Patients with cheiro-oral syndrome(COS) often present with minor perioral and upper extremity sensory disturbances,which can be easily overlooked in busy emergency departments(EDs).^([1]) COS,a rare spectrum of stroke...Patients with cheiro-oral syndrome(COS) often present with minor perioral and upper extremity sensory disturbances,which can be easily overlooked in busy emergency departments(EDs).^([1]) COS,a rare spectrum of stroke syndromes,necessitates expeditious and aggressive modification of risk factors.展开更多
BACKGROUND:Sepsis is one of the main causes of mortality in intensive care units(ICUs).Early prediction is critical for reducing injury.As approximately 36%of sepsis occur within 24 h after emergency department(ED)adm...BACKGROUND:Sepsis is one of the main causes of mortality in intensive care units(ICUs).Early prediction is critical for reducing injury.As approximately 36%of sepsis occur within 24 h after emergency department(ED)admission in Medical Information Mart for Intensive Care(MIMIC-IV),a prediction system for the ED triage stage would be helpful.Previous methods such as the quick Sequential Organ Failure Assessment(qSOFA)are more suitable for screening than for prediction in the ED,and we aimed to fi nd a light-weight,convenient prediction method through machine learning.METHODS:We accessed the MIMIC-IV for sepsis patient data in the EDs.Our dataset comprised demographic information,vital signs,and synthetic features.Extreme Gradient Boosting(XGBoost)was used to predict the risk of developing sepsis within 24 h after ED admission.Additionally,SHapley Additive exPlanations(SHAP)was employed to provide a comprehensive interpretation of the model's results.Ten percent of the patients were randomly selected as the testing set,while the remaining patients were used for training with 10-fold cross-validation.RESULTS:For 10-fold cross-validation on 14,957 samples,we reached an accuracy of 84.1%±0.3%and an area under the receiver operating characteristic(ROC)curve of 0.92±0.02.The model achieved similar performance on the testing set of 1,662 patients.SHAP values showed that the fi ve most important features were acuity,arrival transportation,age,shock index,and respiratory rate.CONCLUSION:Machine learning models such as XGBoost may be used for sepsis prediction using only a small amount of data conveniently collected in the ED triage stage.This may help reduce workload in the ED and warn medical workers against the risk of sepsis in advance.展开更多
BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We per...BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points.RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.展开更多
BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gather...BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gathered from the National Hospital Ambulatory Medical Care Survey(NHAMCS) from 2007 to 2018.The study population included individuals of all ages presenting to USA EDs.The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain.The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.RESULTS:There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007(244,000 visits) to 2018(92,000 visits).The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older(from 43.8% to 57.6%),female patients(from 54.5% to 62.0%),black patients(from 22.5% to 30.4%),and Hispanic/Latino patients(from 9.4% to 19.6%).Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007,with a decrease to 68.5% in 2018.Pure oxycodone was the second most prescribed medication,accounting for 6.1% in 2007 and 31.5% in 2018.CONCLUSION:The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018.However,that number trended upward in 45-year-old and older,female,black,or Hispanic/Latino patients from 2007 to 2018.The total amount of pure oxycodone increased significantly from 2007 to 2008.展开更多
BACKGROUND: Emergencies such as road traffic accidents(RTAs), acute myocardial infarction(AMI) and cerebrovascular accident(CVA) are the most common causes of death and disability in India. Robust emergency medicine(E...BACKGROUND: Emergencies such as road traffic accidents(RTAs), acute myocardial infarction(AMI) and cerebrovascular accident(CVA) are the most common causes of death and disability in India. Robust emergency medicine(EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department(ED) is needed.METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences(KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35%(n=662) were male and 44.7%(n=534) were female. The majority(67.14%, n=803) were adults, while only 3.85%(n=46) were infants. The most common chief complaints were fever(21.5%, n=257), renal colic(7.3%, n=87), and dyspnea(6.9%, n=82). The most common ED diagnoses were gastrointestinal(15.5%, n=185), pulmonary(12.3%, n=147), tropical(11.1%, n=133), infectious disease and sepsis(9.9%, n=118), and trauma(8.4%, n=101).CONCLUSION: The patient demographics, diagnoses, and distribution of resources identifi ed by this study can help guide and shape Indian EM training programs and faculty development to more accurately refl ect the burden of acute disease in India.展开更多
