Diagnostic Efficacy of the Modified Alvarado Score for Acute Appendicitis in Pregnant Women

PURPOSE: We aimed to evaluate whether the modified Alvarado score-which is currently being used to diagnose acute appendicitis-can be applicable in the diagnosis of diseases in pregnant women. METHODS: We retrospectively analyzed the medical records of 252 pregnant women who visited our emergency department (ED) with a chief complaint of abdominal pain and a suspicion of acute appendicitis, and ultimately underwent appendix ultrasonography or appendix magnetic resonance imaging (MRI). The modified Alvarado score was calculated for each pregnant woman. A receiver operating characteristic (ROC) curve was drawn for each subject, those in the first trimester, second trimester, and third trimester, from which the best cut-off value, sensitivity and specificity were induced. RESULTS: For all 252 pregnant women who visited our ED, the area under the curve was 0.742 (p<0.001), with sensitivity and specificity of 75.41% and 62.30%, respectively, when using the value of 5 as the cut-off point for the modified Alvarado score. The area under the curve was 0.811 (p<0.001) for those in their first trimester and 0.749 (p<0.001) for those in the second trimester, while it was 0.641, with the p-value of 0.109, for those in the third trimester. CONCLUSION: There is a limitation using the modified Alvarado score alone in pregnant woman, and if there is uncertainty in the diagnosis, other imaging studies, such as appendix ultrasonography or appendix MRI, should be considered.

Appropriateness of Glasgow-Blatchford Scoring System in Early Prediction of High Risk Group for Old Age Upper Gastrointestinal Bleeding Patients Visiting Emergency Department

PURPOSE: Upper gastrointestinal bleeding (UGIB) is one of the most common causes of emergency department (ED) presentation which can lead to a fatal condition. Many clinical scoring systems intended to predict the prognosis of UGIB patients were developed and validated, including Glasgow-Blatchford score (GBS) and Rockall score (RS). In particular, GBS has shown its superiority in prediction of mortality, the necessity of endoscopic intervention and admission, compared with other scoring systems, in recent studies. However, GBS does not include the age of the patient as its component and has clearly shown its efficacy only in subjects under age 70. Hence, we aimed to assess whether GBS could also be used in old age UGIB patients as a useful risk stratifying method as in younger age. METHODS: UGIB patients who visited our ED for one year were retrospectively enrolled in the analysis. Medical records of the subjects were reviewed, and their GBS and clinical RS were calculated. Receiver-operating characteristics (ROC) curve of each score in prediction of high risk UGIB was drawn and area under curve (AUC) was calculated. Correlation analysis of each score and hospital length of stay was also performed. To assess the validity of each score for use in old age patients, all analyses were also performed in subgroups of age over 60 years, and under that. RESULTS: ROC curves suggest that GBS has significant detecting power for high risk UGIB in overall subjects, subgroups of age over 60 and under (p=<0.001 for all, AUC=0.919, 0.935, 0.901, respectively). Otherwise, clinical RS only showed significant results in overall group and subgroup of age over 60 with lower AUC. CONCLUSION: GBS may also be used safely as an initial risk stratifying method in old age UGIB patients visiting the ED, as in other age groups.

Observation of Emergency Department Adult Patient Presenting Primary Symptoms of Upper Digestive Tract Oreign Body Ingestion

PURPOSE: The purpose of this study is to search for factors which can help in deciding on proper treatment for patients who visit the Emergency department (ED) with symptoms of foreign body ingestion. METHODS: This study was a retrospective review of medical records of ED patients with primary symptoms of foreign body ingestion. The patients' demographic data, elapsed time since the ingestion, type of foreign body, symptoms, and the method of removal were analyzed. Receiver operating characteristic (ROC) curve was used for analysis of whether these factors can be used to decide on proper treatment. RESULTS: Among 321 patients, a foreign body was removed successfully in 285 patients and the foreign body was not found in the remaining 36 patients. Of the successfully treated cases, 76 were removed grossly, 133 were removed using a laryngoscope, 74 were removed with endoscopy, and 2 were removed spontaneously. Comparing the group in which a foreign body was found and the other group, there was a significant difference in elapsed time since the onset of symptoms (p=0.013) and the type of foreign body (p=0.001). There was no significant reliable factor which can predict the existence of a foreign body. CONCLUSION: There was no significant factor which can predict the existence of a foreign body. Considering that the foreign body was found in most suspected patients, and that numerous patients in which a foreign body was not found had shown signs of complications due to foreign body, constructive treatment should be advocated.

