The Prognostic Value of Alveolar-arterial Oxygen Gradient for Community-Acquired Pneumonia in the ED

PURPOSE: The purpose of this study was to investigate the value of the alveolar-arterial (A-a) oxygen gradient for patients with community-acquired pneumonia (CAP) in the emergency department (ED). METHODS: A prospective study of patients with CAP in the ED was performed. Patients with clinical and a radiographic diagnosis of CAP were enrolled. Inflammatory biomarkers, such as WBC (white blood cell) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and A-a oxygen gradient were measured. The severity of CAP was assessed by three prediction rules: The Pneumonia Severity Index (PSI), CURB65 (confusion, blood urea nitrogen, respiratory rate, blood pressure and age> or =65 yrs), and the Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) rules. The value of each biomarker (WBC, CRP, ESR) and A-a oxygen gradient for the prediction of mortality and CAP severity were assessed. RESULTS: A total of 126 patients with CAP were included. Sixteen patients, older and in the high-risk group, died within 30 days. Non-survivors had a significantly increased A-a oxygen gradient compared to survivors (91.20 vs. 46.71 mmHg, respectively; p<.01) and a high-sensitivity to C-reactive protein (158.57 vs. 91.28 mg/dL, respectively; p<.01). The median A-a oxygen gradient was significantly higher with severe disease based on the three prediction rules. In regression logistic analyses, the area under the receiver operating characteristic curve of the alveolar-arterial oxygen gradient was 0.807(95% confidence interval, 0.727-0.872). The addition of A-a oxygen gradient to the three prediction rules significantly increased the area under the receiver operating characteristic curve. CONCLUSION: These results suggest that A-a oxygen gradient is useful for the prediction of mortality and disease severity among CAP patients in the ED. The A-a oxygen gradient, as an adjunct to CAP prediction rules, may be worth while for the assessment of prognosis and severity.

The Prognostic Value of Alveolar-arterial Oxygen Gradient for Community-Acquired Pneumonia in the ED

PURPOSE: The purpose of this study was to investigate the value of the alveolar-arterial (A-a) oxygen gradient for patients with community-acquired pneumonia (CAP) in the emergency department (ED). METHODS: A prospective study of patients with CAP in the ED was performed. Patients with clinical and a radiographic diagnosis of CAP were enrolled. Inflammatory biomarkers, such as WBC (white blood cell) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and A-a oxygen gradient were measured. The severity of CAP was assessed by three prediction rules: The Pneumonia Severity Index (PSI), CURB65 (confusion, blood urea nitrogen, respiratory rate, blood pressure and age> or =65 yrs), and the Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) rules. The value of each biomarker (WBC, CRP, ESR) and A-a oxygen gradient for the prediction of mortality and CAP severity were assessed. RESULTS: A total of 126 patients with CAP were included. Sixteen patients, older and in the high-risk group, died within 30 days. Non-survivors had a significantly increased A-a oxygen gradient compared to survivors (91.20 vs. 46.71 mmHg, respectively; p<.01) and a high-sensitivity to C-reactive protein (158.57 vs. 91.28 mg/dL, respectively; p<.01). The median A-a oxygen gradient was significantly higher with severe disease based on the three prediction rules. In regression logistic analyses, the area under the receiver operating characteristic curve of the alveolar-arterial oxygen gradient was 0.807(95% confidence interval, 0.727-0.872). The addition of A-a oxygen gradient to the three prediction rules significantly increased the area under the receiver operating characteristic curve. CONCLUSION: These results suggest that A-a oxygen gradient is useful for the prediction of mortality and disease severity among CAP patients in the ED. The A-a oxygen gradient, as an adjunct to CAP prediction rules, may be worth while for the assessment of prognosis and severity.

Development and Pilot Applications of Simulation-Based Emergency Department Crisis Management Team Training Program

PURPOSE: Emergency departments (EDs) are complex and dynamic working environments in which crises can easily develop. ED members must be trained to recognize and prevent impending crises or resolve active ones. Patient simulation (PS) is emerging as an effective tool in team training. We investigate the participants' responses to a simulation-based ED Crisis Management Team Training (CMTT) program we developed and applied. METHODS: We developed a pilot 2-hour simulation-based ED-CMTT program and applied to ED members who worked in three different types of EDs. The program was consisted of a lecture for principles of crisis resource management (CRM) and team dynamics, orientation to simulator and simulation environment, PS session with videoassisted debriefing and survey. After finishing the program, participants completed a survey and were solicited comments. RESULTS: Fifty-two trainee participated in more than one of total seven pilot programs. The responses for the program are as follow: enjoyable and satisfied, 4.00+/-0.74; helpful for their teamwork, 3.98+/-0.73; understanding of CRM principles, 4.00+/-0.63; attainment of learning objectives, 3.80+/-0.83; quality of faculty, 3.90+/-0.63; time allocation, 3.40+/-0.70. The responses for PS session are as follow: realism of scenario, 3.98+/-0.63; realism of simulator, 3.10+/-1.05; realism of simulation environment, 3.44+/-0.98; quality of audio-visual system, 3.81+/-0.74. Overall comments were positive and commonest request was to have more experiences in variable scenarios. However, some problems like time shortage and lack of realism were also pointed. CONCLUSION: The participants' reaction show that the simulation-based ED-CMTT program was well accepted by ED members. Creating more variable crisis scenarios and realistic simulation setting will be necessary for improving the program.

The Association of Meteorological and Day-of-the-week Factors with Patient Visits to Emergency Centers

PURPOSE: The aim of this study was to determine the relationships between weather and calendar variables and the admission volume at the emergency center in Daejon city. PATIENTS AND METHODS: Daily patient volume from January to November 2003 was matched with calendar and weather variables. Calendar variables included season, day of the week, holidays, and the day after a holiday. Weather variables included daily maximum, minimum, and average temperatures and other factors such as snowfall and rainfall. RESULTS: The average daily admission volume was 282 +/- 54 persons (187~605), and the most highly significant calendar and weather variables related with admission volume were holidays and maximal temperature, respectively. A regression model was calculated as follows: the daily patient volume = 214 + 2 x (maximal temperature) + 113 x (holiday) + 26.8 x (day after a holiday). This equation could estimate about 62.6% of the daily patient volumes. CONCLUSION: This study suggests that the temperature and a holiday may influence the number of visiting patients. Thus, the staffing level should be set appropriately by considering the estimated patient volume.

A Case of Primary Mesenteric Venous Thrombosis Presenting with Acute Abdominal Pain

Mesenteric venous thrombosis (MVT) is a rare, but lifethreatening condition and may induce ischemia or necrosis of small intestine. The predisposing factors of MVT are variable and include previous abdominal surgery, a hypercoagulable state, etc. When no possible predisposing factors exist, we call it primary MVT. A 29-year-old man was presented with upper abdominal pain and was diagnosed as having a MVT by using an abdominal computed tomography scan. The protein C and S levels were decreased at the ED, but were normal on the 49th hospital day. We did not find any predisposing factors, so we classified this patient as having primary MVT. We report this case along with a literature review.