BACKGROUND:Since demographic changes have contributed to the growth of emergency medicine,a highly populous nation such as India needs to give physicians associated due credit and recognition.The management of knowled...BACKGROUND:Since demographic changes have contributed to the growth of emergency medicine,a highly populous nation such as India needs to give physicians associated due credit and recognition.The management of knowledge source must also be conducted with due care as the work environment is completely different from that of any other clinicians.METHODS:The data were collected by direct interaction with residents of the department.Additional information was gathered by observation.The data were verified for validity.RESULTS:This study was to bring out the benefits of proactive decisions that could further enhance the emergency department.But such decisions did not always result in positive responses and improved morale.When such decisions were retracted as it causes misalignment with the existing system.An academic emergency department was expected and physicians should enrich their knowledge about emergency medicine.CONCLUSIONS:The problems faced by emergency department might be similar but the way in which one tackles the situation would be different.Decision making in this hospital may not be the best but it would've been the optimum one given the conditions available.展开更多
BACKGROUND: Emergency medical service system (EMSS) in China is becoming more important. However, studies on mortality of emergency departments (EDs) patients in tertiary hospitals and on the trends in mortality of ED...BACKGROUND: Emergency medical service system (EMSS) in China is becoming more important. However, studies on mortality of emergency departments (EDs) patients in tertiary hospitals and on the trends in mortality of ED patients all over China are stagnant. The objective of this study was to quantify and describe the trends in mortality of ED patients in China. METHODS: Nine tertiary teaching hospitals were selected from tertiary teaching hospitals in different regions. The annual numbers of ED visits and deaths of these hospitals in 2004, 2009 and 2014 were recorded and analyzed. Chi-square test was used to compare the mortality of the EDs’ visits. Moreover, data on the mortality of ED patients in China from 2005 to 2015 were summarized and analyzed from the China Health and Family Planning Statistical Yearbooks (2006–2016). RESULTS: From 2004 to 2014, the overall annual mortalities in EDs increased among the tertiary hospitals (P<0.001). However, the overall annual mortality in EDs all over China decreased from 0.12% in 2005 to 0.08% in 2015. And the mortalities of EDs patients in the eastern, central and western regions of China all decreased. In addition, the average mortality of EDs patients in northern China was obviously higher than that in southern China (P<0.05). CONCLUSION: The ED mortality was increased in tertiary hospitals while decreased all over China during the past decade, which may be partly caused by some critical challenges faced by China’s EMSS, such as overcrowding and long length of stay in EDs of tertiary hospitals.展开更多
BACKGROUND:Consenting to do-not-resuscitate(DNR)orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments(EDs).The DNR decision in EDs ...BACKGROUND:Consenting to do-not-resuscitate(DNR)orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments(EDs).The DNR decision in EDs has not been extensively studied,especially in the Chinese mainland.METHODS:This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019.The patients with out-of-hospital cardiac arrest were excluded.RESULTS:There were 214 patients’deaths in the ED in the three years.Among them,132 patients were included in this study,whereas 82 with out-of-hospital cardiac arrest were excluded.There were 99(75.0%)patients’deaths after a DNR order medical decision,64(64.6%)patients signed the orders within 24 hours of the ED admission,68(68.7%)patients died within 24 hours after signing it,and 97(98.0%)patients had DNR signed by the family surrogates.Multivariate analysis showed that four independent factors infl uenced the family surrogates’decisions to sign the DNR orders:lack of referral(odds ratio[OR]0.157,95%confi dence interval[CI]0.047–0.529,P=0.003),ED length of stay(ED LOS)≥72 hours(OR 5.889,95%CI 1.290–26.885,P=0.022),acute myocardial infarction(AMI)(OR 0.017,95%CI 0.001–0.279,P=0.004),and tracheal intubation(OR 0.028,95%CI 0.007–0.120,P<0.001).CONCLUSIONS:In the Chinese mainland,the proportion of patients consenting for DNR order is lower than that of developed countries.The decision to sign DNR orders is mainly affected by referral,ED LOS,AMI,and trachea intubation.展开更多
BACKGROUND:To evaluate the accuracy of National Early Warning Score(NEWS)in predicting clinical outcomes(28-day mortality,intensive care unit[ICU]admission,and mechanical ventilation use)for septic patients with commu...BACKGROUND:To evaluate the accuracy of National Early Warning Score(NEWS)in predicting clinical outcomes(28-day mortality,intensive care unit[ICU]admission,and mechanical ventilation use)for septic patients with community-acquired pneumonia(CAP)compared with other commonly used severity scores(CURB65,Pneumonia Severity Index[PSI],Sequential Organ Failure Assessment[SOFA],quick SOFA[qSOFA],and Mortality in Emergency Department Sepsis[MEDS])and admission lactate level.METHODS:Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA≥2 from baseline were enrolled.Demographic characteristics were collected.The primary outcome was the 28-day mortality after admission,and the secondary outcome included ICU admission and mechanical ventilation use.Outcome prediction value of parameters above was compared using receiver operating characteristics(ROC)curves.Cox regression analyses were carried out to determine the risk factors for the 28-day mortality.Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.RESULTS:Among the 340 enrolled patients,90 patients were dead after a 28-day follow-up,62 patients were admitted to ICU,and 84 patients underwent mechanical ventilation.Among single predictors,NEWS achieved the largest area under the receiver operating characteristic(AUROC)curve in predicting the 28-day mortality(0.861),ICU admission(0.895),and use of mechanical ventilation(0.873).NEWS+lactate,similar to MEDS+lactate,outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality(AUROC 0.866)and ICU admission(AUROC 0.905),while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation(AUROC 0.886).Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.CONCLUSIONS:NEWS could be a valuable predictor in septic patients with CAP in emergency departments.Admission lactate did not predict well the outcomes or improve the severity scores.A qSOFA≥2 and a NEWS≥9 were strongly associated with the 28-day mortality,ICU admission,and mechanical ventilation of septic patients with CAP in the emergency departments.展开更多