Prediction of Complicated Acute Cholecystitis During Emergency Department Stay

PURPOSE: The aim of the study was to determine the factors associated with complicated acute cholecystitis of initial clinical findings during an emergency department (ED) visit, and to use them as a guideline for consideration of early and active surgical intervention, to improve the prognosis of acute cholecystitis. METHODS: Medical records of adult patients diagnosed and treated in the ED as acute cholecystitis were reviewed retrospectively. Clinical findings including demographic data, past medical history, symptoms, physical exam, and laboratory test results were included in the analysis. A case associated with gall bladder empyema, gangrene, perforation, hydrops, or failure of initial laparoscopic approach was defined as complicated acute cholecystitis. Factors showing significance in univariate analyses were included in binary logistic regression analysis for prediction of complicated acute cholecystitis. RESULTS: Age, sex, hypertension history, anorexia, body temperature, white blood cell count (WBC), aspartate aminotransferase, creatinine, total bilirubin, amylase, and lipase were significant in univariate analyses, and included in multivariate analysis. Age (p=0.039), male sex (p=0.004), and WBC (p=0.019) were significant in multivariate analysis. CONCLUSION: Age, sex, and initial WBC of patients diagnosed and treated in the ED as acute cholecystitis were independently associated with complicated acute cholecystitis.

Analysis of Factors Affecting Length of Hospital Stay in Geriatric Patients Transferred from Long-term Care Hospitals

PURPOSE: The number of geriatric patients transferred from long-term care hospitals to emergency department (ED) is increasing because the number of long-term care hospitals has increased significantly in recent years. Only a few studies showing the characteristics of geriatric patients transferred from long-term care hospitals to ED have been reported. We assessed factors affecting length of hospital stay in geriatric non-trauma patients transferred from long-term care hospital to ED. METHODS: This study was a retrospective review of the medical records of 143 patients who were transferred from long-term care hospital to ED. Admitted patients were classified according to two groups (general ward group and intensive care unit group). Univariate analyses were performed relating initial vital signs and laboratory methods for prediction of the length of hospital stay. Cox proportional hazard analysis was then derived, with all variables in the final model significant at p<0.05. RESULTS: A total of 189 patients were enrolled in the study. Results of univariate analysis for Glasgow Coma Scale, heart rate, oxygen saturation, white blood cell count, segmented granulocyte percent, erythrocyte sedimentation rate, and C-reactive protein were significant. In multivariate analysis results for oxygen saturation (p=0.014, hazard ratio=1.065) and segmented granulocyte percent (p=0.025, hazard ratio=0.975) were significant. CONCLUSION: Higher oxygen saturation and lower segmented granulocyte percent are independent factors leading to earlier discharge from the hospital in geriatric non-trauma patients transferred from long-term care hospitals.

The Factors Affecting the Precaution and Request of Medical Direction for Prehospital Emergency Treatment of Major Trauma Patients by 119 Rescue Services

PURPOSE: This study examined the factors affecting the precaution and request of medical direction for prehospital emergency treatment of major trauma patients by 119 rescue services. METHODS: Medical records and prehospital run reports of major trauma patients with an Injury Severity Score (ISS) above 15 were reviewed. In total, 123 patients who were transferred by 119 rescue services to the Emergency Department of one hospital from December 1, 2010 to February 28, 2013 were enrolled. A total of 123 patients with major trauma satisfied the ISS criterion. Excluding 26 patients with missing data, 97 patients were included in this study. Out of these 97 patients, 72 patients were male and the mean age was 46+/-16.1 years. The statistical methods used in the analysis were the Receiver-Operating Characteristic curve and Fisher's exact test. RESULTS: Between the hospital precaution group and non-precaution group, the only significant difference was in the RTS score (p=0.007). In total, 52 patients (39 male patients; mean age 49.52+/-16.14 years) with major trauma were transferred during the medical direction period. Between groups that requested medical direction and groups that did not, the only significant difference was the time interval from the call to hospital arrival (p=0.032). CONCLUSION: Within the variables we examined, transport of major trauma patients, in addition to low incidence of precaution and request for medical direction by 119 rescue services, only a few were considered.

