Epidemiology and Outcome of Non-traumatic critically ill patients treated in Resuscitation rooms in German and Danish Emergency Departments (EpiDanGer study) – a shared, transnational research approach

Epidemiology and Outcome of Non-traumatic critically ill patients treated in Resuscitation rooms in German and Danish Emergency Departments (EpiDanGer study) – a shared, transnational research approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Epidemiology and Outcome of Non-traumatic critically ill patients treated in Resuscitation rooms in German and Danish Emergency Departments (EpiDanGer study) – a shared, transnational research approach Stefan Posth, Annmarie Lassen, Christoph Wasser, Sebastian Bergrath, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8976194/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background and importance : In contrast to trauma care, evidence on the epidemiology and outcomes of non-traumatic critically ill (NTCI) patients admitted to emergency departments (EDs) remains limited. Objectives : This study examined the epidemiology, incidence and outcomes of NTCI patients in nine German and Danish EDs using a shared transnational research approach. Design : Data from adult NTCI patients across four German centres (2014–2021) were pooled and compared with data from patients triaged as the most urgent level (red in Danish Emergency Process Triage) in five EDs in Southern Denmark (2016–2018). Main results : Altogether, 408,673 Danish and 174,306 German ED admissions were analysed. In Denmark, 1.4% of ED admissions (range 0.7–2.0%) involved non-traumatic critical illness, similar to 1.6% (range 0.5–1.6%) in Germany. Mean patient age was 63–70 years, with 51–60% male across sites. Most patients presented with acute breathing (B) problems (21.7–45.8%), circulation (C) problems (31.2–47.4%), or disability (D) problems (11.3–41.2%). Admission rates to intensive or intermediate care were markedly higher in German centres (76.0–85.5%) compared with Danish sites (9.3–20.0%). Thirty-day mortality was also higher in Germany (31.6%) than in Denmark (26.5%). Conclusion : Approximately 1.4% of all ED patients required care for non-traumatic critical illness, most commonly presenting with acute breathing, circulation, or neurological impairment. These patients show high mortality and substantial need for advanced in-hospital care, underlining the need for targeted clinical pathways. Differences between German and Danish centres, particularly in admission strategies and mortality, highlight the necessity for standardized 24/7 management and future research on organizational factors and optimal treatment pathways for NTCI patients. resuscitation room management critically ill patients alarm criteria ABCDE Figures Figure 1 Background There is a paucity of data on the epidemiology and outcome of patients presenting to the emergency department (ED) with non-traumatic critical illness. However, in recent years, a few monocentric studies from Germany and Denmark, both retrospective and prospective, have described a wide variety of emergencies treated in the ED for non-traumatic critically ill (NTCI) patients in the ED resuscitation room with higher mortality rates than patients suffering from trauma [1-7]. NTCI ED patients are brought by emergency medical services (EMS) with a leading ABCDE problem (A = airway, B = breathing, C = circulation, D = disability, E = environment/exposure), but the final diagnosis can often only be made after initial treatment and further assessment in the resuscitation room. Here, the current published data showed that these NTCI ED patients suffered from a wide spectrum of critical illnesses. Numerous measures were required to treat these patients promptly (e.g., airway management, non-invasive and invasive ventilation, catecholamines) and extensive diagnostic are needed to find the cause of the patient´s life-threatening condition. Keeping these aspects in mind, many EDs in Germany have established a structure for the resuscitation management of NTCI patients according to new developed national guidelines, and a new training concept for non-traumatic critically ill patients (Advanced Critical Illness Life Support, ACiLS) [8,9]. As well as in Germany, all EDs in Denmark have the necessary structures in place to treat NTCI patients [7]. There is currently no standardized training program for NTCI patients in Denmark. The specifical features of these structures, emergency treatment, and personal participation vary from one hospital to another, in Germany and in Denmark, respectively. It remains to be noted, so far there are no comparable standardized nationwide structures for the management of these NTCI ED patients in Germany and Demark, and many other European and Scandinavian countries, whereas training concepts and registries for patients suffering from trauma have been in place for decades all over the world (Advanced Trauma Life Support, ATLS). While there are individual monocentric studies in Germany, there has been established a national register for all acute patient in Denmark, and it is a plan to pinpoint those with a red triage who are NTCI patients [10]. The aim of this study was to investigate the epidemiology, incidence and outcome of NTCI patients in nine German and Danish EDs in a comparative transnational research approach. Material and methods To be able to compare the epidemiology and treatment outcome of NTCI patients in Germany and Denmark by means of this study, the results of care in the Danish and German study centers first had to be collected and made comparable in a step-by-step process. German data recruitment: The reported data from four German ED sites were included: Leipzig (university hospital, 2 prospective studies [1,2]), Düsseldorf (university hospital, 1 retrospective study [3]), Mönchengladbach (academic teaching hospital, 1 retrospective study [4]), and Stuttgart (academic teaching hospital, 1 prospective study [5]) The study sites all participated in previous studies, from which the data was pooled. Thereby, all five studies from four study centres reported the epidemiology, interventions, and outcome of adult NTCI patients (≥18 years), which fulfilled the local non-trauma team activation criteria between 2014 and 2021. The German data were based on the OBSERvE dataset published in 2018, in which specific data points of care in the resuscitation room were recorded [1]. Ethical approval for each German study cohort was obtained by the respective study centers for the original study and published elsewhere [1-5], with the responsible ethics committees waiving the requirement to obtain consent to participate in each case. Danish data recruitment: From the five Danish EDs we included the corresponding data of all adult patients (≥18 years) in the Region of Southern Denmark (population 1.2 million), who were admitted and registered in the data management system with the highest triage level (red level DEPT triage) between January 2016 and March 2018. Patients with red triage are managed in the resuscitation room in Denmark [7]. The study cites were chosen because of the access to an existing database [11]. Follow up regarding mortality is based on the Danish Civil Registration System [28], all other follow up is described in a previous research paper [11]. In Denmark, ethical approval was deemed unnecessary according to national regulations.“ Description of the Danish study sites: Aabenraa (academic teaching hospital (ATH), level 2 trauma center) Esbjerg (ATH), level 2 trauma center Kolding (ATH), level 2 trauma center Odense (university hospital, level 1 trauma center) Svendborg (ATH) Details of the ED and NTCI visits are shown in Table 1 . Results From all study centres in Germany and Denmark, in total 582,974 patients were included (total ED visits). We found that 1.5% (5929/408,673) ED visits at the Danish centres and 1.2% (2016/174,306) ED visits in the German sites had resuscitation room managed NTCI. This ranged from 0.7% (575/82,803) to 2.0% (1556/77,142) in the Danish sites and 0.5% (213/40,346) to 1.6% (532/34,303) in the German sites. At all nine EDs, NTCI patients arrived at the resuscitation room 24/7 with a variety of 45-48 % during daytime (8.00- 16.00), 33-38% evening (16.00-24.00) and 14-21% night (00.00- and 8.00). Patient characteristics At all sites, mean age of NTCI patients ranged between 68±16 years at the German study centres and 67±19 years at the Danish sites, and a proportion of 51 and 60% were male patients, respectively. Most of the patients presented with a life-threatening B -problem (breathing), ranges from 21.7-45.8%, a C -problem (circulation) range from 31.2-47.4%, or a D problem (disability) range between 11.3-41.2%. In the Danish registry, A-problems were not recorded. Outcome Including OHCA, the thirty-day-mortality at the German sites ranged between 18.5 (115/621 NTCI ED visits) and 39.9% (85/213 NTCI ED visits). At the Danish study centres, the thirty-day mortality ranged between 21,5% (335/1556 NTCI ED visits) and 30,5% (288/945 NTCI ED visits). All data is shown in Table 1 and Figure 