BACKGROUND: To evaluate the utilization of point-of-care ultrasound(POCUS) for the assessment of emergency department(ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decis...BACKGROUND: To evaluate the utilization of point-of-care ultrasound(POCUS) for the assessment of emergency department(ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED. RESULTS: A total of 264 subjects(92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the fi nal analysis. Most common symptomatic sites were knee(31.8%) and ankle(16.3%). Joint effusion was the most common fi nding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them(73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records.CONCLUSION: Our study fi ndings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.展开更多
BACKGROUND： Emergency physicians frequently encounter patients with acute small bowel obstructions （SBO）. Although computed tomography （CT） imaging is the current gold standard in the assessment of patients with ...BACKGROUND： Emergency physicians frequently encounter patients with acute small bowel obstructions （SBO）. Although computed tomography （CT） imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS： We evaluated the accuracy of ultrasound performed in the ED by a variety of providers （physicians with various levels of training, physician assistants） compared to CT imaging in 47 patients with suspected SBOs. RESULTS： Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION： Ultrasound can play an important role in the identification of small bowe obstructions in ED patients.展开更多
BACKGROUND:This study was undertaken to validate the use of the modified early warning score(MEWS) as a predictor of patient mortality and intensive care unit(ICU)/ high dependency(HD)admission in an Asian population....BACKGROUND:This study was undertaken to validate the use of the modified early warning score(MEWS) as a predictor of patient mortality and intensive care unit(ICU)/ high dependency(HD)admission in an Asian population.METHODS:The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department(ED) between November 2006 and December2007.Individual MEWS was calculated based on vital signs parameters on arrival at ED.Outcomes of mortality and ICU/HD admission were obtained from hospital records.The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed.Sensitivity,specificity,positive and negative predictive values were derived and compared with values from other cohorts.A MEWS of ≥4 was chosen as the cut-off value for poor prognosis based on previous studies.RESULTS:A total of 311(30.4%) critically ill patients were presented with a MEWS ≥4.Their mean age was 61.4 years(SD 18.1) with a male to female ratio of 1.10.Of the 311 patients,53(17%)died within 30 days,64(20.6%) were admitted to ICU and 86(27.7%) were admitted to HD.The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0%and a specificity of 72.1%in addition to a positive predictive value(PPV) of 17.0%and a negative predictive value(NPV)of 93.4%(MEWS cut-off of ≥4) for predicting mortality.CONCLUSION:The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.展开更多
BACKGROUND: Harmless acute pancreatitis score(HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width(RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute panc...BACKGROUND: Harmless acute pancreatitis score(HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width(RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department(ED).METHODS: Patients diagnosed with acute pancreatitis(K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography(CT) in the ED were not included in the study.RESULTS: Ultimately, 322 patients were included in the study. The median age of the patients was 53.1(IQR=36–64). Of the patients, 68.1%(n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3%(n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification(OR: 15; 95% CI: 3.5 to 64.4).CONCLUSIONS: HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classifi cation.展开更多
BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifica...BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS: The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association(AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council(ERC) guidelines for resuscitation, and the 2013 American College of Surgeons(ACS) Advanced Trauma Life Support(ATLS) 9 th edition.RESULTS: There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION: Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.展开更多
BACKGROUND: Timely identifi cation of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care(POC) testing is being increasingly utili...BACKGROUND: Timely identifi cation of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care(POC) testing is being increasingly utilized in the emergency department(ED). We examined the accuracy and timesaving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fi ngertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation(ICC) and Bland and Altman plots.RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method(ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method(ICC=0.95 & ICC=0.97, respectively).CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.KEY WORDS: Sepsis; Point of care; Lactate; Emergency department;展开更多
