Deirdre O'Riordan

St. James's Hospital, Dublin, Leinster, Ireland

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Publications (27)40.58 Total impact

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    ABSTRACT: Chronic Disabling Disease is present in nearly 90% of emergency medical admissions. We have examined its impact on outcomes and costs in one institution, using a database of episodes collected prospectively over 12 years.
    QJM: monthly journal of the Association of Physicians 10/2014; · 2.36 Impact Factor
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    ABSTRACT: Physician experience has been shown to improve clinical outcomes. Limited numbers of experienced clinicians make it unfeasible that they would care for all patients. We hypothesised that physician experience would impact outcomes for patients with high, but not low, risk of mortality.
    QJM: monthly journal of the Association of Physicians 08/2014; · 2.36 Impact Factor
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    ABSTRACT: Blood cultures are performed in the emergency room when sepsis is suspected, and a cohort of patients is thereby identified. The present study investigated the outcomes (mortality and length of hospital stay) in this group following an emergency medical admission.
    European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 08/2014;
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    Richard Conway, Deirdre O'Riordan, Bernard Silke
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    ABSTRACT: There is interest in health service reform and efficiencies; health service providers collect statistics, set targets and compare institutions. In January 2009, in Ireland, a national waiting time target of 6 h was set from registration in the emergency department (ED) to admission or discharge. The aim of this study was to assess the consequences of the introduction of this target on our institution and the Acute Medical Admission Unit. All emergency medical admissions were tracked over 7 years and in-hospital mortality, length of stay and ED 'wait' numbers and times were summarized. There were 43 471 admissions in 28 862 patients. In-hospital mortality for 2006-2008 averaged 5.9% [95% confidence interval (CI) 5.5-6.2%] compared with 4.8% (95% CI 4.6-5.1%) for 2009-2012 - a relative risk reduction of 18.3% (95% CI 11.5-24.5%) (P<0.001). The median length of stay was unaltered: 5.1 days (interquartile range 2.1-9.8) versus 5.0 days (interquartile range 2.0-9.5) (P=0.16). An ED 'first ward' allocation decreased six-fold with redistribution to the Acute Medical Admission Unit (two-fold increase) and the medical wards (four-fold increase). The time to on-call medical assessment decreased (time to team pre/post 4.5 vs. 4.2 h, P<0.001). However, calculations directly on the real-time log of arrival and first in-patient time showed a worsening of the position (time to ward pre/post 7.1 vs. 8.4 h, P<0.001). Target setting may result in unintended consequences in other areas in addition to its stated goal. These unintentional consequences of targets should be borne in mind by those planning and instituting healthcare reform.
    European Journal of Emergency Medicine 04/2014; · 1.02 Impact Factor
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    ABSTRACT: Troponin estimation is increasingly performed on emergency medical admissions. We report on a high-sensitivity troponin (hscTn) assay, introduced in January 2011, and its relevance to in-hospital mortality in such patients. To evaluate the impact of hscTn results on in-hospital mortality and the value of incorporating troponin into a predictive score of in-hospital mortality. All patients admitted as general medical emergencies between January 2011 and October 2012 were studied. Patients admitted under other admitting services including cardiology were excluded. We examined outcomes using generalised estimating equations, an extension of generalised linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect. A total of 11 132 admission episodes were recorded. The in-hospital mortality for patients with predefined cut-offs was 1.9% when no troponin assay was requested, 5.1% when the troponin result was below the 25 ng/L 'normal' cut-off, 9.7% for a troponin result ≥25 and <50 ng/L, 14.5% for a troponin result ≥50 and <100 ng/L, 34.4% for a troponin result ≥100 and <1000 ng/L, and 58.3% for a troponin result >1000 ng/L. The OR for an in-hospital death for troponin-positive patients was 2.02 (95% CI 1.84 to 2.21); when adjusted for other mortality predictors including illness severity, the OR remained significant at 2.83 (95% CI 2.20 to 3.64). The incorporation of troponin into a multivariate logistic predictive algorithm resulted in an area under the receiver operating characteristic curve to predict an in-hospital death of 0.87 (95% CI 0.85 to 0.88). An increase in troponin carries prognostic information in acutely ill medical patients; the extent of the risk conferred justifies incorporation of this information into predictive algorithms for hospital mortality.
