such as sepsis survival campaign, the first major international initiative to improve the outcome of patients with sepsis. 
Comorbidities increase the risk of ICU admissions.  However, they did not predict poor prognosis in our study. Prognosis in such patients depends on the duration and ongoing treatment of comorbidities. Presence of comorbidities can predict ICU deaths after 48 h of admission, morbidities, or disabilities after ICU discharge, which requires a different study design.
Patients' severe GCS is the worst risk factor for poor prognosis. In such calls, the highest priority should be given to reach EMS at the scene earlier. Installation of measures of patients' GCS assessment on the call and provision of quickest measures to be taken for severe GCS can help improve their prognosis. The level of ambulance service dispatched to each call (advanced life support, basic life support, and specialty care transport) can be based on the severity of the patient. Appropriate protocols need to be developed that take into account the patient's GCS, the duration of the injury or illness, and the ongoing care or monitoring that the patient may require  as well as location from where call is received. Mobile applications can help a lot in this direction to get automatic GPS location of the caller/informer. Adoption of all terrain vehicles and two wheeler ambulances can be utilized to reach the remotest of areas.  Calls from far distances can be referred to nearby EMSs. It helps attend patients with severe GCS as early and effectively as possible.
The "Reach" component of EMS is also very crucial for improved outcome. EMSs are expected to reach within 18 min of call received under the initiative "108 ambulance services."  Though hospital EMS's average is 18 min, for patients in this study, EMS reached at an average of 25 min at the scene. Poor prognosis was not associated with any delay >18 min [Table 1].
The effectiveness of any EMS system lies essentially on the quality of prehospital care provided during transit.  Some studies report decrease in survival among patients with moderate-to-severe traumatic brain injury who were intubated during emergency transport. , The EMS airway checklist should be in routine use that ensures paramedics are prepared before intubating and that all steps are performed properly. , In our study, though patients who required endotracheal intubation had poor prognosis, endotracheal intubation done was not an independent predictor of poor prognosis. Other study designs are required to assess quality and impact on prognosis of endotracheal intubation and other lifesaving procedures done while prehospital care.
| Conclusion|| |
Severe condition according to GCS and breathlessness as purpose of call to EMS remained predictors of poor prognosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]