BACKGROUND： The purpose of triage is to identify patients needing immediate resuscitation, toassign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures asappropriate. This st...BACKGROUND： The purpose of triage is to identify patients needing immediate resuscitation, toassign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures asappropriate. This study aimed to use emergency severity index （ESI） in a pediatric emergency room.METHODS： From July 2006 to August 2010, a total of 21 904 patients visited the InternationalDepartment of Beijing Children＇s Hospital. The ESI was measured by nurses and physicians, andcompared using SPSS.RESULTS： Nurses of the hospital took approximately 2 minutes for triage. The results of triagemade by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This findingindicated that the nurses are able to identify severe pediatric cases.CONCLUSION： In pediatric emergency rooms, ESI is a suitable tool for identifying severecases and then immediate interventions can be performed accordingly.展开更多
BACKGROUND: We aimed to explore the impact of the emergency department length of stay(EDLOS) on the outcome of trauma patients.METHODS: A retrospective study was conducted on all trauma patients requiring hospitalizat...BACKGROUND: We aimed to explore the impact of the emergency department length of stay(EDLOS) on the outcome of trauma patients.METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS(<4 h, 4–12 h,12–24 h, and >24 h). Data were analyzed using Chi-square test(categorical variables), Student’s t-test(continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality.RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. Onefifth of patients had a short EDLOS(<4 h) and had higher level trauma team T1 activation(TTA-1), higher Injury Severity Score(ISS), higher shock index(SI), and more head injuries than the other groups(P=0.001). Patients with an EDLOS >24 h were older(P=0.001) and had more comorbidities(P=0.001) and fewer deaths(P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1(odds ratio [OR]=4.081, 95%CI: 2.364–7.045), head injury(OR=3.920, 95%CI: 2.413–6.368), blood transfusion(OR=2.773, 95%CI: 1.668–4.609), SI(OR=2.132, 95%CI: 1.364–3.332), ISS(OR=1.077, 95%CI: 1.057–1.096), and age(OR=1.040, 95%CI: 1.026–1.054). CONCLUSIONS: Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes;however, the burden of prolonged boarding in the ED needs further elaboration.展开更多
BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage syst...BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.METHODS: This was a prospective observational study. This study was divided into two phases. The fi rst phase determined the inter-rater reliability of fi ve triage systems: Manchester Triage System(MTS), Emergency Severity Index(ESI) version 4, Pediatric Canadian Triage and Acuity Scale(CTAS), Australasian Triage Scale(ATS), and Ramathibodi Triage System(RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients(triage level 1, 2) and low acuity patients(triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0(P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8–0.9(P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5–0.7(P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123(11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specifi city of 81%, and AUC 0.78(95%CI 0.74–0.81).CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.展开更多
BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach ...BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to(1) evaluate the current patient flow in ED,(2) to identify and eliminate the non-valued added process, and(3) to modify the existing process.METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage(PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T(hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed(38.24 minutes; SD 66.35) and blood testing result(mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward(EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program(P<0.05).CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.展开更多
BACKGROUND： Altered mental status （AMS） is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly ...BACKGROUND： Altered mental status （AMS） is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of AMS patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management.METHODS： This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months （June 2009 to June 2011）. Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected prospectively.RESULTS： In 1934 patients with AMS recruited, accounting for 0.93% of all emergency department （ED） patients, 1 026 （53.1%） were male, and 908 （46.9%） female. Their average age was 51.95±15.71 years. Etiologic factors were neurological （n=641; 35.0%）, pharmacological and toxicological （n=421; 23.0%）, systemic and organic （n=266; 14.5%）, infectious （n=167; 9.1%）, endocrine/metabolic （n=145; 7.9%）, psychiatric （n=71; 3.9%）, traumatic （n=38; 2.1%）, and gynecologic and obstetric （n=35; 1.9%）. Total mortality rate was 8.1% （n=156）. The death rate was higher in elderly patients （≥60） than in younger patients （10.8% vs. 6.9%, P=-0.003）.CONCLUSION： Patients with AMS pose a challenge for ED physicians. The most frequently encountered diagnostic categories causing AMS were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. AMS has a high fatality rate in the ED. AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.展开更多
文摘Patients with cheiro-oral syndrome(COS) often present with minor perioral and upper extremity sensory disturbances,which can be easily overlooked in busy emergency departments(EDs).^([1]) COS,a rare spectrum of stroke syndromes,necessitates expeditious and aggressive modification of risk factors.