    Postgraduate medical journal 04/2014; · 1.38 Impact Factor
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    ABSTRACT: Concurrent with an extension in longevity, a prodrome of ill-health ('disability' identifiable by certain ICD9/ICD10 codes) predates the acute emergency presentation. To date, no study has assessed the effect of such 'disability' on outcomes of emergency medical admissions. To devise a new method of scoring the burden of 'disability' and assess its relevance to outcomes of acute hospital admissions. All emergency admissions (67,971 episodes in n=37,828 patients) to St James' Hospital, Dublin, Ireland over an 11-year period (2002-2012) were studied and 30-day in-hospital mortality and length of stay (LOS) assessed as objective end-points. Patients were classified according to a validated 'disability' classification method, and scored from 0 to 4+ (5 classes), dependent on number of ICD9/ICD10 'hits' in hospital episode codes. A disabling score of zero was present in 10.6% of patients. Scores of 1, 2, 3 and 4+ (classified by the number of organ systems involved) occurred with frequencies of 23.3%, 28.7%, 21.9% and 15.5% respectively. The 'disability' score was strongly driven by age. The 30-day mortality rates were 0.9% (no score), 2.6%, 4.1%, 6.3% and 10.9%. Surviving patients remained in hospital for medians of 1.8 (no score), 3.9, 6.1, 8.1 and 9.7 days respectively. High 'disability' and illness severity predicted a particularly bad outcome. Disability burden, irrespective of organ system at emergency medical admission independently predicts worse outcomes and a longer in-hospital stay.
    Internal Medicine Journal 04/2014; · 1.82 Impact Factor
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    Richard Conway, Deirdre O'Riordan, Bernard Silke
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    ABSTRACT: There are little data on the experiential learning of certified consultant specialists and outcomes in acute medicine. We have examined the 30-day in-hospital mortality and hospital length of stay (LOS) in relation to practice duration, using a database of emergency admissions. All emergency admissions (60,864 episodes in 35,168 patients) over eleven years (January 2002 to December 2012) were evaluated. Consultant staff were categorised by duration of clinical practice as <15years, 15-20years, >20≤25years and >25years. We used a stepwise logistic regression model to predict 30-day in-hospital death, adjusting risk estimates for major predictor variables. Marginal analysis used adjusted predictions to test for interactions of key predictors, while controlling for other variables. Thirty-day in-hospital mortality correlated with time in clinical practice; decreasing from 8.9% and 9.1% with <15 and 15-20years to 7.7% for each of the categories of >20≤25years and >25years. There was a progressive shortening of LOS with extent of clinical practice - from a median 5.0days (IQR 1.8, 10.3) for consultants within 15 years of registration to 4.6 (IQR 1.7-8.9; p<0.05) at >20≤25years and 4.4 (IQR 1.7-9.0; p<0.01) with >25years. Duration of clinical practice predicted mortality in the univariable analysis - odds ratio (OR) 0.85 (95% CI: 0.78, 0.91; p<0.001); when adjusted in a multivariable model, it remained independently predictive - OR 0.87 (95% CI: 0.79, 0.96; p<0.001) for 30-day in-hospital mortality. Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20years in clinical practice.