1 . Relocation area The admission rate to ICU (intensive care unit) or IMC (intermediate medical unit) was higher in the German study centres with 76-85.5% in comparison to the Danish EDs with 9.3-20%. In one Danish study centre, no data of ICU admission was recorded. Discussion In this comparative transnational research approach data from more than half a million ED visits in Denmark and Germany were compared. The incidence of patients admitted due to non-traumatic critically illness averaged 1.5% at Danish centres and 1.2% in the German EDs. The patient cohorts showed comparable epidemiological data regarding mean age and sex. The underlying life-threatening B-, C-, and D-problems differed markedly between the study sites. The admission rate to ICU or IMC as well as the 30 day-mortality of the NCTI patients was higher in the German cohort compared to the Danish ED cohort. These findings show both similarities and clear differences between the individual patient cohorts from and structural differences between Denmark and Germany. The treatment of NTCI patients in the ED is increasingly coming into focus of modern emergency medicine training and research. While trauma management has been established for many years, the epidemiology and resuscitation room management of NTCI patients have only been investigated in the last few years and is still not inaugurated in many EDs. Though the structure of the involved EDs in Germany and Denmark differs from maximum-care to intermediate care and university and academic teaching hospitals, all patients were treated in the ED by specialized teams with main field of activity in the ED. In all nine study sites from Germany and Denmark, the epidemiologic issues (e.g. age, gender distribution) and the incidence of NTCI emergencies according to the total ED visits were comparable between the different hospital structures, despite of differences in the public health systems in Germany and Denmark. Healthcare system in Germany and Denmark In Germany, with a population of about 84 million people, there are 1.874 hospitals with a capacity of 430.000 beds and about 17.2 million inpatients per year ( https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/) In the last years many hospitals were closed due to mainly economic reasons, actual further reform plans are discussed by the federal government. Denmark has a population of 5.9 million people [2022, Danmarks Statistik (https://www.dst.dk)], which are served by 21 hospitals with EDs, with an overall capacity of 13.984 beds and about 1.8 million acute patient visits per year (https://www.sundhed.dk/content/cms/59/67559_dah_aarsrapport-2023.pdf). Since 2007, the amount of hospitals with EDs in Denmark were reduced from 40 to 21, following a national plan in order to strengthen the emergency system (Styrket akutberedskab - planlægningsgrundlag for det regionale sundhedsvæsen, 2007, Sundhedsstyrelsen). Beyond the reduction of the overall amount of emergency hospitals, a part of this plan was, to implement independent EDs in all emergency hospitals. The public health systems differ greatly between Germany and Denmark with 2.2 vs. 0.36 acute visits per 100.000 inhabitants and 512 vs. 237 hospital beds per 100.000 inhabitants. In Denmark, about 1.8 million acute hospital contacts per year are registered for about 6 million inhabitants. About 57% of all acute hospital contacts in Denmark are in EDs [12]. The hospital density is higher in Germany, while in Denmark the emergency hospital landscape has changed drastically in recent years, and emergency care is now limited to few emergency hospitals. Details are shown in Table 2 . Development of inhospital emergency medicine in Germany and Denmark In Germany, emergency medicine has changed in the last years. In 2018, a federal committee (Gemeinsamer Bundesausschuss, G-BA) demanded a consistent structure for all EDs (e.g. an own medical direction, three different care levels according to the medical spectrum, a mandatory specialty training in clinical acute and emergency medicine) [13]. EDs developed independence, built up own core teams and implemented a new movement of emergency medicine. In Decembre 2024 the German Ministry of Health finally introduced Emergency Medicine as an in-hospital specialty (”Leistungsgruppe”) with quality requirements regarding qualifications of personnel in the ED and equipment in the ED. Despite all these reform developments, there is still no specialty in emergency medicine in Germany. In 2006, the Danish Society of Emergency Medicine (DASEM) was founded. In 2008, the ministry of health acknowledged the sub-specialty of emergency medicine, as a supplemental two-year raining program for specialists in other fields of medicine. In 2018, emergency medicine became a specialty. Out-of-hospital emergency service in Germany and Denmark In Germany, the well-established out-of-hospital EMS system is two-tiered and is staffed by either paramedic-equivalent (“Notfallsanitäter”) or emergency physicians. While paramedic-equivalent are responsible for basic out-of-hospital care, special qualified out-of-hospital emergency physicians are disposed for critical emergencies (e.g., cardiac arrest, major trauma, severe pediatric emergencies), and staff the ground- and air-based vehicle additionally. The qualification for out-of-hospital emergency physicians is a further training for all specialties. In Denmark, physician-based rapid response cars were added to the pre-existing ambulance service in Copenhagen 1986 and was national fully implemented in 2008. Most physicians on the rapid response cars are anesthesiologists by training and are disposed for critical emergencies with similar criteria as in Germany [14]. Red triage in DEPT, used prehospitally, is the alarm criteria for NTCI calls. The majority of NTCI patients are treated by paramedics without the assistance of physicians. Critically ill patients in the resuscitation room in Germany and Denmark The resuscitation room management for trauma patients has been well established in German EDs for years. The German Society of Trauma Surgery introduced a white paper [15] and a nationwide trauma register [16]. There are different mandatory education concepts for trauma-associated resuscitation room management [e.g., Advanced Trauma Life Support, European Trauma Course] and there is a nationwide guideline for the out-of-hospital and hospital treatment of trauma patients [17]. For the treatment of NTCI patients, a white paper was published by the German society for acute and emergency medicine (DGINA e.V.) in 2022 and offered the first nation-wide standardized alarm criteria for the resuscitation room for NTCI patients [18]. Also in 2022, the first validated alarm criteria were published as the “V 2 iSiOn-rule” [19]. Meanwhile, these resuscitation room activation criteria are used in some EMS systems in Germany [20]. Many EDs are using local or adapted resuscitation room activation criteria for NTCI patients as shown in a survey concerning the status quo of resuscitation room management in Germany [21]. The white paper for the treatment of NTCI patients implemented a standardized concept including technical equipment, team requirements, and an education structure [18]. In addition, a treatment algorithm for NTCI patients, the (PR_E-)AUD²IT-algorithm was published and implemented in many EDs [22]. As an educational concept, the Advanced Critical illness Life Support (ACiLS) course system was inaugurated in 2022 in Germany in addition to trauma course concepts in order to focus on the complex treatment of NTCI patients [8,9]. In Denmark, there has been an overall agreement that there was a need for a triggered team response for non-traumatic critically ill patients since 2007. In 2023, a survey showed, that all emergency hospitals used and trained such a team response, though team composition and experience of the staff participating in the trigger calls differs greatly [7]. Nationally, the DEPT triage system is used prehospitally and in most emergency hospitals, and red triage in DEPT for non-traumatic patients triggers a team response [23, DEPT generisk, version 2.0 (deptriage.dk)]. In conclusion, there are differences between the medical systems in Denmark and Germany, though we could show similarities in the epidemiology of critically ill patients in our transnational study. Within the last years, the heterogenous group of critically ill patients got in the focus of several studies both in Germany and Denmark. While the treatment of trauma patients in the resuscitation room has been under surveillance for many years by large registers [16], there is a lack of data for non-traumatic conditions. Until today, there is no nation-wide register for critically ill patients and non-traumatologic resuscitation room management in Germany. A registry of all acute hospital contacts has been implemented in Denmark and includes a plan for registration of triage level at arrival including read triage as proxy registration for NTIC patients [Database for Akutte Hospitalskontakter, Databasen for Akutte Hospitalskontakter (DAH) - RKKP]. Available