The Factors Affecting the Precaution and Request of Medical Direction for Prehospital Emergency Treatment of Major Trauma Patients by 119 Rescue Services

PURPOSE: This study examined the factors affecting the precaution and request of medical direction for prehospital emergency treatment of major trauma patients by 119 rescue services. METHODS: Medical records and prehospital run reports of major trauma patients with an Injury Severity Score (ISS) above 15 were reviewed. In total, 123 patients who were transferred by 119 rescue services to the Emergency Department of one hospital from December 1, 2010 to February 28, 2013 were enrolled. A total of 123 patients with major trauma satisfied the ISS criterion. Excluding 26 patients with missing data, 97 patients were included in this study. Out of these 97 patients, 72 patients were male and the mean age was 46+/-16.1 years. The statistical methods used in the analysis were the Receiver-Operating Characteristic curve and Fisher's exact test. RESULTS: Between the hospital precaution group and non-precaution group, the only significant difference was in the RTS score (p=0.007). In total, 52 patients (39 male patients; mean age 49.52+/-16.14 years) with major trauma were transferred during the medical direction period. Between groups that requested medical direction and groups that did not, the only significant difference was the time interval from the call to hospital arrival (p=0.032). CONCLUSION: Within the variables we examined, transport of major trauma patients, in addition to low incidence of precaution and request for medical direction by 119 rescue services, only a few were considered.

Predictors for the Failure of Expectant Management for the Spontaneous Passage of Ureteral Calculi

PURPOSE: Ureteral calculi are commonly encountered in the emergency department. Ureteral calculi influence the quality of life of patients, causing pain and economic burden. The optimal management of ureteral calculi remains a challenge for practicing physicians; therefore, this study was designed to determine which factors are related to the failure of their spontaneous passage. METHODS: This study was a retrospective review of the medical records of one hundred ninety-five patients who visited the emergency department complaining of renal colic from February 2012 to December 2012. Bivariate analyses were conducted relating physical, laboratory, and radiological methods to predict the failure of spontaneous passage. A multivariate logistic regression model was then derived, with all variables in the final model significant at p<0.05. RESULTS: One hundred twenty-eight stones were spontaneously expelled and sixty-seven were not. The mean stone size was significantly larger in the non-passage group than the passage group (p<0.001). When the stones were located in the upper ureter, or on the right side, the spontaneous passage rate was lower (p<0.001, p=0.035). Increased neutrophils and positive tests for urinary protein and bilirubin were also associated with the decreased likelihood of spontaneous passage (p=0.046, p=0.029, and p=0.048, respectively). In addition, the longer duration of symptoms and a previous history of ureteral calculi were related to a lower chance of spontaneous passage (p=0.005, p=0.019). CONCLUSION: Prognostic factors of failure, after the initial expectant management of ureteral calculi, included: calculi size, location (e.g., side), the duration of symptoms, the previous history, neutrophil levels, urinary bilirubin levels, and urinary protein levels. Therefore, emergency physicians need to cautiously decide between watchful waiting and interventions in these patients.

The Prognostic Abilities of Severity Scoring Systems for Patients with Septic Shock

PURPOSE: The aim of the study was to validate abbreviated mortality in emergency department sepsis (MEDS) scoring system by comparing it with original MEDS score and to assess the prognostic value of other prognostic factor for sepsis patients including multiple organ dysfunction score (MODS), sepsis-related organ failure assessment (SOFA) score, and serum procalcitonin level. METHODS: Adult patients visiting emergency department (ED) with evidence of septic shock were enrolled to the study. MEDS score, MODS, and SOFA score were calculated based on initial clinical data. Receiver-operating characteristics (ROC) analyses were used to assess the prognostic factors for predicting mortality. Kaplan-Meier survival analyses (KMSA) were used to determine whether the prognostic factors had correlation with survival time. RESULTS: Only MODS showed significant predicting power for mortality (p=0.003, area under curve=0.625). Estimated median survival of all the patients calculated by KMSA was 11.0 (standard error 1.7) days, and predefined criteria of all prognostic factors showed significant differences in survival time. CONCLUSION: MEDS, abbreviated MEDS, MODS, and SOFA scoring systems were useful factors for predicting survival time of septic shock patients visiting ED.