基金supported by the National Key Research and Development Program of China(2021YFC2500803)the CAMS Innovation Fund for Medical Sciences(2021-I2M-1-056).
文摘BACKGROUND:Sepsis is one of the main causes of mortality in intensive care units(ICUs).Early prediction is critical for reducing injury.As approximately 36%of sepsis occur within 24 h after emergency department(ED)admission in Medical Information Mart for Intensive Care(MIMIC-IV),a prediction system for the ED triage stage would be helpful.Previous methods such as the quick Sequential Organ Failure Assessment(qSOFA)are more suitable for screening than for prediction in the ED,and we aimed to fi nd a light-weight,convenient prediction method through machine learning.METHODS:We accessed the MIMIC-IV for sepsis patient data in the EDs.Our dataset comprised demographic information,vital signs,and synthetic features.Extreme Gradient Boosting(XGBoost)was used to predict the risk of developing sepsis within 24 h after ED admission.Additionally,SHapley Additive exPlanations(SHAP)was employed to provide a comprehensive interpretation of the model's results.Ten percent of the patients were randomly selected as the testing set,while the remaining patients were used for training with 10-fold cross-validation.RESULTS:For 10-fold cross-validation on 14,957 samples,we reached an accuracy of 84.1%±0.3%and an area under the receiver operating characteristic(ROC)curve of 0.92±0.02.The model achieved similar performance on the testing set of 1,662 patients.SHAP values showed that the fi ve most important features were acuity,arrival transportation,age,shock index,and respiratory rate.CONCLUSION:Machine learning models such as XGBoost may be used for sepsis prediction using only a small amount of data conveniently collected in the ED triage stage.This may help reduce workload in the ED and warn medical workers against the risk of sepsis in advance.
基金supported by the Health and Medical Research Fund of the Food and Health Bureau of the Hong Kong Special Administrative Region(Project No.19201161)Seed Fund from the University of Hong Kong.
文摘BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points.RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.
文摘BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gathered from the National Hospital Ambulatory Medical Care Survey(NHAMCS) from 2007 to 2018.The study population included individuals of all ages presenting to USA EDs.The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain.The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.RESULTS:There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007(244,000 visits) to 2018(92,000 visits).The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older(from 43.8% to 57.6%),female patients(from 54.5% to 62.0%),black patients(from 22.5% to 30.4%),and Hispanic/Latino patients(from 9.4% to 19.6%).Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007,with a decrease to 68.5% in 2018.Pure oxycodone was the second most prescribed medication,accounting for 6.1% in 2007 and 31.5% in 2018.CONCLUSION:The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018.However,that number trended upward in 45-year-old and older,female,black,or Hispanic/Latino patients from 2007 to 2018.The total amount of pure oxycodone increased significantly from 2007 to 2008.
文摘BACKGROUND: Emergencies such as road traffic accidents(RTAs), acute myocardial infarction(AMI) and cerebrovascular accident(CVA) are the most common causes of death and disability in India. Robust emergency medicine(EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department(ED) is needed.METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences(KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35%(n=662) were male and 44.7%(n=534) were female. The majority(67.14%, n=803) were adults, while only 3.85%(n=46) were infants. The most common chief complaints were fever(21.5%, n=257), renal colic(7.3%, n=87), and dyspnea(6.9%, n=82). The most common ED diagnoses were gastrointestinal(15.5%, n=185), pulmonary(12.3%, n=147), tropical(11.1%, n=133), infectious disease and sepsis(9.9%, n=118), and trauma(8.4%, n=101).CONCLUSION: The patient demographics, diagnoses, and distribution of resources identifi ed by this study can help guide and shape Indian EM training programs and faculty development to more accurately refl ect the burden of acute disease in India.