data on epidemiology and outcome of NTCI patients in Germany and Denmark Despite the differences in the healthcare systems, the basic diagnostic procedures and invasive interventions in emergency care are largely comparable between Germany and Denmark. According to the ABCDE of resuscitation, B, C and D problems were the main problems in all study centres, while D problems showed a wider range in the studies. With regard to the main problems, differences were found in the various studies: Respiratory problems were rarely found in the German studies, while in Denmark ‘A problems’ were not recorded and possibly subsumed under the B problems. Within the ten studies, the proportion of B problems varied between 21 and 45%, which could be explained by seasonal effects or the combination of A and B problems in some studies. The C problems were similar in all included studies. An increased mortality rate was found in patients with out-of-hospital cardiac arrest (OHCA). In the Danish registry, OHCA patients could not be identified among the NTCI patients. Their number is probably low, as OHCA patients with suspected STEMI are admitted directly to the cardiac catheter laboratory and bypass the ED. In Germany, OHCA patients are often stabilised in the resuscitation room, based on the concept of certified cardiac arrest centres. C problems, which include patients with shock, cardiac arrhythmias or aortic emergencies (e.g. aortic dissection), had the highest mortality rate. The incidence of D problems also differed between the study centres. This could be explained by the presence of a neurology department or stroke unit in some participating hospitals. On the other hand, D problems included a large number of emergencies without a neurological cause, highlighting the need for structured resuscitation room management excluding the most common and critical differential diagnoses. E-problems are rarely found in NTCI patients in all study centres. E-problems (E = ‘environment’, ‘exposure’) can be difficult to define. In the German white paper for NTCI patients [18], E-problems include severe hypo- and hyperthermia, patients with prolonged trauma, metabolic disorders or with a generally critical impression. In the Danish register, E problems are insufficiently recorded and often not registered. The most common emergencies in both countries include neurovascular, cardiovascular and respiratory problems. In Denmark, there is only one study from a university hospital that describes the epidemiology of all types of critically ill patients, including NTCI patients [6]. This study, published in 2021, compares patients admitted to a university hospital by a trigger team (trauma, NTCI, stroke, STEMI) between November 2012 and October 2015. Due to the organization of the healthcare system, all critically ill patients, regardless of the suspected diagnosis, from the hospital's catchment area were admitted there, so that a direct comparison of the results is possible. With a few exceptions, all patients were referred to the activation team by the emergency services. In the catchment area, activation / 100,000 population per year was 339 for NTCI, 160 for trauma, 73 for stroke and 65 for STEMI. These results are consistent with other studies that found a non-trauma to trauma ratio of 4:1, as reported by Vincent et al [24]. Focusing on the results of NTCI patients, the 30-day all-cause mortality in Germany was significantly higher (35%) than in Denmark (24%), and almost three times higher than the mortality rate for trauma patients as reported in the German trauma registry (12%, [16]). German patients generally stay longer in the ED than Danish patients. The length of stay in the resuscitation room, defined as initial treatment, was between 31±22 and 148±203 minutes. Overall, there are no major delays in admission to the intensive care unit in Denmark [6]. A major difference between the German and Danish study results is the rate of ICU admission. While most German patients are in a critical condition after initial treatment and up to 80% require treatment in an intensive care unit [25], only 10-20% of the identified red triaged patients were admitted to the intensive care unit in the Danish study centres. This could be due to the fact that in Denmark most OHCA and out-of-hospital identified STEMI are received at the cardiac catheter unit, and that patients with suspected stroke are admitted directly by the stroke teams in the hospitals' MR scanners, with both patient groups bypassing the EDs. In addition, many of the Danish patient are admitted to special high acuity areas in the EDs where some treatments that are otherwise performed in IMC/ICU departments are performed in the EDs (e.g. treatment with non-invasive ventilation, treatment of ketoacidosis). Historically, there are hardly any IMC units in Denmark but the high acuity areas serve as such. A stay in one of these areas is not registered as an ICU stay in the Danish data, which is in contrast to the German data where a stay in IMC is registered as an ICU stay. The higher rate of admission to the ICU in Germany is probably due to the differences in the healthcare systems and the type of patients admitted to the EDs in the two countries. In Germany, there is a higher density of hospitals, whereas in Denmark, emergency care is more centralized and the focus is more on outpatient services. In the German study centres, a longer length of stay in the resuscitation room was described, which had a major association with further treatment including ventilation, sedation, catheter management and other interventions. In one study centre, the median treatment time of NTCI patients was 7 hours until admission to the intensive care unit [3]. This fact shows the need for a treatment concept for NTCI patients that goes beyond the initial treatment in the resuscitation room [26,27]. The treatment of OHCA patients is different in both countries, which may have an impact on the mortality rate. In both Germany and Denmark, it is difficult to maintain a consistent team day and night. Due to the longer length of stay in the ED and the limited capacity of the intensive care unit, there is a greater need for an emergency critical care (ECC) concept in Germany for the ongoing treatment of critically ill patients ECC is already established in the United States and other countries, but is coming into focus in Germany due to a lack of intensive care capacity despite of a high number ot total intensive care beds [27]. In general, the prolonged stay of patients ED in the waiting for an ICU bed is not a major problem in Denmark. This seems to be one of the major differences between the German and the Danish cohorts. Limitations This study includes data from retrospective and prospective monocentric studies. The observation periods differ between the five German (2014-2021) and the Danish centres (2016-2019) and overlap. Most observation periods were before the start of the Covid-19 pandemic in 2020, but at least one study continued during the pandemic, which could have an impact on treatment outcomes and outcome. In addition, there is a wide range of ED visits, levels of care and catchment areas of those involved. Another limitation could be due to the different structures of hospitals and the public healthcare system in Germany and Denmark. In Germany, there are no nationwide alert criteria for activation of the resuscitation room for NTCI patients, although initial criteria are being introduced there. Finally, the data from the study centres in both countries do not represent the entire national healthcare system, as there are only individual study centres in Germany and only the region of Southern Denmark was included. Conclusion NTCI patients make up only a small percentage of ED visits but have a high mortality rate. The most common problems in NTCI patients are respiratory, circulatory and neurological problems. Despite the differences in healthcare systems and geographical location, the study found similar results in German and Danish EDs. There is a need for standardized treatment protocols and registries for NTCI patients in both countries. Further prospective studies should investigate the effectiveness of standardized treatment of NTCI patients. The introduction of standardized alert criteria and registries for NTCI patients in Germany is crucial. Abbreviations DEPT – Danish Emergency Process Triage ED – Emergency department EMS – emergency medical system NTCI – Non-traumatic critically ill OHCA – out-of-hospital cardiac arrest IMC – Intermediate care unit ICU – Intensive care unit Declarations Conflicts of interest: none declared Ethics approval and consent to participate The study protocols for the original works in Germany are documented before by the respective study centers for the original study, with the responsible ethics committees waiving the requirement to obtain consent to participate in each case. In Denmark, ethical approval was deemed unnecessary according to national regulations. Informed consent to participate was obtained from all of the participants in the studies. Consent for publication Not applicable. Availability of data and materials The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no conflicts of interest. Funding There was no funding received for this study. Authors' contributions All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. References Bernhard M, Doll S, Hartwig T, et al. Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study). Eur J Emerg Med. Aug 2018;25(4):e9-e17. doi:10.1097/MEJ.0000000000000543 Grahl C, Hartwig T, Weidhase L, et al. 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Notfall Rettungsmedizin 25:491–498 DEPT, DEPT generisk, version 2.0 (deptriage.dk) Piagnerelli M, Van Nuffelen M, Maetens Y, Lheureux P, Vincent JL. A 'shock room' for early management of the acutely ill. Anaesth Intensive Care. 2009 May;37(3):426-31. doi: 10.1177/0310057X0903700307. PMID: 19499862. Bernhard, M., Kumle, B., Wasser, C. et al. Epidemiologie, Hintergründe, Zahlen und Fakten zum nichttraumatologischen Schockraummanagement kritisch kranker Patienten. Notfall Rettungsmed 26, 473–481 (2023). https://doi.org/10.1007/s10049-023-01195-0 23. Kemper, J.J., Michael, M., Kümpers, P. et al. Grundlagen des notfallmedizinischen „Bridgings“ von kritisch kranken Patienten in der Notaufnahme bis zur Intensivstationsverlegung. Notfall Rettungsmed (2024). https://doi.org/10.1007/s10049-023-01276-0 Reindl, M., Rovas, A., Köhnke, R. et al. „Emergency critical care“ in der Notaufnahme. Literaturübersicht und aktuelle Konzepte. Notfall Rettungsmed (2024). https://doi.org/10.1007/s10049-024-01309-2 Schmidt M, Pedersen L, Sørensen HT. The Danish Civil Registration System as a tool in epidemiology. Eur J Epidemiol. 2014;29(8):541–9 Further references: https://www.sundk.dk/media/q14d1yqh/dtr_aarsrapport_2025_offentlig-version-30102025.pdf Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1ResultsNewversion.docx Table2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 26 Apr, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 16 Apr, 2026 Editor assigned by journal 27 Feb, 2026 Submission checks completed at journal 27 Feb, 2026 First submitted to journal 26 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8976194","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628290147,"identity":"5a584773-7f51-47e2-9a1d-958c2386c710","order_by":0,"name":"Stefan Posth","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"","lastName":"Posth","suffix":""},{"id":628290148,"identity":"17cb313d-da97-468b-a050-e7754be5ed51","order_by":1,"name":"Annmarie Lassen","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Annmarie","middleName":"","lastName":"Lassen","suffix":""},{"id":628290149,"identity":"602a6a11-5595-4634-9cf9-4683bd1720a1","order_by":2,"name":"Christoph Wasser","email":"","orcid":"","institution":"Robert Bosch Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christoph","middleName":"","lastName":"Wasser","suffix":""},{"id":628290150,"identity":"222d2683-eeff-4559-9c2a-6dc524069452","order_by":3,"name":"Sebastian Bergrath","email":"","orcid":"","institution":"Maria Hilf Hospital, Academic Teaching Hospital of RWTH Aachen University","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Bergrath","suffix":""},{"id":628290151,"identity":"cade8988-5a66-4c8b-b945-6eafadd57d50","order_by":4,"name":"Jana Vienna Roedler","email":"","orcid":"","institution":"Maria Hilf Hospital, Academic Teaching Hospital of RWTH Aachen University","correspondingAuthor":false,"prefix":"","firstName":"Jana","middleName":"Vienna","lastName":"Roedler","suffix":""},{"id":628290152,"identity":"6488cfb7-395b-4f23-8b29-aaafa6e6553d","order_by":5,"name":"Peter Biesenbach","email":"","orcid":"","institution":"University Hospital of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Biesenbach","suffix":""},{"id":628290153,"identity":"4bb573fd-9fa5-4f0f-b7a4-1b994d802bb4","order_by":6,"name":"Lone Wulff Madsen","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Lone","middleName":"Wulff","lastName":"Madsen","suffix":""},{"id":628290154,"identity":"d2481540-b97b-4eaf-95c2-cef71dc8e223","order_by":7,"name":"Christian Backer Mogensen","email":"","orcid":"","institution":"Hospital of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"Backer","lastName":"Mogensen","suffix":""},{"id":628290155,"identity":"aaafec6c-7678-4275-b7d1-e449de616123","order_by":8,"name":"Michael Bernhard","email":"","orcid":"","institution":"University Hospital Duesseldorf, Heinrich Heine University","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Bernhard","suffix":""},{"id":628290156,"identity":"1bb9ea24-81e1-47ea-bb41-c428911c5ae7","order_by":9,"name":"Mark Michael","email":"data:image/png;base64,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","orcid":"","institution":"University Hospital Duesseldorf, Heinrich Heine University","correspondingAuthor":true,"prefix":"","firstName":"Mark","middleName":"","lastName":"Michael","suffix":""}],"badges":[],"createdAt":"2026-02-26 09:42:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8976194/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8976194/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107833732,"identity":"f7d1441f-73f7-4be0-9e98-192bdfd83954","added_by":"auto","created_at":"2026-04-26 15:40:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128612,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical abstract: EpiDanGer results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eED: emergency department; NTCI: non-traumatic critically ill; ICU: intensive care unit\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8976194/v1/96d3edd341a89bc4530260f4.png"},{"id":107872153,"identity":"2a3ce3f2-b7ff-4c4f-a95d-8f20c90326cc","added_by":"auto","created_at":"2026-04-27 07:55:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":285050,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8976194/v1/9d5e6bdf-f9cc-42df-82ae-9284b67b2d71.pdf"},{"id":107870179,"identity":"90e1af23-5d30-4008-810b-6fc0c3ffc089","added_by":"auto","created_at":"2026-04-27 07:39:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22054,"visible":true,"origin":"","legend":"","description":"","filename":"Table1ResultsNewversion.docx","url":"https://assets-eu.researchsquare.com/files/rs-8976194/v1/db228f74429085e2509fe9b8.docx"},{"id":107833734,"identity":"baaa5920-efd2-4f1b-9c55-cca7ab7d7951","added_by":"auto","created_at":"2026-04-26 15:40:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20719,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8976194/v1/3aada732d70ccefb557d9abe.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiology and Outcome of Non-traumatic critically ill patients treated in Resuscitation rooms in German and Danish Emergency Departments (EpiDanGer study) – a shared, transnational research approach","fulltext":[{"header":"Background","content":"\u003cp\u003eThere is a paucity of data on the epidemiology and outcome of patients presenting to the emergency department (ED) with non-traumatic critical illness. However, in recent years, a few monocentric studies from Germany and Denmark, both retrospective and prospective, have described a wide variety of emergencies treated in the ED for non-traumatic critically ill (NTCI) patients in the ED resuscitation room with higher mortality rates than patients suffering from trauma [1-7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNTCI ED patients are brought by emergency medical services (EMS) with a leading ABCDE problem (A = airway, B = breathing, C = circulation, D = disability, E = environment/exposure), but the final diagnosis can often only be made after initial treatment and further assessment in the resuscitation room. Here, the current published data showed that these NTCI ED patients suffered from a wide spectrum of critical illnesses. Numerous measures were required to treat these patients promptly (e.g., airway management, non-invasive and invasive ventilation, catecholamines) and extensive diagnostic are needed to find the cause of the patient\u0026acute;s life-threatening condition.\u003c/p\u003e\n\u003cp\u003eKeeping these aspects in mind, many EDs in Germany have established a structure for the resuscitation management of NTCI patients according to new developed national guidelines, and a new training concept for non-traumatic critically ill patients (Advanced Critical Illness Life Support, ACiLS) [8,9]. As well as in Germany, all EDs in Denmark have the necessary structures in place to treat NTCI patients [7]. There is currently no standardized training program for NTCI patients in Denmark. The specifical features of these structures, emergency treatment, and personal participation vary from one hospital to another, in Germany and in Denmark, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt remains to be noted, so far there are no comparable standardized nationwide structures for the management of these NTCI ED patients in Germany and Demark, and many other European and Scandinavian countries, whereas training concepts and registries for patients suffering from trauma have been in place for decades all over the world (Advanced Trauma Life Support, ATLS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile there are individual monocentric studies in Germany, there has been established a national register for all acute patient in Denmark, and it is a plan to pinpoint those with a red triage who are NTCI patients [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to investigate the epidemiology, incidence and outcome of NTCI patients in nine German and Danish EDs in a comparative transnational research approach.