    European Journal of Internal Medicine 01/2014; · 2.30 Impact Factor
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    Richard Conway, Deirdre O'Riordan, Bernard Silke
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    ABSTRACT: There is interest in emergency medical admissions, the outcomes of major reconfigurations and the development of systems and processes for Acute Medicine. We report on the long-term outcomes of an Acute Medical Admissions Unit (AMAU), using a database of emergency admissions to St James' Hospital, Dublin, from 2002-2012. All emergency admissions (67,971 episodes in 37,828 patients) were tracked and in-hospital mortality, length of stay and emergency 'wait' numbers and times summarized. We examined outcomes using generalized estimating equations, an extension of generalized linear models that permitted adjustment for correlated observations (readmissions). Margins statistics used adjusted predictions to test for interactions of key predictors while controlling for other variables using computations of the average marginal effect. By episode, the in-hospital mortality averaged 5.8% (95%CI 5.6% - 5.9%); the relative risk reduction (RRR) was 35.0% between 2002 and 2012, from 7.0% to 4.6% (p = 0.001), with a number needed to treat (NNT) of 40.7. By unique patient the in-hospital mortality averaged 10.3% (95%CI 10.0% - 10.6%) with a RRR of 60.0% from 14.5% to 5.7% (p = 0.001), with a NNT of 11.4. Emergency Department 'wait' numbers decreased by 43%. The main mortality outcome predictors were Illness Severity, Charlson Co-Morbidity, Manchester Triage Category, O2 saturation, blood culture results, transfusion requirement, and a primary respiratory or neurological diagnosis; the model had a high AUROC - 0.88 (95% CI 0.87, 0.88). Institution reform can result in substantial outcome and process measure benefits, improving care delivery to emergency medical admissions.
    QJM: monthly journal of the Association of Physicians 01/2014; · 2.36 Impact Factor
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    ABSTRACT: Aim: to create and validate a Risk Index for Geriatric Acute Medical Admissions (RIGAMA) for those aged ≥ 65, based on accumulation of deficits. Methods: we retrospectively validated a 30-item RIGAMA against inpatient mortality, length of stay (LOS), discharge to long-term care (LTC) and 30-day readmission, adjusted for age. Results: ≥ 1 RIGAMA deficit was superior to age in predicting mortality and prolonged LOS, with a clear incremental effect. The latter was true for ≥3 deficits in predicting 30-day readmission. Three to 5 deficits predicted discharge to LTC better than age. Conclusions: RIGAMA is easy to collect by the admitting junior doctor and may help trigger early senior support and inform the appropriate use of hospital resources by older patients.
    Acute medicine 01/2014; 13(1):6-11.
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    ABSTRACT: Air quality degraded by black smoke (particulate matter, PM10), sulphur dioxide (SO2) and nitrogen oxide (NOX) affect human health. Improvements following national legislation have lowered death rates. Whether background air pollution levels continue to affect human health remains unclear. To determine impact of air pollutant concentrations (PM10, SO2 and NOX) on in-hospital mortality for acute medical admissions to St James's Hospital over a decade (2002-2011). All emergency admissions (55,596 episodes in n=32,581 patients) were tracked prospectively and mortality assessed. Daily levels of PM10, SO2 and NOx were obtained from monitoring stations in our catchment area. Univariate and multivariate logistic regression was employed to examine relationships between pollutant concentration and Odds Ratio (OR) for death following adjustment for other mortality predictors. Mortality related to each pollutant variable assessed (as quintiles of increasing atmospheric concentration) were significantly predictive. For PM10 and SO2, mortality in the highest three quintile concentrations (compared to base quintile) was significantly increased (p<0.001) with univariate ORs of 1.24, 1.36 and 1.25 for PM10 and 1.43, 1.54 and 1.58 for SO2 respectively. Mortality in all quintile concentrations (compared to base quintile) was significantly increased (p<0.05) for NOX with univariate ORs of 1.14, 1.18, 1.28 and 1.35 respectively. Following adjustment for other mortality predictors such as acute illness severity, all three air pollutants were independently predictive of mortality. Despite improvement to air quality in Dublin, prevailing background pollutant concentrations continue to affect human health at levels considered safe and below that previously recognized.
