Out of hospital cardiac arrest outcomes report - using Utstein template

Emergency Medicine service and training system in Thailand are in its developing stage. Cardiac arrest and result of cardiopulmonary resuscitation is one of the most important indicator in ED. Improvement of those need standardized and reliable database. Aim of this study is to initiate using Utstein template for collecting out of hospital cardiac arrest and outcome data in ED Ramathibodi hospital. From April 1, 2006 to April 30, 2007. All medical records of Out-of-Hospital cardiac arrest (OHCA) patients who were sent to Emergency room Ramathibodi Hospital were reviewed. Core element data (according to Utstein definition) were recorded. Ninety-Six Out-of-Hospital cardiac arrest patients were sent to ED. 30 files were lost. 51 OHCA patients were suspected cardiac cause of cardiac arrest and completed CPR. The majority of OHCA occurred at home. Only 4 patients got pre-hospital resuscitation. Six patients showed shockable rhythm as the first mornitoried rhythm. Twenty patients had returned of spontaneous circulation (ROSC) but nobody survived to discharge. Sex and kind of the first monitored rhythm do not affect to result of outcome.

Non-invasive positive pressure ventilation (NIPPV) as a first line treatment for acute respiratory failure in the emergency room : the new experience in Ramathibodi Emergency Department

Background: The Ramathibodi Hospital is a big University hospital that has many problems in the bed management especial ICU beds. The patients presenting with severe respiratory symptoms have waited for in-patient admissions so long time at the Ramathibodi Emergency room and sometimes they have changed their status into acute or impending respiratory failure. Most of these acute or impending respiratory failure patients have needed to be intubated and admitted at a limited amount of ICU beds. This study is to use NIPPV early in the acute or impending respiratory failure patients for reducing the rate of intubation and improving the patients’ conditions so they would have more opportunities to be admitted at in-patient beds instead of a limited amount of ICU beds only.Objective: To compare the effects between using by NIPPV plus standard treatment and only standard treatment on the rate of intubation, length of hospitalization and mortality rate in the patients with acute respiratory failure in Emergency Department.Methods: This research was a prospective cohort study with historical control, and was designed to compare the efficiency of NIPPV method plus standard treatment and only standard treatment in the patients with acute respiratory failure at Emergency Department (ED). The medical records of 88 patients with acute respiratory failure who visited ED at Ramathibodi hospital were enrolled in the study from July 2006 to December 2007. Based on the inclusion criteria, All patients were applied by either NIPPV method plus standard treatment (44 patients) or only standard treatment (44 patients). The researcher collected data in the only standard treatment group by reviewing medical records retrospectively. The on duty Emergency physicians who applied NIPPV to the patients recorded data in the forms and sent to the researcher for data collection. Patients’ demographic data and all clinical outcome variables (respiratory rate, pulse rate, oxygen saturation, intubation rate, length of hospital stay, mortality rate, subjective score of compliance to therapy) were analysed.Results: Statistically significant differences were found in the NIPPV plus standard treatment group for reducing intubation rate (p-value = 0.001) or length of hospitalization (p-value =0.011). Patients who were applied by NIPPV showed no significant differences of mortality rate (p=0.398), possibly due to the small sample size and missed data.Conclusion: The NIPPV plus standard treatment group has improved the outcomes of acute respiratory failure patients as a comparison with the only standard treatment group. NIPPV as an adjuvant treatment has benefits for acute respiratory failure and impending respiratory failure patients in the ED especially in the situation of overcrowded ED and limited beds for ICU admission.

Pain Assessment and Management in Emergency Room Ramathibodi Hospital

Background: In every Emergency Department (ED), pain is among one of the most common complaints of patients. There are many evidences shown that, despite the increasing of concern for pain management, it is still undertreated. Emergency medicine in Thailand is in its developing stage and in the past there was very little concern about proper pain management in ED. Pain score was not routinely used and with many different incomparable methods. Objective: To study quality and efficiency of pain management process in emergency room Ramathibodi hospital and introduce pain score as a pain assessment instrument in emergency room setting of Ramathibodi hospital. Method: A cross-sectional study was performed between November to December 2006. Patients who were older than 15 years old, able to communicate and presented at ER with any kind of pain were enrolled. Numerical rating scale (NRS-11) was applied first at arrival and again before discharge from ED. Aside from pain score we also collected data on chief complaints, arrival time, time to analgesics given, type and root of analgesics given and demographic data of the patients. Results: 259 medical records were reviewed, only 147 records are completed for analysis. Overall mean pain score improvement is 4.02 (p \< 0.001). In patients who receive analgesics mean pain score improvement is 4.86 (SD = 2.956, 95% CI = 4.26-5.43) compare to 1.93 (P \< 0.001, 95% CI = 1.11-2.750) in non-treatment group. 105 patients receive analgesic, 6 were exclude due to missing time of analgesic given, mean time to analgesic given is 56.1 minutes (3-260, SD = 42). In severe pain group takes the longest mean time to analgesic given, which is 59.3 minutes (3-260, SD = 49). Discussion: Overall, there is statistically and clinically significant decrease in pain score. The pain score improvement is obviously different between treatment and non-treatment group. In term of waiting time for pain relief, patients have to wait for a long time to receive analgesics. Patients in severe pain group wait longer and even worse, some patients did not receive treatment at all. This may be implied to the lacking of concern about pain problems in our emergency department. Conclusion: This study revealed problems in many aspects regarding pain management system in our ED. In term of quality improvement, more comprehensive studies are required. Pain score, as a pain assessment instrument, is essential for both further research and quality improvement program.