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eTo be able to compare the epidemiology and treatment outcome of NTCI patients in Germany and Denmark by means of this study, the results of care in the Danish and German study centers first had to be collected and made comparable in a step-by-step process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGerman data recruitment:\u003c/strong\u003e The reported data from \u003cstrong\u003efour\u003c/strong\u003e German ED sites were included:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eLeipzig (university hospital, 2 prospective studies [1,2]),\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eD\u0026uuml;sseldorf (university hospital, 1 retrospective study [3]),\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eM\u0026ouml;nchengladbach (academic teaching hospital, 1 retrospective study [4]), and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStuttgart (academic teaching hospital, 1 prospective study [5])\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe study sites all participated in previous studies, from which the data was pooled.\u003c/p\u003e\n\u003cp\u003eThereby, all five studies from four study centres reported the epidemiology, interventions, and outcome of adult NTCI patients (\u0026ge;18 years), which fulfilled the local non-trauma team activation criteria between 2014 and 2021. The German data were based on the OBSERvE dataset published in 2018, in which specific data points of care in the resuscitation room were recorded [1]. Ethical approval for each German study cohort was obtained by the respective study centers for the original study and published elsewhere [1-5], with the responsible ethics committees waiving the requirement to obtain consent to participate in each case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDanish data recruitment:\u0026nbsp;\u003c/strong\u003eFrom the five Danish EDs we included the corresponding data of all adult patients (\u0026ge;18 years) in the Region of Southern Denmark (population 1.2 million), who were admitted and registered in the data management system with the highest triage level (red level DEPT triage) between January 2016 and March 2018. Patients with red triage are managed in the resuscitation room in Denmark [7]. The study cites were chosen because of the access to an existing database [11]. \u0026nbsp;Follow up regarding mortality is based on the Danish Civil Registration System [28], all other follow up is described in a previous research paper [11]. In Denmark, ethical approval was deemed unnecessary according to national regulations.\u0026ldquo;\u003c/p\u003e\n\u003cp\u003eDescription of the Danish study sites:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAabenraa (academic teaching hospital (ATH), level 2 trauma center)\u003c/li\u003e\n \u003cli\u003eEsbjerg (ATH), level 2 trauma center\u003c/li\u003e\n \u003cli\u003eKolding (ATH), level 2 trauma center\u003c/li\u003e\n \u003cli\u003eOdense (university hospital, level 1 trauma center)\u003c/li\u003e\n \u003cli\u003eSvendborg (ATH)\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDetails of the ED and NTCI visits are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom all study centres in Germany and Denmark, in total 582,974 patients were included (total ED visits). We found that 1.5% (5929/408,673) ED visits at the Danish centres and 1.2% (2016/174,306) ED visits in the German sites had resuscitation room managed NTCI. This ranged from 0.7% (575/82,803) to 2.0% (1556/77,142) in the Danish sites and 0.5% (213/40,346) to 1.6% (532/34,303) in the German sites. At all nine EDs, NTCI patients arrived at the resuscitation room 24/7 with a variety of 45-48 % during daytime (8.00- 16.00), 33-38% evening (16.00-24.00) and 14-21% night (00.00- and 8.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt all sites, mean age of NTCI patients ranged between 68\u0026plusmn;16 years at the German study centres and 67\u0026plusmn;19 years at the Danish sites, and a proportion of 51 and 60% were male patients, respectively. Most of the patients presented with a life-threatening B -problem (breathing), ranges from 21.7-45.8%, a C -problem (circulation) range from 31.2-47.4%, or a D problem (disability) range between 11.3-41.2%. In the Danish registry, A-problems were not recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncluding OHCA, the thirty-day-mortality at the German sites ranged between 18.5 (115/621 NTCI ED visits) and 39.9% (85/213 NTCI ED visits). At the Danish study centres, the thirty-day mortality ranged between 21,5% (335/1556 NTCI ED visits) and 30,5% (288/945 NTCI ED visits). All data is shown in \u003cstrong\u003eTable 1\u003c/strong\u003e and \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelocation area\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe admission rate to ICU (intensive care unit) or IMC (intermediate medical unit) was higher in the German study centres with 76-85.5% in comparison to the Danish EDs with 9.3-20%. In one Danish study centre, no data of ICU admission was recorded.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this comparative transnational research approach data from more than half a million ED visits in Denmark and Germany were compared. The incidence of patients admitted due to non-traumatic critically illness averaged 1.5% at Danish centres and 1.2% in the German EDs. The patient cohorts showed comparable epidemiological data regarding mean age and sex. The underlying life-threatening B-, C-, and D-problems differed markedly between the study sites. The admission rate to ICU or IMC as well as the 30 day-mortality of the NCTI patients was higher in the German cohort compared to the Danish ED cohort. These findings show both similarities and clear differences between the individual patient cohorts from and structural differences between Denmark and Germany. \u003c/p\u003e\n\u003cp\u003eThe treatment of NTCI patients in the ED is increasingly coming into focus of modern emergency medicine training and research. While trauma management has been established for many years, the epidemiology and resuscitation room management of NTCI patients have only been investigated in the last few years and is still not inaugurated in many EDs. Though the structure of the involved EDs in Germany and Denmark differs from maximum-care to intermediate care and university and academic teaching hospitals, all patients were treated in the ED by specialized teams with main field of activity in the ED. \u003c/p\u003e\n\u003cp\u003eIn all nine study sites from Germany and Denmark, the epidemiologic issues (e.g. age, gender distribution) and the incidence of NTCI emergencies according to the total ED visits were comparable between the different hospital structures, despite of differences in the public health systems in Germany and Denmark.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eHealthcare system in Germany and Denmark\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Germany, with a population of about 84 million people, there are 1.874 hospitals with a capacity of 430.000 beds and about 17.2 million inpatients per year ( https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/) In the last years many hospitals were closed due to mainly economic reasons, actual further reform plans are discussed by the federal government.\u003c/p\u003e\n\u003cp\u003eDenmark has a population of 5.9 million people [2022, Danmarks Statistik (https://www.dst.dk)], which are served by 21 hospitals with EDs, with an overall capacity of 13.984 beds and about 1.8 million acute patient visits per year (https://www.sundhed.dk/content/cms/59/67559_dah_aarsrapport-2023.pdf).\u003c/p\u003e\n\u003cp\u003eSince 2007, the amount of hospitals with EDs in Denmark were reduced from 40 to 21, following a national plan in order to strengthen the emergency system (Styrket akutberedskab - planl\u0026aelig;gningsgrundlag for det regionale sundhedsv\u0026aelig;sen, 2007, Sundhedsstyrelsen). Beyond the reduction of the overall amount of emergency hospitals, a part of this plan was, to implement independent EDs in all emergency hospitals.