文摘BACKGROUND:Since demographic changes have contributed to the growth of emergency medicine,a highly populous nation such as India needs to give physicians associated due credit and recognition.The management of knowledge source must also be conducted with due care as the work environment is completely different from that of any other clinicians.METHODS:The data were collected by direct interaction with residents of the department.Additional information was gathered by observation.The data were verified for validity.RESULTS:This study was to bring out the benefits of proactive decisions that could further enhance the emergency department.But such decisions did not always result in positive responses and improved morale.When such decisions were retracted as it causes misalignment with the existing system.An academic emergency department was expected and physicians should enrich their knowledge about emergency medicine.CONCLUSIONS:The problems faced by emergency department might be similar but the way in which one tackles the situation would be different.Decision making in this hospital may not be the best but it would've been the optimum one given the conditions available.
基金supported by National Key R&D Program of China(2017YFC0908700,2017YFC0908703,2018FY100600)Taishan Scholar Climbing Program of Shandong Province(tspd20181220)+5 种基金Taishan Young Scholar Program of Shandong Province(tsqn20161065)Fundamental Research Funds of Shandong University(2014QLKY04)National Natural Science Foundation of China(81601717,81571934,81570401,81772036,81671952)China Postdoctoral Science Foundation(2016M602149)the Natural Science Foundation of Shandong Province(BS2014YY032)the Key R&D Program of Shandong Province(2017G006013,2016GSF201235,2016ZDJS07A14,2018GSF118003)
文摘BACKGROUND: Emergency medical service system (EMSS) in China is becoming more important. However, studies on mortality of emergency departments (EDs) patients in tertiary hospitals and on the trends in mortality of ED patients all over China are stagnant. The objective of this study was to quantify and describe the trends in mortality of ED patients in China. METHODS: Nine tertiary teaching hospitals were selected from tertiary teaching hospitals in different regions. The annual numbers of ED visits and deaths of these hospitals in 2004, 2009 and 2014 were recorded and analyzed. Chi-square test was used to compare the mortality of the EDs’ visits. Moreover, data on the mortality of ED patients in China from 2005 to 2015 were summarized and analyzed from the China Health and Family Planning Statistical Yearbooks (2006–2016). RESULTS: From 2004 to 2014, the overall annual mortalities in EDs increased among the tertiary hospitals (P<0.001). However, the overall annual mortality in EDs all over China decreased from 0.12% in 2005 to 0.08% in 2015. And the mortalities of EDs patients in the eastern, central and western regions of China all decreased. In addition, the average mortality of EDs patients in northern China was obviously higher than that in southern China (P<0.05). CONCLUSION: The ED mortality was increased in tertiary hospitals while decreased all over China during the past decade, which may be partly caused by some critical challenges faced by China’s EMSS, such as overcrowding and long length of stay in EDs of tertiary hospitals.
基金The study protocol was reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Zhejiang University School of Medicine(IRB number:IR2020001036).
文摘BACKGROUND:Consenting to do-not-resuscitate(DNR)orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments(EDs).The DNR decision in EDs has not been extensively studied,especially in the Chinese mainland.METHODS:This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019.The patients with out-of-hospital cardiac arrest were excluded.RESULTS:There were 214 patients’deaths in the ED in the three years.Among them,132 patients were included in this study,whereas 82 with out-of-hospital cardiac arrest were excluded.There were 99(75.0%)patients’deaths after a DNR order medical decision,64(64.6%)patients signed the orders within 24 hours of the ED admission,68(68.7%)patients died within 24 hours after signing it,and 97(98.0%)patients had DNR signed by the family surrogates.Multivariate analysis showed that four independent factors infl uenced the family surrogates’decisions to sign the DNR orders:lack of referral(odds ratio[OR]0.157,95%confi dence interval[CI]0.047–0.529,P=0.003),ED length of stay(ED LOS)≥72 hours(OR 5.889,95%CI 1.290–26.885,P=0.022),acute myocardial infarction(AMI)(OR 0.017,95%CI 0.001–0.279,P=0.004),and tracheal intubation(OR 0.028,95%CI 0.007–0.120,P<0.001).CONCLUSIONS:In the Chinese mainland,the proportion of patients consenting for DNR order is lower than that of developed countries.The decision to sign DNR orders is mainly affected by referral,ED LOS,AMI,and trachea intubation.
基金Capital Clinical Characteristic Application Research of Beijing Municipal Science & Technology Commission (Z171100001017057).