Multivariate Analysis of Predictive Factors for the Severity in Stable Patients with Severe Injury Mechanism

PURPOSE: For determining the prognosis of critically injured patients, transporting patients to medical facilities capable of providing proper assessment and management, running rapid assessment and making rapid decisions, and providing aggressive resuscitation is vital. Considering the high mortality and morbidity rates in critically injured patients, various studies have been conducted in efforts to reduce those rates. However, studies related to diagnostic factors for predicting severity in critically injured patients are still lacking. Furthermore, patients showing stable vital signs and alert mental status, who are injured via a severe trauma mechanism, may be at a risk of not receiving rapid assessment and management. Thus, this study investigates diagnostic factors, including physical examination and laboratory results, that may help predict severity in trauma patients injured via a severe trauma mechanism, but showing stable vital signs. METHODS: From March 2010 to December 2011, all trauma patients who fit into a diagnostic category that activated a major trauma team in CHA Bundang Medical Center were analyzed retrospectively. The retrospective analysis was based on prospective medical records completed at the time of arrival in the emergency department and on sequential laboratory test results. PASW statistics 18(SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Patients with relatively stable vital signs and alert mental status were selected based on a revised trauma score of more than 7 points. The final diagnosis of major trauma was made based on an injury severity score of greater than 16 points. Diagnostic variables include systolic blood pressure and respiratory rate, glasgow coma scale, initial result from focused abdominal sonography for trauma, and laboratory results from blood tests and urine analyses. To confirm the true significance of the measured values, we applied the Kolmogorov-Smirnov one sample test and the Shapiro-Wilk test. When significance was confirmed, the Student's t-test was used for comparison; when significance was not confirmed, the Mann-Whitney u-test was used. The results of focused abdominal sonography for trauma (FAST) and factors of urine analysis were analyzed using the Chi-square test or Fisher's exact test. Variables with statistical significance were selected as prognostics factors, and they were analyzed using a multivariate logistics regression model. RESULTS: A total of 269 patients activated the major trauma team. Excluding 91 patients who scored a revised trauma score of less than 7 points, 178 patients were subdivided by injury severity score to determine the final major trauma patients. Twenty-one(21) patients from 106 major trauma patients and 9 patients from 72 minor trauma patients were also excluded due to missing medical records or untested blood and urine analysis. The investigated variables with p-values less than 0.05 include the glasgow coma scale, respiratory rate, white blood cell count (WBC), serum AST and ALT, serum creatinine, blood in spot urine, and protein in spot urine. These variables could, thus, be prognostic factors in major trauma patients. A multivariate logistics regression analysis on those 8 variables showed the respiratory rate (p=0.034), WBC (p=0.005) and blood in spot urine (p=0.041) to be independent prognostic factors for predicting the clinical course of major trauma patients. CONCLUSION: In trauma patients injured via a severe trauma mechanism, but showing stable vital signs and alert mental status, the respiratory rate, WBC count and blood in the urine can be used as predictable factors for severity. Using those laboratory results, rapid assessment of major trauma patients may shorten the time to diagnosis and the time for management.

Analysis of Factors Affecting Length of Hospital Stay in Severe Trauma Patients

PURPOSE: Severe trauma is indicative of poor patient prognosis and higher mortality rates. Moreover, severe trauma may be related with higher hospital costs. Our recent study showed that severe trauma costs significantly more per patient than general trauma. Length of hospital stay was shown to be an independent factor contributing to higher cost in the study. We assessed factors affecting length of hospital stay in severe trauma patients. METHODS: Data from the severe trauma registry was collected prospectively and retrospectively reviewed. Time of emergency department (ED) registration, mechanism of injury, initial vital signs, revised trauma score (RTS), injury severity scale (ISS), specialty consultation time, time to admission decision, ED length of stay, and overall hospital length of stay (LOS) were evaluated. All factors listed above were put into a univariate, Cox proportional hazard analysis. LOS and other factors resulting in p-values under 0.20 were included in the multivariate analysis. RESULTS: A total of 249 patients were enrolled to the study. There were significant univariate analysis results for RTS and ISS (p=0.001, 0.006, respectively). The only significant multivariate analysis result was for RTS (p=0.025, hazard ratio=1.167). CONCLUSION: Higher RTS score is an independent factor leading to earlier discharge from the hospital in severe trauma patients.