\u003c/p\u003e\n\u003cp\u003eThe public health systems differ greatly between Germany and Denmark with 2.2 vs. 0.36 acute visits per 100.000 inhabitants and 512 vs. 237 hospital beds per 100.000 inhabitants. In Denmark, about 1.8 million acute hospital contacts per year are registered for about 6 million inhabitants. About 57% of all acute hospital contacts in Denmark are in EDs [12]. The hospital density is higher in Germany, while in Denmark the emergency hospital landscape has changed drastically in recent years, and emergency care is now limited to few emergency hospitals. Details are shown in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDevelopment of inhospital emergency medicine in Germany and Denmark\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Germany, emergency medicine has changed in the last years. In 2018, a federal committee (Gemeinsamer Bundesausschuss, G-BA) demanded a consistent structure for all EDs (e.g. an own medical direction, three different care levels according to the medical spectrum, a mandatory specialty training in clinical acute and emergency medicine) [13]. EDs developed independence, built up own core teams and implemented a new movement of emergency medicine. In Decembre 2024 the German Ministry of Health finally introduced Emergency Medicine as an in-hospital specialty (\u0026rdquo;Leistungsgruppe\u0026rdquo;) with quality requirements regarding qualifications of personnel in the ED and equipment in the ED. Despite all these reform developments, there is still no specialty in emergency medicine in Germany. \u003c/p\u003e\n\u003cp\u003eIn 2006, the Danish Society of Emergency Medicine (DASEM) was founded. In 2008, the ministry of health acknowledged the sub-specialty of emergency medicine, as a supplemental two-year raining program for specialists in other fields of medicine. In 2018, emergency medicine became a specialty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOut-of-hospital emergency service in Germany and Denmark\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Germany, the well-established out-of-hospital EMS system is two-tiered and is staffed by either paramedic-equivalent (\u0026ldquo;Notfallsanit\u0026auml;ter\u0026rdquo;) or emergency physicians. While paramedic-equivalent are responsible for basic out-of-hospital care, special qualified out-of-hospital emergency physicians are disposed for critical emergencies (e.g., cardiac arrest, major trauma, severe pediatric emergencies), and staff the ground- and air-based vehicle additionally. The qualification for out-of-hospital emergency physicians is a further training for all specialties. \u003c/p\u003e\n\u003cp\u003eIn Denmark, physician-based rapid response cars were added to the pre-existing ambulance service in Copenhagen 1986 and was national fully implemented in 2008. Most physicians on the rapid response cars are anesthesiologists by training and are disposed for critical emergencies with similar criteria as in Germany [14]. Red triage in DEPT, used prehospitally, is the alarm criteria for NTCI calls. The majority of NTCI patients are treated by paramedics without the assistance of physicians.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCritically ill patients in the resuscitation room in Germany and Denmark\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe resuscitation room management for trauma patients has been well established in German EDs for years. The German Society of Trauma Surgery introduced a white paper [15] and a nationwide trauma register [16]. There are different mandatory education concepts for trauma-associated resuscitation room management [e.g., Advanced Trauma Life Support, European Trauma Course] and there is a nationwide guideline for the out-of-hospital and hospital treatment of trauma patients [17]. For the treatment of NTCI patients, a white paper was published by the German society for acute and emergency medicine (DGINA e.V.) in 2022 and offered the first nation-wide standardized alarm criteria for the resuscitation room for NTCI patients [18]. Also in 2022, the first validated alarm criteria were published as the \u0026ldquo;V\u003csup\u003e2\u003c/sup\u003eiSiOn-rule\u0026rdquo; [19]. Meanwhile, these resuscitation room activation criteria are used in some EMS systems in Germany [20]. Many EDs are using local or adapted resuscitation room activation criteria for NTCI patients as shown in a survey concerning the status quo of resuscitation room management in Germany [21]. The white paper for the treatment of NTCI patients implemented a standardized concept including technical equipment, team requirements, and an education structure [18]. In addition, a treatment algorithm for NTCI patients, the (PR_E-)AUD\u0026sup2;IT-algorithm was published and implemented in many EDs [22]. As an educational concept, the Advanced Critical illness Life Support (ACiLS) course system was inaugurated in 2022 in Germany in addition to trauma course concepts in order to focus on the complex treatment of NTCI patients [8,9].\u003c/p\u003e\n\u003cp\u003eIn Denmark, there has been an overall agreement that there was a need for a triggered team response for non-traumatic critically ill patients since 2007. In 2023, a survey showed, that all emergency hospitals used and trained such a team response, though team composition and experience of the staff participating in the trigger calls differs greatly [7]. Nationally, the DEPT triage system is used prehospitally and in most emergency hospitals, and red triage in DEPT for non-traumatic patients triggers a team response [23, DEPT generisk, version 2.0 (deptriage.dk)].\u003c/p\u003e\n\u003cp\u003eIn conclusion, there are differences between the medical systems in Denmark and Germany, though we could show similarities in the epidemiology of critically ill patients in our transnational study.\u003c/p\u003e\n\u003cp\u003eWithin the last years, the heterogenous group of critically ill patients got in the focus of several studies both in Germany and Denmark. While the treatment of trauma patients in the resuscitation room has been under surveillance for many years by large registers [16], there is a lack of data for non-traumatic conditions. Until today, there is no nation-wide register for critically ill patients and non-traumatologic resuscitation room management in Germany. \u003c/p\u003e\n\u003cp\u003eA registry of all acute hospital contacts has been implemented in Denmark and includes a plan for registration of triage level at arrival including read triage as proxy registration for NTIC patients [Database for Akutte Hospitalskontakter, Databasen for Akutte Hospitalskontakter (DAH) - RKKP]. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailable data on epidemiology and outcome of NTCI patients in Germany and Denmark\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the differences in the healthcare systems, the basic diagnostic procedures and invasive interventions in emergency care are largely comparable between Germany and Denmark. According to the ABCDE of resuscitation, B, C and D problems were the main problems in all study centres, while D problems showed a wider range in the studies. With regard to the main problems, differences were found in the various studies: Respiratory problems were rarely found in the German studies, while in Denmark \u0026lsquo;A problems\u0026rsquo; were not recorded and possibly subsumed under the B problems. Within the ten studies, the proportion of B problems varied between 21 and 45%, which could be explained by seasonal effects or the combination of A and B problems in some studies. The C problems were similar in all included studies. An increased mortality rate was found in patients with out-of-hospital cardiac arrest (OHCA). In the Danish registry, OHCA patients could not be identified among the NTCI patients. Their number is probably low, as OHCA patients with suspected STEMI are admitted directly to the cardiac catheter laboratory and bypass the ED.\u003c/p\u003e\n\u003cp\u003eIn Germany, OHCA patients are often stabilised in the resuscitation room, based on the concept of certified cardiac arrest centres. C problems, which include patients with shock, cardiac arrhythmias or aortic emergencies (e.g. aortic dissection), had the highest mortality rate. The incidence of D problems also differed between the study centres. This could be explained by the presence of a neurology department or stroke unit in some participating hospitals. On the other hand, D problems included a large number of emergencies without a neurological cause, highlighting the need for structured resuscitation room management excluding the most common and critical differential diagnoses. \u003c/p\u003e\n\u003cp\u003eE-problems are rarely found in NTCI patients in all study centres. E-problems (E = \u0026lsquo;environment\u0026rsquo;, \u0026lsquo;exposure\u0026rsquo;) can be difficult to define. In the German white paper for NTCI patients [18], E-problems include severe hypo- and hyperthermia, patients with prolonged trauma, metabolic disorders or with a generally critical impression. In the Danish register, E problems are insufficiently recorded and often not registered. The most common emergencies in both countries include neurovascular, cardiovascular and respiratory problems. \u003c/p\u003e\n\u003cp\u003eIn Denmark, there is only one study from a university hospital that describes the epidemiology of all types of critically ill patients, including NTCI patients [6]. This study, published in 2021, compares patients admitted to a university hospital by a trigger team (trauma, NTCI, stroke, STEMI) between November 2012 and October 2015. Due to the organization of the healthcare system, all critically ill patients, regardless of the suspected diagnosis, from the hospital\u0026apos;s catchment area were admitted there, so that a direct comparison of the results is possible.