文摘BACKGROUND:To evaluate the accuracy of National Early Warning Score(NEWS)in predicting clinical outcomes(28-day mortality,intensive care unit[ICU]admission,and mechanical ventilation use)for septic patients with community-acquired pneumonia(CAP)compared with other commonly used severity scores(CURB65,Pneumonia Severity Index[PSI],Sequential Organ Failure Assessment[SOFA],quick SOFA[qSOFA],and Mortality in Emergency Department Sepsis[MEDS])and admission lactate level.METHODS:Adult patients diagnosed with CAP admitted between January 2017 and May 2019 with admission SOFA≥2 from baseline were enrolled.Demographic characteristics were collected.The primary outcome was the 28-day mortality after admission,and the secondary outcome included ICU admission and mechanical ventilation use.Outcome prediction value of parameters above was compared using receiver operating characteristics(ROC)curves.Cox regression analyses were carried out to determine the risk factors for the 28-day mortality.Kaplan-Meier survival curves were plotted and compared using optimal cut-off values of qSOFA and NEWS.RESULTS:Among the 340 enrolled patients,90 patients were dead after a 28-day follow-up,62 patients were admitted to ICU,and 84 patients underwent mechanical ventilation.Among single predictors,NEWS achieved the largest area under the receiver operating characteristic(AUROC)curve in predicting the 28-day mortality(0.861),ICU admission(0.895),and use of mechanical ventilation(0.873).NEWS+lactate,similar to MEDS+lactate,outperformed other combinations of severity score and admission lactate in predicting the 28-day mortality(AUROC 0.866)and ICU admission(AUROC 0.905),while NEWS+lactate did not outperform other combinations in predicting mechanical ventilation(AUROC 0.886).Admission lactate only improved the predicting performance of CURB65 and qSOFA in predicting the 28-day mortality and ICU admission.CONCLUSIONS:NEWS could be a valuable predictor in septic patients with CAP in emergency departments.Admission lactate did not predict well the outcomes or improve the severity scores.A qSOFA≥2 and a NEWS≥9 were strongly associated with the 28-day mortality,ICU admission,and mechanical ventilation of septic patients with CAP in the emergency departments.
文摘BACKGROUND: To evaluate the utilization of point-of-care ultrasound(POCUS) for the assessment of emergency department(ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED. RESULTS: A total of 264 subjects(92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the fi nal analysis. Most common symptomatic sites were knee(31.8%) and ankle(16.3%). Joint effusion was the most common fi nding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them(73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records.CONCLUSION: Our study fi ndings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.
文摘BACKGROUND： Emergency physicians frequently encounter patients with acute small bowel obstructions （SBO）. Although computed tomography （CT） imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS： We evaluated the accuracy of ultrasound performed in the ED by a variety of providers （physicians with various levels of training, physician assistants） compared to CT imaging in 47 patients with suspected SBOs. RESULTS： Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION： Ultrasound can play an important role in the identification of small bowe obstructions in ED patients.
基金supported by grants from SingHealth Talent Development Fund,Singapore(TDF/CS001/2006)InfoComm Research Cluster,Nanyang Technological University,Singapore(2006ICT09)
文摘BACKGROUND:This study was undertaken to validate the use of the modified early warning score(MEWS) as a predictor of patient mortality and intensive care unit(ICU)/ high dependency(HD)admission in an Asian population.METHODS:The MEWS was applied to a retrospective cohort of 1 024 critically ill patients presenting to a large Asian tertiary emergency department(ED) between November 2006 and December2007.Individual MEWS was calculated based on vital signs parameters on arrival at ED.Outcomes of mortality and ICU/HD admission were obtained from hospital records.The ability of the composite MEWS and its individual components to predict mortality within 30 days from ED visit was assessed.Sensitivity,specificity,positive and negative predictive values were derived and compared with values from other cohorts.A MEWS of ≥4 was chosen as the cut-off value for poor prognosis based on previous studies.RESULTS:A total of 311(30.4%) critically ill patients were presented with a MEWS ≥4.Their mean age was 61.4 years(SD 18.1) with a male to female ratio of 1.10.Of the 311 patients,53(17%)died within 30 days,64(20.6%) were admitted to ICU and 86(27.7%) were admitted to HD.The area under the receiver operating characteristic curve was 0.71 with a sensitivity of 53.0%and a specificity of 72.1%in addition to a positive predictive value(PPV) of 17.0%and a negative predictive value(NPV)of 93.4%(MEWS cut-off of ≥4) for predicting mortality.CONCLUSION:The composite MEWS did not perform well in predicting poor patient outcomes for critically ill patients presenting to an ED.
文摘BACKGROUND: Harmless acute pancreatitis score(HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width(RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department(ED).METHODS: Patients diagnosed with acute pancreatitis(K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography(CT) in the ED were not included in the study.RESULTS: Ultimately, 322 patients were included in the study. The median age of the patients was 53.1(IQR=36–64). Of the patients, 68.1%(n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3%(n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification(OR: 15; 95% CI: 3.5 to 64.4).CONCLUSIONS: HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classifi cation.