Prognostic Factor, for Major Trauma Patients in the Emergency Medical Service System

PURPOSE: A few studies have assessed the factors affecting the prognoses for major trauma patients and those improving the circumstances when dealing with the trauma system. In that light, we analyzed factors, such as pre-hospital factors, the time to admission, the length of stay in the emergency department (ED) and emergency operation, influencing the outcomes for trauma patients. METHODS: The patients who visited our emergency department from April 1, 2009, to February 29, 2011, due to major trauma were enrolled in the study. The inclusion criterion was a revised trauma score (RTS) or = 16. We used reviews of medical records, to analyze each step of emergency medical care with respect to patients' sex, age, visit time and visit date. Continuous variables were described as a median with an interquartile range, and we compared the variables between the survival and the mortality groups by using the Mann-Whitney U test. Fisher's exact test was used for nominal variables. Using the variables that showed statistical significance in univariate comparisons, we performed a logistic regression analysis, and we tested the model's adequacy by the using the Hosmer-Lemeshow method. RESULTS: A total of 261 patients with major trauma satisfied either the RTS score criterion or the ISS score criterion. Excluding 12 patients with missing data, 249 patients were included in this study. The overall mortality rate was 16.9%. Time to ED arrival, time to admission, time of ED stay, RTS, ISS, and visit date being a holiday showed statistically significant differences between the survival and the mortality groups in the univariate analysis. RTS, ISS, length of ED stay, and visit date being a holiday showed statistical significance in the multivariate analysis. CONCLUSION: The mortality rate did not show a significant relationship with the time to ED arrival, use of 119, on time to admission. Rather, it elicited a quite significant correlation with the trauma scoring system (RTS and ISS), the time of ED stay, and the visit date being a holiday.

Multivariate Analysis of Physical and Laboratory Factors for Acute Abdomen Detection in Young Women Visiting the Emergency Department due to Non-Traumatic Abdominal Pain

PURPOSE: One of the most challenging groups of patients to diagnose that visit an emergency department (ED) is the female with acute abdominal pain. The causes of acute abdominal pain range from minor, self-limiting conditions to life-threatening disorders. Differential diagnosis for these patients is extensive and frequently requires multiple examinations and tests. This study analyzed the effectiveness of surgical abdomen detection using various physical examination and clinical laboratory methods, for young women reporting non-traumatic abdominal pain. METHODS: This study reviewed computed tomography (CT) reports for 232 women, aged 21~35 years old, who visited our ED for nontraumatic abdominal pain from July 2009 to June 2010. Bivariate analyses relating physical and laboratory methods used to detect surgical abdomen were conducted. A multivariate logistic regression model was then derived, with all variables in the final model significant at p<0.05. RESULTS: The number of patients who required surgical intervention was 88, while the number who did not require surgery was 144. Significant predictive methods for identifying surgical abdomen were maximal tenderness site (p=0.019), rebound tenderness (p=0.037), white blood cell count (p=0.012) and urine blood (p=0.037). The bootstrap result was identical in 1000 samples with a 95% confidence interval. CONCLUSION: Maximal tenderness site, rebound tenderness, and results indicating leukocytosis and hematuria were found to be independently valid factors for detection of surgical abdomen in young women evaluated in our ED due for nontraumatic abdominal pain.

The Effect of Emergency Department Treatment Time on Outcomes in Acute Stroke Patients / 대한구급학회지

BACKGROUND: Stroke is a disease that leads to a long period of disability and death. Accordingly, the initial treatment is so influential on the prognosis of a patient that shortening the time to initial treatment after hospital admission has a very important role in the entire treatment regimen. This study aimed to demonstrate the effect of the Emergency Department treatment time at Bundang CHA Hospital for acute stroke patients to improve the treatment regimen through six sigma activities. METHODS: The outcomes for 246 patients with suspected acute strokes who were admitted to the Emergency Department of Bundang CHA Hospital, the flow of the emergency department process divided into 11 phases, and the duration of each phase were determined. Patients were classified as before and after six sigma activities and compared. RESULTS: The five phases statistically demonstrated the effect of meaningful improvement in the duration of visit-receiving CT prescriptions, visit-receiving lab prescriptions, consult request-arriving to the emergency department, visit-CT angiography results, and visit-the issue of hospital admissions. In the next 2 phases, the sigma level also improved by 0.71sigma and 0.06sigma. However, the total emergency department stay time was not statistically meaningful. The time required time was increased and the sigma level was decreased by 0.19sigma. CONCLUSIONS: The result of six sigma activities showed the effect of the treatment system improvement with a partial decrease in the duration of each phase, but the total emergency department stay time was not improved owing to environmental factors. For better results, continuous improvement of the treatment system and expansion of hospital facilities will be required.