\u003c/p\u003e\n\u003cp\u003eWith a few exceptions, all patients were referred to the activation team by the emergency services. In the catchment area, activation / 100,000 population per year was 339 for NTCI, 160 for trauma, 73 for stroke and 65 for STEMI. These results are consistent with other studies that found a non-trauma to trauma ratio of 4:1, as reported by Vincent et al [24].\u003c/p\u003e\n\u003cp\u003eFocusing on the results of NTCI patients, the 30-day all-cause mortality in Germany was significantly higher (35%) than in Denmark (24%), and almost three times higher than the mortality rate for trauma patients as reported in the German trauma registry (12%, [16]). \u003c/p\u003e\n\u003cp\u003eGerman patients generally stay longer in the ED than Danish patients. The length of stay in the resuscitation room, defined as initial treatment, was between 31\u0026plusmn;22 and 148\u0026plusmn;203 minutes. Overall, there are no major delays in admission to the intensive care unit in Denmark [6]. A major difference between the German and Danish study results is the rate of ICU admission. While most German patients are in a critical condition after initial treatment and up to 80% require treatment in an intensive care unit [25], only 10-20% of the identified red triaged patients were admitted to the intensive care unit in the Danish study centres. \u003c/p\u003e\n\u003cp\u003eThis could be due to the fact that in Denmark most OHCA and out-of-hospital identified STEMI are received at the cardiac catheter unit, and that patients with suspected stroke are admitted directly by the stroke teams in the hospitals\u0026apos; MR scanners, with both patient groups bypassing the EDs. In addition, many of the Danish patient are admitted to special high acuity areas in the EDs where some treatments that are otherwise performed in IMC/ICU departments are performed in the EDs (e.g. treatment with non-invasive ventilation, treatment of ketoacidosis). Historically, there are hardly any IMC units in Denmark but the high acuity areas serve as such. A stay in one of these areas is not registered as an ICU stay in the Danish data, which is in contrast to the German data where a stay in IMC is registered as an ICU stay. The higher rate of admission to the ICU in Germany is probably due to the differences in the healthcare systems and the type of patients admitted to the EDs in the two countries. In Germany, there is a higher density of hospitals, whereas in Denmark, emergency care is more centralized and the focus is more on outpatient services. \u003c/p\u003e\n\u003cp\u003eIn the German study centres, a longer length of stay in the resuscitation room was described, which had a major association with further treatment including ventilation, sedation, catheter management and other interventions. In one study centre, the median treatment time of NTCI patients was 7 hours until admission to the intensive care unit [3]. This fact shows the need for a treatment concept for NTCI patients that goes beyond the initial treatment in the resuscitation room [26,27].\u003c/p\u003e\n\u003cp\u003eThe treatment of OHCA patients is different in both countries, which may have an impact on the mortality rate. In both Germany and Denmark, it is difficult to maintain a consistent team day and night. Due to the longer length of stay in the ED and the limited capacity of the intensive care unit, there is a greater need for an emergency critical care (ECC) concept in Germany for the ongoing treatment of critically ill patients ECC is already established in the United States and other countries, but is coming into focus in Germany due to a lack of intensive care capacity despite of a high number ot total intensive care beds [27]. In general, the prolonged stay of patients ED in the waiting for an ICU bed is not a major problem in Denmark. This seems to be one of the major differences between the German and the Danish cohorts.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study includes data from retrospective and prospective monocentric studies. The observation periods differ between the five German (2014-2021) and the Danish centres (2016-2019) and overlap. Most observation periods were before the start of the Covid-19 pandemic in 2020, but at least one study continued during the pandemic, which could have an impact on treatment outcomes and outcome. In addition, there is a wide range of ED visits, levels of care and catchment areas of those involved. Another limitation could be due to the different structures of hospitals and the public healthcare system in Germany and Denmark. In Germany, there are no nationwide alert criteria for activation of the resuscitation room for NTCI patients, although initial criteria are being introduced there. Finally, the data from the study centres in both countries do not represent the entire national healthcare system, as there are only individual study centres in Germany and only the region of Southern Denmark was included.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNTCI patients make up only a small percentage of ED visits but have a high mortality rate. The most common problems in NTCI patients are respiratory, circulatory and neurological problems. Despite the differences in healthcare systems and geographical location, the study found similar results in German and Danish EDs. There is a need for standardized treatment protocols and registries for NTCI patients in both countries. Further prospective studies should investigate the effectiveness of standardized treatment of NTCI patients. The introduction of standardized alert criteria and registries for NTCI patients in Germany is crucial.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDEPT \u0026ndash;\u0026nbsp;Danish Emergency Process Triage\u003c/p\u003e\n\u003cp\u003eED \u0026ndash; Emergency department\u003c/p\u003e\n\u003cp\u003eEMS \u0026ndash; emergency medical system\u003c/p\u003e\n\u003cp\u003eNTCI \u0026ndash; Non-traumatic critically ill\u003c/p\u003e\n\u003cp\u003eOHCA \u0026ndash; out-of-hospital cardiac arrest\u003c/p\u003e\n\u003cp\u003eIMC \u0026ndash; Intermediate care unit\u003c/p\u003e\n\u003cp\u003eICU \u0026ndash; Intensive care unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e none declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocols for the original works in Germany are documented before by the respective study centers for the original study, with the responsible ethics committees waiving the requirement to obtain consent to participate in each case. In Denmark, ethical approval was deemed unnecessary according to national regulations. Informed consent to participate was obtained from all of the participants in the studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBernhard M, Doll S, Hartwig T, et al. Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study). Eur J Emerg Med. Aug 2018;25(4):e9-e17. doi:10.1097/MEJ.0000000000000543\u003c/li\u003e\n \u003cli\u003eGrahl C, Hartwig T, Weidhase L, et al. Early in-hospital course of critically ill nontrauma patients in a resuscitation room of a German emergency department (OBSERvE2 study). Anaesthesist. Apr 30 2021;Fruher innerklinischer Verlauf kritisch kranker nichttraumatischer Patienten im Schockraum einer deutschen Notaufnahme (OBSERvE2-Studie). doi:10.1007/s00101-021-00962\u003c/li\u003e\n \u003cli\u003eDziegielewski J, Schulte FC, Jung C, et al. Resuscitation room management of patients with non-traumatic critical illness in the emergency department (OBSERvE-DUS-study). BMC Emerg Med. Apr 17 2023;23(1):43. doi:10.1186/s12873-023-00812-y\u003c/li\u003e\n \u003cli\u003eKre\u0026szlig; JS, R\u0026uuml;ppel M, Haake H, Vom Dahl J, Bergrath S. Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department. Anaesthesist. 2022 Jan;71(1):30-37. English. doi: 10.1007/s00101-021-00953-4. Epub 2021 Apr 8. PMID: 33830277.\u003c/li\u003e\n \u003cli\u003eWasser, C., Schmid, N., M\u0026uuml;ller, M. et al. Management of critically ill nontrauma patients in a nonuniversity emergency department. Notfall Rettungsmed (2022). https://doi.org/10.1007/s10049-022-01027-7\u003c/li\u003e\n \u003cli\u003ePosth S, Froberg L, Bak S, Jensen LO, Brabrand M, Lassen A. Trigger team activation in the emergency department at a tertiary university hospital. Dan Med J 2021;68(11)doi:A04210317\u003c/li\u003e\n \u003cli\u003eBrink E, Jakobsen TS, Lassen AT, Weile J, Posth S. Management of medical emergency patients in Danish emergency departments. Danish Medical Journal. 