    QJM: monthly journal of the Association of Physicians 12/2013; · 2.36 Impact Factor
  • Richard Conway, Bernard Silke, Deirdre O'Riordan
    Irish medical journal 10/2013; 106(9):258. · 0.51 Impact Factor
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    O Lyons, J Loh, M Lim, D O'Riordan, B Silke
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    ABSTRACT: The objective of this study was to assess appropriate thromboprophylaxis prescription rates in a university hospital and to re-audit after a series of interventions. The notes of all acute medical patient admissions over a 4-week period were assessed for VTE risk factors and prescription of thromboprophylaxis. Subsequently, a series of hospital wide interventions including educational initiatives and a new drug prescription chart were introduced. 2 years post intervention the audit was repeated. Pre-intervention, 104 of 265 (39%) "at risk" patients were prescribed appropriate thromboprophylaxis. Post intervention the prescription rate increased to 108 of 188 (57%) "at risk patients". The results of the pre- intervention audit are consistent with the published literature. While there was a significant increase in prescription rates post intervention, over 40% of "at risk" patients still did not receive thromboprophylaxis highlighting the challenge in attempting to close the gap between guidelines and actual practice.
    Irish medical journal 09/2013; 106(8):235-8. · 0.51 Impact Factor
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    R Conway, D O'Riordan, B Silke
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    ABSTRACT: BACKGROUND: Increasing hospital or specialist volumes has been shown to improve outcomes; there are little data on volumes and outcomes in emergency medical admissions. We have examined the hospital length of stay (LOS) and 30-day mortality for patients admitted under a consultant 'of the day' having high- or low-admission volumes. METHODS: An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2011, using anonymous patient data. We calculated the numbers of unique patients admitted to each 'on call' consultant and allocated the latter to a high- (70th centile with 8/22 consultants) or low-volume (14/22 consultants) category. We examined outcomes (LOS and in-hospital 30-day mortality), by these cut-offs employing logistic regression to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: The hospital LOS was shorter (P < 0.001) for high [median 4.2, inter-quartile range (IQR) 1.7, 8.7] compared with the lower volume group (median 4.8, IQR 1.9, 9.7). There was a reduced 30-day in hospital mortality for high-volume (8.2%) compared with low-volume consultants (9.6%: P < 0.01). An admission under a high-volume consultant was independently predictive of survival, after adjustment for other outcome predictors including co-morbidity; the relative risk reduction was 25% [OR 0.75 (95% CI 0.68-0.82): P < 0.001]. CONCLUSION: In an era of increasing specialization, these data provide support for the concept that the frequency of being 'on-call' contributes to maintaining competence with an associated improvement in patient outcomes.
    QJM: monthly journal of the Association of Physicians 05/2013; · 2.36 Impact Factor
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    ABSTRACT: BACKGROUND: Material deprivation in cold weather may increase the risk of hypothermia and contribute to excess winter mortality. To date, there were no local data to support the potential contribution of material deprivation to the incidence of hypothermia in Irish older people. AIM: To contribute evidence from a hospital-based perspective. METHODS: Patient series from St James's Hospital Dublin, Ireland. Of all patients aged ≥65 years experiencing their last medical admission between 1 January 2002 and 31 December 2010, we selected those who presented with a body temperature of <35 °C. Their clinical characteristics were compared with those of a random sample of 200 age and gender-matched non-hypothermic patients. Multivariate logistic regression was used to identify predictors of presentation with hypothermia. The following predictors were considered: age, gender, mean air temperature on the day of admission, year of admission, comorbidity, major diagnostic categories, and material deprivation as per the Irish National Deprivation Index (NDI). RESULTS: Eighty patients presented with hypothermia over the period. They presented in colder days (mean 8.8 vs. 10.8 °C, P < 0.001) were less likely to present in summer (P < 0.002), more likely to present in winter (P = 0.010), and their mortality was high (50 vs. 17 %, P < 0.001). The interaction NDI* air temperature was a significant multivariate predictor of hypothermia (OR = 1.03, 95 % CI 1.01-1.06, P = 0.033). CONCLUSIONS: The NDI could be an adequate tool to target fuel poverty in older people.