The Effect of Six Sigma Activity in Major Trauma Patients on the Time Spent in the Emergency Department

PURPOSE: This study was conducted to shorten the time spent at each stage of treatment and to reduce the total amount of time patients spend in the emergency department (ED) by applying Six Sigma in the treatment of major trauma patients. METHODS: This is a comparative study encompassing 60 patients presenting to the ED of Bundang CHA Hospital from January 2008 to December 2008 and from July 2009 to March 2010. The stages of treatment for major trauma patients were divided into six categories (T1: total emergency department staying time, T2: duration of visit-radiologic evaluation time, T3: duration of visit-consult to department of admission, T4: duration of consultation-issue of hospital admissions time, T5: duration of visit-issue of hospital admissions time, T6: duration of issue of hospital admission-emergency department discharge time) and the total time patients spent in the ED was compared and analyzed for periods; before and after the application of Six Sigma. RESULTS: After the application of Six Sigma, the numerical values in four of the six categories were significantly reduced; T2, T3, T4, and T5. However, the average of the total time patients spent in the ED did not show any remarkable change because the T6 increased highly. The level of Six Sigma increased 0.17sigma. CONCLUSION: The application of Six Sigma for major trauma patients in the ED resulted in a significant improvement in the error rate for the total time patients spent in the ED. The Six Sigma activity has shown great potential. Therefore, the project is expected to bring better results in every stage of treatment if the levels of the hospital facilities are improved.

Effect of the Six Sigma Protocol on the Time Required to get STEMI Patients to Reperfusion Therapy Via PTCA

PURPOSE: To minimize the process that acute myocardial infarction (AMI) patients have to go through when visiting the emergency room (ER), and thus to provide prompt reperfusion therapy using the six sigma protocol, a business management renovation strategy to standardize the clinical process. METHODS: Analysis was done on data obtained both before and after implementation of the six sigma protocol. Data were collected from ST segment elevation myocardial infarction (STEMI) patients who visited the ER between February 2006 and March 2009 and received reperfusion therapy. For statistical analysis used we used an unpaired t-test. RESULTS: After the six sigma protocol was put into practice, total visiting time was reduced from 124.4+/-76.1 minutes to 91.5+/-50.3 minutes, and the reduction was statistically significant (p<0.0045). Six sigma (6 sigma) means 3.4 PPM, that is, among 1 million cases no more than 3.4 cases should exceed the time limit of 90 minutes from the arrival of the patient to the needle puncture, making the task hard to achieve. sigma score was greatly elevated-from 1.48 sigma to 2.48 sigma and the sigma error rate (the proportion of cases that exceeded 90 min) improved from 62% to 45% . CONCLUSION: In this study we verified that applying the six Sigma protocol significantly reduced the time to reperfusion therapy for AMI patients. The reduction in time was due to changes in software (developed from the existing system) rather than to hardware improvements such as changes in test facilities or manpower amplification. The entire process, from a patient arriving at the ER until the patient received reperfusion therapy was viewed as one systemic flow and applying the six Sigma protocol to such flow was successful as shown by the result of this study. This shows that the six sigma protocol can be applied to a medical system if configured effectively. Further, this method can be useful not only for AMI patients, but also for many other urgent procedures such as acute cerebral infarction patients who require prompt diagnosis and hemolytic therapy, when the definition of the error rate is corrected according to the specific patients groups.

Effect of the Six Sigma Protocol on the Time Required to get STEMI Patients to Reperfusion Therapy Via PTCA