2023;70(9)\u003c/li\u003e\n \u003cli\u003eMichael M, Biermann H, Gr\u0026ouml;ning I et al (2022) Development of the interdisciplinary and interprofessional course concept \u0026ldquo;advanced critical illness life support\u0026rdquo;. FrontMed 9:939187. https://doi.org/10.3389/fmed.2022.939187\u003c/li\u003e\n \u003cli\u003eMichael, M., Biermann, H., Gr\u0026ouml;ning, I. et al. ACiLS \u0026ndash; das Ausbildungskonzept f\u0026uuml;r die nichttraumatologische Schockraumversorgung. Notfall Rettungsmed 26, 493\u0026ndash;500 (2023). https://doi.org/10.1007/s10049-023-01228-8\u003c/li\u003e\n \u003cli\u003eDatabase for Akutte Hospitalskontakter, https://www.sundhed.dk/sundhedsfaglig/kvalitet/kliniske-kvalitetsdatabaser/akutte-sygdomme/databasen-for-akutte-hospitalskontakter/\u003c/li\u003e\n \u003cli\u003eArvig MD, Mogensen CB, Skj\u0026oslash;t-Arkil H, Johansen IS, Rosenvinge FS, Lassen AT Chief Complaints, Underlying Diagnoses, and Mortality in Adult, Non-trauma Emergency Department Visits: A Population-based, Multicenter Cohort Study West J Emerg Med. 2022 Oct 31;23(6):855-863. doi: 10.5811/westjem.2022.9.56332.PMID: 36409936\u003c/li\u003e\n \u003cli\u003e\u0026Aring;rsrapport for akutte hospitalskontakter https://www.sundk.dk/media/u3qc2scp/dah_aarsrapport-2024.pdf\u003c/li\u003e\n \u003cli\u003e13.Regelungen des Gemeinsamen Bundesausschusses zu einem gestuften System von Notfallstrukturen in Krankenh\u0026auml;usern gem\u0026auml;\u0026szlig; \u0026sect; 136c Absatz 4 des F\u0026uuml;nften Buches im Sozialgesetzbuch (SGB V), in der Fassung vom 19. April 2018 ver\u0026ouml;ffentlicht im Bundesanzeiger BAnzAT 18.05.2018 B4 in Kraft getreten am 19. Mai 2018\u003c/li\u003e\n \u003cli\u003eMikkelsen S, Lassen AT. The Danish prehospital system. Eur J Emerg Med. 2020 Dec;27(6):394-395. doi: 10.1097/MEJ.0000000000000774. PMID: 33105290.\u003c/li\u003e\n \u003cli\u003eWei\u0026szlig;buch Schwerverletztenversorgung. Empfehlungen zur Struktur, Organisation, Ausstattung sowie F\u0026ouml;rderung von Qualit\u0026auml;t und Sicherheit in der Schwerverletztenversorgung in der Bundesrepublik Deutschland. 3. Auflage 2019, www.auc-online.de/fileadmin/AUC/Dokumente/Zertifizierung/TraumaNetzwerk_DGU/dgu-weissbuch_schwerverletztenversorgung_2020_3._Auflage.pdf\u003c/li\u003e\n \u003cli\u003eTraumaRegister DGU\u0026reg;, Allgemeiner Jahresbericht 2023 Sektion NIS der DGU, AUC 2 Jahresbericht 2023 - TraumaRegister DGU\u0026reg; f\u0026uuml;r das Unfalljahr 2022, online access on 25/04/2024: www.auc-online.de/fileadmin/AUC/Dokumente/Register/TraumaRegister_DGU/TR-DGU-Jahresbericht_2023a.pdf\u003c/li\u003e\n \u003cli\u003eDeutsche Gesellschaft f\u0026uuml;r Unfallchirurgie (2023) S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung. https://register.awmf.org/assets/guidelines/187-023k_S3_Polytrauma-Schwerverletzten-Behandlung_2023-06.pdf\u003c/li\u003e\n \u003cli\u003eBernhard M, Kumle B, Dodt C et al (2022) Versorgung kritisch kranker, nicht-traumatologischer Patienten im Schockraum. Notfall Rettungsmed 25(Suppl 1):1\u0026ndash;14 https://doi.org/10.1007/s10049-022-00997-y\u003c/li\u003e\n \u003cli\u003eRovas A, Paracikoglu E, Michael, M. et al. Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study. Scand J Trauma Resusc Emerg Med 29, 160 (2021). https://doi.org/10.1186/s13049-021-00973-4\u003c/li\u003e\n \u003cli\u003eK\u0026ouml;hnke R, Rovas A, de Goede E et al. Alarmierungskriterien f\u0026uuml;r den nichttraumatologischen Schockraum \u0026ndash; erstes Res\u0026uuml;mee nach Einf\u0026uuml;hrung definitiver Kriterien (V\u003csub\u003e2\u003c/sub\u003eiSiOn-Kriterien) in M\u0026uuml;nster. Notfall Rettungsmed 26, 482\u0026ndash;492 (2023). https://doi.org/10.1007/s10049-023-01227-9\u003c/li\u003e\n \u003cli\u003eMichael M, Bax S, Finke M et al (2022) Aktuelle IST-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland. Notfall Rettungsmed 25:107\u0026ndash;115\u003c/li\u003e\n \u003cli\u003eGr\u0026ouml;ning I, Hoffmann F, Biermann H et al (2022) Das (PR_E-)AUD2IT-Schema als R\u0026uuml;ckgrat fur eine strukturierte Notfallversorgung und Dokumentation nichttraumatologischer kritisch kranker Schockraumpatienten. Notfall Rettungsmedizin 25:491\u0026ndash;498\u003c/li\u003e\n \u003cli\u003eDEPT, DEPT generisk, version 2.0 (deptriage.dk)\u003c/li\u003e\n \u003cli\u003ePiagnerelli M, Van Nuffelen M, Maetens Y, Lheureux P, Vincent JL. A \u0026apos;shock room\u0026apos; for early management of the acutely ill. Anaesth Intensive Care. 2009 May;37(3):426-31. doi: 10.1177/0310057X0903700307. PMID: 19499862.\u003c/li\u003e\n \u003cli\u003eBernhard, M., Kumle, B., Wasser, C. et al. Epidemiologie, Hintergr\u0026uuml;nde, Zahlen und Fakten zum nichttraumatologischen Schockraummanagement kritisch kranker Patienten. Notfall Rettungsmed 26, 473\u0026ndash;481 (2023). https://doi.org/10.1007/s10049-023-01195-0 23.\u003c/li\u003e\n \u003cli\u003eKemper, J.J., Michael, M., K\u0026uuml;mpers, P. et al. Grundlagen des notfallmedizinischen \u0026bdquo;Bridgings\u0026ldquo; von kritisch kranken Patienten in der Notaufnahme bis zur Intensivstationsverlegung. Notfall Rettungsmed (2024). https://doi.org/10.1007/s10049-023-01276-0\u003c/li\u003e\n \u003cli\u003eReindl, M., Rovas, A., K\u0026ouml;hnke, R. et al. \u0026bdquo;Emergency critical care\u0026ldquo; in der Notaufnahme. Literatur\u0026uuml;bersicht und aktuelle Konzepte. Notfall Rettungsmed (2024). https://doi.org/10.1007/s10049-024-01309-2\u003c/li\u003e\n \u003cli\u003eSchmidt M, Pedersen L, S\u0026oslash;rensen HT. The Danish Civil Registration System as a tool in epidemiology. Eur J Epidemiol. 2014;29(8):541\u0026ndash;9\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eFurther references:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ehttps://www.sundk.dk/media/q14d1yqh/dtr_aarsrapport_2025_offentlig-version-30102025.pdf\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"resuscitation room management, critically ill patients, alarm criteria, ABCDE","lastPublishedDoi":"10.21203/rs.3.rs-8976194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8976194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and importance\u003c/strong\u003e: In contrast to trauma care, evidence on the epidemiology and outcomes of non-traumatic critically ill (NTCI) patients admitted to emergency departments (EDs) remains limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e: This study examined the epidemiology, incidence and outcomes of NTCI patients in nine German and Danish EDs using a shared transnational research approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e: Data from adult NTCI patients across four German centres (2014–2021) were pooled and compared with data from patients triaged as the most urgent level (red in Danish Emergency Process Triage) in five EDs in Southern Denmark (2016–2018).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain results\u003c/strong\u003e: Altogether, 408,673 Danish and 174,306 German ED admissions were analysed. In Denmark, 1.4% of ED admissions (range 0.7–2.0%) involved non-traumatic critical illness, similar to 1.6% (range 0.5–1.6%) in Germany. Mean patient age was 63–70 years, with 51–60% male across sites. Most patients presented with acute breathing (B) problems (21.7–45.8%), circulation (C) problems (31.2–47.4%), or disability (D) problems (11.3–41.2%). Admission rates to intensive or intermediate care were markedly higher in German centres (76.0–85.5%) compared with Danish sites (9.3–20.0%). Thirty-day mortality was also higher in Germany (31.6%) than in Denmark (26.5%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Approximately 1.4% of all ED patients required care for non-traumatic critical illness, most commonly presenting with acute breathing, circulation, or neurological impairment. These patients show high mortality and substantial need for advanced in-hospital care, underlining the need for targeted clinical pathways. Differences between German and Danish centres, particularly in admission strategies and mortality, highlight the necessity for standardized 24/7 management and future research on organizational factors and optimal treatment pathways for NTCI patients.\u003c/p\u003e","manuscriptTitle":"Epidemiology and Outcome of Non-traumatic critically ill patients treated in Resuscitation rooms in German and Danish Emergency Departments (EpiDanGer study) – a shared, transnational research approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 15:40:18","doi":"10.21203/rs.3.rs-8976194/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"101324620897808214002923960164721173321","date":"2026-04-26T12:27:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T09:45:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288544011964149819809110451993440199615","date":"2026-04-16T14:09:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T13:22:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-27T10:22:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-27T10:21:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2026-02-26T09:27:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0cf86a63-602a-4e35-8f6d-6baa612616f1","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T15:40:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 15:40:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8976194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8976194","identity":"rs-8976194","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}