Elsevier

Resuscitation

Volume 78, Issue 1, July 2008, Pages 52-58
Resuscitation

Clinical paper
Derivation and validation of a score based on Hypotension, Oxygen saturation, low Temperature, ECG changes and Loss of independence (HOTEL) that predicts early mortality between 15 min and 24 h after admission to an acute medical unit

https://doi.org/10.1016/j.resuscitation.2008.02.011Get rights and content

Summary

Background

Predictive scores such as APACHE II have been used to assess patients in intensive care units, but few scores have been used to assess acutely ill general medical patients.

Design

Examination of the ability of clinical variables documented at the time of admission to predict early mortality between 15 min and 24 h after admission.

Setting

An Irish rural hospital.

Subjects

10290 consecutive patients admitted as acute medical emergencies, divided into a derivation cohort of 6947 patients and a validation cohort of 3343 patients.

Results

40 patients of the derivation cohort (0.6%) died within 24 h of hospital admission. Multivariate analysis revealed 11 independent predictors of early death from which a simplified model with minimal loss of predictive ability was derived. Since this model contained only the five variables of Hypotension (systolic blood pressure < 100 mmHg), low Oxygen saturation (<90%), low Temperature (<35 °C, abnormal ECG and Loss of independence (unable to stand unaided) it was named the HOTEL score (one point for each variable). There were no differences in the early mortality predicted by this score between the derivation and validation cohorts—the area under the receiver operator characteristic curves for the derivation and validation cohorts were 86.5% and 85.4%, respectively. None of the patients with a score of zero died within 15 min and 24 h and a score of one had an early mortality of 0.3% in both cohorts. A score of two had an early mortality of 0.9% in the derivation cohort and 1.7% in the validation cohort, while a score of three or greater had an early mortality of 10.2% in the derivation and 5.6% the validation cohort.

Conclusions

The HOTEL score quickly identifies patients at a low and high risk of death between 15 min and 24 h after admission, thus enabling prompt triage and placement within a health care facility.

Section snippets

Background

Although the measurement of vital signs has been standard practice for over a century there have been few attempts to quantify their clinical performance. Nevertheless changes in the vital signs have been used by various “track and trigger” systems such as the Early Warning Scoring System (EWSS),1 the Modified Early Warning Score (MEWS),2 Patient At-Risk Teams (PARTs)3 and others.4, 5 Most of these calling criteria were determined empirically by expert opinion. The Rapid Emergency Medicine

Methods

As previously reported8 Nenagh Hospital is small general hospital in rural Ireland serving a population of 60,000. It has a 36 bed acute medical unit with 2800 admissions per year almost all of which are unplanned emergencies. It is served by three consultant physicians each assisted by a team of three physicians in training—each team is on-call every third day. From February 17, 2000 to January 29, 2004 all medical patients admitted to Nenagh Hospital had their history and physical data

Results

The continuous variables of age, oxygen saturation and vital signs were partitioned into categorical variables either by identifying cut-points associated with the highest odds ratio for early mortality, or by placing them into groups that were then bar graphed against early mortality. The pattern for systolic blood pressure is shown in Figure 1.

In the case of pulse rate the traditionally accepted normal ranges were used.17 A Shock Index >1.4, a temperature <35 °C, systolic blood pressures <77

Discussion

The HOTEL score uses five easily available clinical variables that divide acutely ill medical patients into four fifths at a very low risk and one fifth at a markedly increased risk of death within 24 h. Unlike other scores HOTEL requires almost no computational ability and can be determined easily, quickly and at no cost by any competent health care worker. Although there were several statistically significant differences between the derivation and validation cohorts these differences were of

Conflict of interest

This study was entirely funded by our employers the Mid-Western Health Board—now re-named the Health Service Executive. None of the authors have any other potential conflict of interest, financial or otherwise.

Acknowledgements

The authors would like to acknowledge the help of all the medical, nursing and administrative staff of Nenagh Hospital in the collection of data that made this paper possible. In particular we would like to thank Mrs. Marie Kennedy for her meticulous help. This study was entirely funded by the authors’ employers the Mid-Western Health Board.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.02.011.

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