PURPOSE: To minimize the process that acute myocardial infarction (AMI) patients have to go through when visiting the emergency room (ER), and thus to provide prompt reperfusion therapy using the six sigma protocol, a business management renovation strategy to standardize the clinical process. METHODS: Analysis was done on data obtained both before and after implementation of the six sigma protocol. Data were collected from ST segment elevation myocardial infarction (STEMI) patients who visited the ER between February 2006 and March 2009 and received reperfusion therapy. For statistical analysis used we used an unpaired t-test. RESULTS: After the six sigma protocol was put into practice, total visiting time was reduced from 124.4+/-76.1 minutes to 91.5+/-50.3 minutes, and the reduction was statistically significant (p<0.0045). Six sigma (6 sigma) means 3.4 PPM, that is, among 1 million cases no more than 3.4 cases should exceed the time limit of 90 minutes from the arrival of the patient to the needle puncture, making the task hard to achieve. sigma score was greatly elevated-from 1.48 sigma to 2.48 sigma and the sigma error rate (the proportion of cases that exceeded 90 min) improved from 62% to 45% . CONCLUSION: In this study we verified that applying the six Sigma protocol significantly reduced the time to reperfusion therapy for AMI patients. The reduction in time was due to changes in software (developed from the existing system) rather than to hardware improvements such as changes in test facilities or manpower amplification. The entire process, from a patient arriving at the ER until the patient received reperfusion therapy was viewed as one systemic flow and applying the six Sigma protocol to such flow was successful as shown by the result of this study. This shows that the six sigma protocol can be applied to a medical system if configured effectively. Further, this method can be useful not only for AMI patients, but also for many other urgent procedures such as acute cerebral infarction patients who require prompt diagnosis and hemolytic therapy, when the definition of the error rate is corrected according to the specific patients groups.

Effect of an RSST (Rapid Streptococcal Screening Test) and Education about Centor Criteria on the Use of Antibiotics for Patients with Sore Throat

PURPOSE: This study evaluated the effect of Rapid Streptococcal Screening Test (RSST) results on the use of antibiotics for patients with sore throat in the ER setting and the effect of education about Centor criteria for primary physicians on the use of antibiotics. METHODS: Between June 2008 and January 2009, we recruited 786 patients with sore throat who visited our emergency center. Patients were classified into 2 groups according to the RSST. Centor scores and antibiotic usage were assessed. Primary physicians were educated about Centor scoring and RSST. We analyzed the use of antibiotics to evaluate the effect of education on Centor scoring and RSST. RESULTS: RSST results significantly correlated with antibiotic usage for the RSST done on a group of patients with sore throat (p or =3) was not significantly reduced (p=0.6394) after education regarding Centor criteria. CONCLUSION: The use of an RSS test and education of primary physicians will reduce the unnecessary use of antibiotics by patients and will result in appropriate use of antibiotics for patients who need antibiotics.

The Parameters Affecting the Success Rate for Endotracheal Intubation in Emergency Department: Multi-center Trial using Korean Emergency Airway Management Registry

PURPOSE: To determine the parameters affecting the success rate for endotracheal intubation in emergency department (ED) of teaching hospitals in the metropolitan area of Korea. METHODS: This was a prospective observational study in six teaching hospitals. From February 25 to August 31, 2006, physicians performing intubations at six university-affiliated EDs in the Seoul metropolitan area completed a data form from which data were entered into the Korean Emergency Airway Management Registry (KEAMR). Data were abstracted from KEAMR and analyzed. RESULTS: A total of 703 intubations were registered over this period with overall success rate of 78.2%. As indicated by univariate analysis, endotracheal intubation was most successful when the glottic exposure grade (GEG) was lower (p<0.001), the specialty of the intubator was emergency medicine (p<0.001), the level of training was higher (p<0.001) and the intubation method was rapid sequence intubation (p=0.039). In logistic regression analysis, GEG, specialty of the intubator, and level of training were related to success rate. But no significant differences were shown among the intubation methods. CONCLUSION: Success rates for endotracheal intubation in emergency departments of teaching hospitals in the Seoul metropolitan area were related to GEG, specialty of the intubator, and level of training.

A Lethal Case of Sodium Azide Ingestion

Sodium azide (NaN3) is a white to colorless, crystalline powder that is highly water soluble, tasteless, and odorless. It is used mainly as a preservative in aqueous laboratory reagents and biologic fluids and also as an automobile airbag gas generant. Although it has caused deaths for decades, the toxic properties and effects of sodium azide in humans remains unknown. A 31-year-old comatose female was transported to the emergency department with an empty bottle labeled sodium azide. She developed cardiac arrest 15 minutes after arrival and expired in spite of 30 minutes of resuscitative effort. Subsequently, resuscitation team members incidentally suffered from sodium azide's exposure and developed eye discomfort, skin rashes parasthesias, pruritus, sore throat, and headache.