    Irish Journal of Medical Science 12/2012; · 0.51 Impact Factor
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    ABSTRACT: BACKGROUND: Deprivation in the general population predicts mortality. We have investigated its relevance to an acute medical admission, using a database of all emergency admissions to St James' Hospital, Dublin, over a 10-year period (2002-11). METHODS: All emergency admissions, based on geocoding of residence, were allocated to a Small Area Health Research Unit division, with a corresponding deprivation index. We then examined this index as a univariate (unadjusted) and independent (adjusted) predictor of 30-day in-hospital mortality. RESULTS: The 30-day in-hospital mortality, over the 10-year period, was higher for those in the upper half of the deprivation distribution (9.6 vs. 8.6%; P = 0.002). Indeed, there was a stepwise increase in 30-day mortality over the quintiles of deprivation from 7.3% (Quintile 1) to 8.8, 10.0, 10.0 and 9.3%, respectively. Univariate logistic regression of the deprivation indices (quintiles) against outcome showed an increased risk (P = 0.002) of a 30-day death with odds ratios (ORs), respectively (compared with lowest deprivation quintile) of 1.39 [95% confidence intervals (CI) 1.21, 1.58], 1.47 (95% CI 1.29, 1.68), 1.44 (95% CI 1.26, 1.64) and 1.39 (95% CI 1.22, 1.59). The deprivation index was an independent predictor of outcome in a model when adjusted for illness severity and co-morbidity. The fully adjusted OR for a 30-day death was increased by 31% (P = 0.001) for patients in the upper half of the deprivation index distribution (OR 1.35; 95% CI 1.23, 1.48; P < 0.001). CONCLUSION: Deprivation, independent of co-morbidity or acute illness severity, is an independent predictor of 30-day mortality in acute medical admissions.
    QJM: monthly journal of the Association of Physicians 12/2012; · 2.36 Impact Factor
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    ABSTRACT: The utility of risk stratification following an emergency medical admission has been debated. We have examined the predictability of outcomes, from a database of all emergency admissions to St James' Hospital, Dublin, over a six year period (2005-2010). Analysis was performed using the hospital in-patient enquiry system, linked to the patient administration system and laboratory data. The utility of a fractional polynomial laboratory only model to predict 30-day in-hospital mortality was determined. The AUROC for the laboratory parameters to predict a 30 day death was 0.90 ( 95% CI 0.89, 0.90) in the 2002 - 2010 derivation dataset and was 0.88 (95% CI 0.86, 0.90) in the 2011 validation set. The addition of co-morbidity measures did not improve the model prediction (0.89 : 95% CI 0.88 - 0.89). A fractional polynomial laboratory only model can reliably predict 30-day hospital mortality following an emergency medical admission, potentially allowing resources to be risk focused and patients to be prioritised.
    Acute medicine 01/2012; 11(2):59-65.
  • R Romero-Ortuno, D O'Riordan, B Silke
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    ABSTRACT: Abstract Aim: to describe the characteristics and outcomes of homeless people admitted to our Internal Medicine service in St. James's Hospital, Dublin (Ireland), between 2002 and 2011. Methods: we interrogated an anonymized in-patient database. Results: there were 1,460 homeless admissions (623 unique patients; 39% admitted more than once). Most patients were young, male, and had low comorbidity levels. Thirty-seven percent of the admissions were alcohol-related and 27% substance abuse-related. Thirteen percent had an active psychiatric illness. Their in-patient mortality rate was 5%. Seventytwo percent were discharged without the residential arrangement being explicitly documented, 15% self-discharged or absconded, and 8% were discharged to a residential facility. Conclusion: results are novel in our context and will be relevant for local policy and practice.
    Acute medicine 01/2012; 11(4):197-204.