文摘BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS: The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association(AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council(ERC) guidelines for resuscitation, and the 2013 American College of Surgeons(ACS) Advanced Trauma Life Support(ATLS) 9 th edition.RESULTS: There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION: Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.
文摘BACKGROUND: Timely identifi cation of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care(POC) testing is being increasingly utilized in the emergency department(ED). We examined the accuracy and timesaving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fi ngertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation(ICC) and Bland and Altman plots.RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method(ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method(ICC=0.95 & ICC=0.97, respectively).CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.KEY WORDS: Sepsis; Point of care; Lactate; Emergency department;
文摘BACKGROUND： The purpose of triage is to identify patients needing immediate resuscitation, toassign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures asappropriate. This study aimed to use emergency severity index （ESI） in a pediatric emergency room.METHODS： From July 2006 to August 2010, a total of 21 904 patients visited the InternationalDepartment of Beijing Children＇s Hospital. The ESI was measured by nurses and physicians, andcompared using SPSS.RESULTS： Nurses of the hospital took approximately 2 minutes for triage. The results of triagemade by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This findingindicated that the nurses are able to identify severe pediatric cases.CONCLUSION： In pediatric emergency rooms, ESI is a suitable tool for identifying severecases and then immediate interventions can be performed accordingly.
文摘BACKGROUND: We aimed to explore the impact of the emergency department length of stay(EDLOS) on the outcome of trauma patients.METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS(<4 h, 4–12 h,12–24 h, and >24 h). Data were analyzed using Chi-square test(categorical variables), Student’s t-test(continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality.RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. Onefifth of patients had a short EDLOS(<4 h) and had higher level trauma team T1 activation(TTA-1), higher Injury Severity Score(ISS), higher shock index(SI), and more head injuries than the other groups(P=0.001). Patients with an EDLOS >24 h were older(P=0.001) and had more comorbidities(P=0.001) and fewer deaths(P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1(odds ratio [OR]=4.081, 95%CI: 2.364–7.045), head injury(OR=3.920, 95%CI: 2.413–6.368), blood transfusion(OR=2.773, 95%CI: 1.668–4.609), SI(OR=2.132, 95%CI: 1.364–3.332), ISS(OR=1.077, 95%CI: 1.057–1.096), and age(OR=1.040, 95%CI: 1.026–1.054). CONCLUSIONS: Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes;however, the burden of prolonged boarding in the ED needs further elaboration.
文摘BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.METHODS: This was a prospective observational study. This study was divided into two phases. The fi rst phase determined the inter-rater reliability of fi ve triage systems: Manchester Triage System(MTS), Emergency Severity Index(ESI) version 4, Pediatric Canadian Triage and Acuity Scale(CTAS), Australasian Triage Scale(ATS), and Ramathibodi Triage System(RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients(triage level 1, 2) and low acuity patients(triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0(P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8–0.9(P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5–0.7(P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123(11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specifi city of 81%, and AUC 0.78(95%CI 0.74–0.81).CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.
文摘BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to(1) evaluate the current patient flow in ED,(2) to identify and eliminate the non-valued added process, and(3) to modify the existing process.METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage(PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T(hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed(38.24 minutes; SD 66.35) and blood testing result(mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward(EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program(P<0.05).CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.
文摘BACKGROUND： Altered mental status （AMS） is a very common emergency case, but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of AMS patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management.METHODS： This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24 months （June 2009 to June 2011）. Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected prospectively.RESULTS： In 1934 patients with AMS recruited, accounting for 0.93% of all emergency department （ED） patients, 1 026 （53.1%） were male, and 908 （46.9%） female. Their average age was 51.95±15.71 years. Etiologic factors were neurological （n=641; 35.0%）, pharmacological and toxicological （n=421; 23.0%）, systemic and organic （n=266; 14.5%）, infectious （n=167; 9.1%）, endocrine/metabolic （n=145; 7.9%）, psychiatric （n=71; 3.9%）, traumatic （n=38; 2.1%）, and gynecologic and obstetric （n=35; 1.9%）. Total mortality rate was 8.1% （n=156）. The death rate was higher in elderly patients （≥60） than in younger patients （10.8% vs. 6.9%, P=-0.003）.CONCLUSION： Patients with AMS pose a challenge for ED physicians. The most frequently encountered diagnostic categories causing AMS were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. AMS has a high fatality rate in the ED. AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.