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    ABSTRACT: Both physiological- and laboratory-derived variables, alone or in combination, have been used to predict mortality among acute medical admissions. Using the Modification of Diet in Renal Disease (MDRD) not as an estimate of glomerular filtration rate but as an outcome predictor for hospital mortality, we examined the relationship between the MDRD value and in-hospital death during an emergency medical admission. An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2008, using the hospital in-patient enquiry system, linked to the patient administration system and laboratory datasets. Hospital mortality (any in-patient death within 30 days) was obtained from a database of deaths occurring during the same period under physicians participating in the 'on-call' roster. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for MDRD value. Univariate analysis identified those with MDRD value of <60 as possessing increased mortality risk. Their 30-day mortality rate was 21.63 versus 4.35% for patients without an abnormal value (P < 0.0001) with an OR of 6.07 (95% CI's 5.49, 6.73: P < 0.001). After adjustment for 12 other outcome predictors including comorbidity, the OR was 4.63 (4.08, 5.25: P < 0.0001). Using the Kidney Disease Outcomes Quality Initiative (KDOQI) class, the respective mortality rates by 30 days increased with a lower MDRD value, from 2.8% in KDOQI Class 1 to 48.6% in KDOQI Class 5. Outcome prediction of in-hospital death, at 5 and 30 days with the MDRD, yielded areas under the receiver operator curves of 0.84 (0.83, 0.84) and 0.77 (0.77, 0.78). Many factors predict survival following an emergency medical admission. The MDRD value offers a novel readily available and reliable estimate of mortality risk.
    Nephrology Dialysis Transplantation 03/2011; 26(10):3155-9. · 3.37 Impact Factor
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    ABSTRACT: A weekend emergency medical admission has been associated with a higher mortality. We have examined all weekend admissions to St James' Hospital, Dublin between 2002 and 2009. We divided admissions by weekday or weekend (Saturday or Sunday) presentation. We utilised a multivariate logistic model, to determine whether a weekend admission was independently predictive of 30 day outcome. There were 49337 episodes recorded in 25883 patients; 30-day inhospital mortality at the weekend (9.9% vs. 9.0%) had an unadjusted Odds Ratio of 1.11 (95% CI 0.99, 1.23: p=0.057). In the full risk unlike the univariate) model, a weekend admission was not independently predictive (OR 1.05; 95% CI: 0.88, 1.24). The case-mix for a weekend admission differed; with more neurological diagnoses (22.8% vs 20.4% : p = 0.001) and less gastrointestinal disease (18.3% vs 21.1% : p = 0.001). A biochemistry only illness severity score predicted a higher mortality for weekend admissions. Patients admitted at the weekend had an approximate 11% increased 30-day in-hospital mortality, compared with a weekday admission. However, admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity. Sicker patients, with a worse outcome, are admitted over the weekend; these considerations should inform the allocation of healthcare resources.
    Acute medicine 01/2011; 10(4):182-7.
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    ABSTRACT: To examine the relationship between admission serum albumin and 30-day mortality during an emergency medical admission. An analysis was performed of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between 1st January 2002 and 31st December 2008, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Mortality was defined as an in-hospital death within 30 days. Logistic regression was used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals for defined albumin subsets. Univariate analysis using predefined criteria based on distribution, identified the groups of <10% and between 10 and 25% of the serum albumin frequency distribution as at increased mortality risk. Their mortality rates were 31.7% and 15.4% respectively; their unadjusted odds rates were 6.35 (5.68, 7.09) and 2.11 (1.90, 2.34). Patients in the lowest 25% of the distribution had a 30-day mortality of 19.9% and this significantly increased risk persisted, after adjustment for other outcome predictors including co-morbidity and illness severity (OR 2.95 (2.49, 3.48): p<0.0001). Serum albumin is predictive of 30-day mortality in emergency medical patients; mortality is non-linearly related to baseline albumin. The disproportionate increased death risk for patients in the lowest 25% of the frequency distribution (<36 g/L) is not due to co-morbidity factors or acute illness severity.
    European Journal of Internal Medicine 02/2010; 21(1):17-20. · 2.30 Impact Factor