Analysis of patient clinical characteristics visiting single regional emergency department in COVID-19 pandemic era: a before-and-after observational study

Objective@#This study aimed at analyzing the clinical characteristics of patients visiting the emergency department (ED) and pre-triage clinic during the coronavirus disease 2019 (COVID-19) pandemic era in Daegu, South Korea. @*Methods@#We conducted a retrospective observational study by using the medical records of patients who visited the ED and pre-triage clinic from February 22 to March 31, 2020 and comparing them with the corresponding period in 2019. @*Results@#The number of patients visiting the ED per day decreased from 122 (115-138) to 77 (66-93). The percentage of patients with respiratory infection increased from 6.6% to 15.4% (P<0.001). The length of the ED stay increased from 269 (150-562) to 559 (293-941) minutes, especially in patients with fever (P<0.001). The rate of injured and less urgent patients decreased from 24.7 to 13.2 and 53.4% to 50.2%, respectively (P<0.001). Sixty-one-point nine percent of patients visiting the ED were triaged and discharged at the pre-triage clinic without entering the ED. @*Conclusion@#In the COVID-19 pandemic era, there was an increase in the proportion of patients with fever and respiratory symptoms and a decrease in the proportion of injured patients. At the pre-triage clinic, a significant number of patients with suspected COVID-19 or less urgent conditions were treated and discharged without their having to enter the ED.

The Significance of the Strong Ion Gap in Predicting Acute Kidney Injury and In-hospital Mortality in Critically Ill Patients with Acute Poisoning

Purpose@#A high anion gap (AG) is known to be a significant risk factor for serious acid-base imbalances and death in acute poisoning cases. The strong ion difference (SID), or strong ion gap (SIG), has recently been used to predict in-hospital mortality or acute kidney injury (AKI) in patients with systemic inflammatory response syndrome. This study presents a comprehensive acidbase analysis in order to identify the predictive value of the SIG for disease severity in severe poisoning. @*Methods@#A cross-sectional observational study was conducted on acute poisoning patients treated in the emergency intensive care unit (ICU) between December 2015 and November 2020. Initial serum electrolytes, base deficit (BD), AG, SIG, and laboratory parameters were concurrently measured upon hospital arrival and were subsequently used along with Stewart’s approach to acid-base analysis to predict AKI development and in-hospital death. The area under the receiver operating characteristic curve (AUC) and logistic regression analysis were used as statistical tests. @*Results@#Overall, 343 patients who were treated in the intensive care unit were enrolled. The initial levels of lactate, AG, and BD were significantly higher in the AKI group (n=62). Both effective SID [SIDe] (20.3 vs. 26.4 mEq/L, p<0.001) and SIG (20.2 vs. 16.5 mEq/L, p<0.001) were significantly higher in the AKI group; however, the AUC of serum SIDe was 0.842 (95% confidence interval [CI]=0.799-0.879). Serum SIDe had a higher predictive capacity for AKI than initial creatinine (AUC=0.796, 95% CI=0.749-0.837), BD (AUC=0.761, 95% CI=0.712-0.805), and AG (AUC=0.660, 95% CI=0.607-0.711). Multivariate logistic regression analyses revealed that diabetes, lactic acidosis, high SIG, and low SIDe were significant risk factors for in-hospital mortality. @*Conclusion@#Initial SIDe and SIG were identified as useful predictors of AKI and in-hospital mortality in intoxicated patients who were critically ill. Further research is necessary to evaluate the physiological nature of the toxicant or unmeasured anions in such patients.

Effect of trauma center establishment to clinical outcome of severe pediatric trauma patients: retrospective single center study

Objective@#Trauma death is one of the most preventable deaths by various efforts in the healthcare sector. The establishment of a regional trauma center will aid in efforts to reduce mortality. On the other hand, the effects of trauma centers on pediatric trauma in Korea are not fully understood. This study compared the clinical outcomes of severe pediatric trauma patients before and after the regional trauma center was set into action. @*Methods@#A cross-sectional, retrospective analysis was performed on the medical records in a single regional emergency and trauma center from November 2014 to October 2016 and from January 2017 to December 2018. The general demographic information, injury details, and clinical outcome data were collected. The cases were divided into two groups, the before and after groups, and comparisons were made. @*Results@#Seventy-three patients were included in the study. Thirty-seven patients were in the before group, and 36 were in the after group. The mortality (21.6% to 5.6%, P=0.04) and interhospital transfer rate (27.0% to 8.3%, P=0.03) were lower in after group than in the before group. On the other hand, the time to receive a transfusion, operation, and intensive care unit (ICU) admission did not differ significantly. The lengths of the emergency department, ICU, and hospital stay were also similar in the two groups. @*Conclusion@#For severe pediatric trauma patients, the mortality and transfer rates decreased after implementing the trauma center. On the other hand, the implementation itself was not identified as a major factor, and the time required to receive a definite treatment or length of stay did not change significantly.

Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City

Background@#When an emergency-care patient is diagnosed with an emerging infectious disease, hospitals in Korea may temporarily close their emergency departments (EDs) to prevent nosocomial transmission. Since February 2020, multiple, consecutive ED closures have occurred due to the coronavirus disease 2019 (COVID-19) crisis in Daegu. However, sudden ED closures are in contravention of laws for the provision of emergency medical care that enable the public to avail prompt, appropriate, and 24-hour emergency medical care. Therefore, this study ascertained the vulnerability of the ED at tertiary hospitals in Daegu with regard to the current standards. A revised triage and surveillance protocol has been proposed to tackle the current crisis. @*Methods@#This study was retrospectively conducted at 6 level 1 or 2 EDs in a metropolitan city where ED closure due to COVID-19 occurred from February 18 to March 26, 2020. The present status of ED closure and patient characteristics and findings from chest radiography and laboratory investigations were assessed. Based on the experience from repeated ED closures and the modified systems that are currently used in EDs, revised triage and surveillance protocols have been developed and proposed. @*Results@#During the study period, 6 level 1 or 2 emergency rooms included in the study were shut down 27 times for 769 hours. Thirty-one confirmed COVID-19 cases, of whom 7 died, were associated with the incidence of ED closure. Typical patient presentation with respiratory symptoms of COVID-19 was seen in less than 50% of patients, whereas abnormal findings on chest imaging investigations were detected in 93.5% of the study population. The chest radiography facility, resuscitation rooms, and triage area were moved to locations outside the ED, and a new surveillance protocol was applied to determine the factors warranting quarantine, including symptoms, chest radiographic findings, and exposure to a source of infection. The incidence of ED closures decreased after the implementation of the revised triage and surveillance protocols. @*Conclusion@#Triage screening by emergency physicians and surveillance protocols with an externally located chest imaging facility were effective in the early isolation of COVID-19 patients. In future outbreaks of emerging infectious diseases, efforts should be focused toward the provision of continued ED treatment with the implementation of revised triage and surveillance protocols.

Comparison of the new and conventional injury severity scoring systems for predicting mortality in severe geriatric trauma

Objective@#This study compared the prognostic performance of the following five injury severity scores: the Geriatric Trauma Outcome Score (GTOS), the Injury Severity Score (ISS), the New Injury Severity Score (NISS), the Revised Trauma Score (RTS), and the Trauma and Injury Severity Score (TRISS) for in-hospital mortality in severe geriatric trauma patients. @*Methods@#A retrospective, cross-sectional, observational study was conducted using a database of severe geriatric trauma patients (age ≥65 years and ISS ≥16) who presented to a single regional trauma center between November 2016 and October 2018. We compared the baseline characteristics between the survivor and mortality groups and the predictive ability of the five scoring systems. @*Results@#A total of 402 patients were included in the analysis; the in-hospital mortality rate was 25.6% (n=103). The TRISS had the highest area under the curve of 0.953 (95% confidence interval [CI], 0.927-0.971); followed by RTS, 0.777 (95% CI, 0.733-0.817); NISS, 0.733 (95% CI, 0.687-0.776); ISS, 0.660 (95% CI, 0.612-0.707); and GTOS, 0.660 (95% CI, 0.611-0.706) in severe geriatric trauma. The TRISS also had the highest area under the curve of 0.961 (0.919-0.985) among the injury severity scoring systems in polytrauma. The predictive ability of TRISS was significantly higher than the other four scores with respect to overall trauma and polytrauma (P<0.001). @*Conclusion@#The TRISS showed the highest prognostic performance for predicting in-hospital mortality among all the injury severity scoring systems in severe geriatric trauma.

Comparison of the new and conventional injury severity scoring systems for predicting mortality in severe geriatric trauma

Objective@#This study compared the prognostic performance of the following five injury severity scores: the Geriatric Trauma Outcome Score (GTOS), the Injury Severity Score (ISS), the New Injury Severity Score (NISS), the Revised Trauma Score (RTS), and the Trauma and Injury Severity Score (TRISS) for in-hospital mortality in severe geriatric trauma patients. @*Methods@#A retrospective, cross-sectional, observational study was conducted using a database of severe geriatric trauma patients (age ≥65 years and ISS ≥16) who presented to a single regional trauma center between November 2016 and October 2018. We compared the baseline characteristics between the survivor and mortality groups and the predictive ability of the five scoring systems. @*Results@#A total of 402 patients were included in the analysis; the in-hospital mortality rate was 25.6% (n=103). The TRISS had the highest area under the curve of 0.953 (95% confidence interval [CI], 0.927-0.971); followed by RTS, 0.777 (95% CI, 0.733-0.817); NISS, 0.733 (95% CI, 0.687-0.776); ISS, 0.660 (95% CI, 0.612-0.707); and GTOS, 0.660 (95% CI, 0.611-0.706) in severe geriatric trauma. The TRISS also had the highest area under the curve of 0.961 (0.919-0.985) among the injury severity scoring systems in polytrauma. The predictive ability of TRISS was significantly higher than the other four scores with respect to overall trauma and polytrauma (P<0.001). @*Conclusion@#The TRISS showed the highest prognostic performance for predicting in-hospital mortality among all the injury severity scoring systems in severe geriatric trauma.

Effects of chest compression only cardiopulmonary resuscitation training on retention of correct cardiopulmonary resuscitation knowledge

OBJECTIVE: Performing high quality cardiopulmonary resuscitation (CPR) is important for improving the survival rate with a good neurological outcome and fewer complications. The retention of accurate CPR knowledge is essential for providing high quality CPR. This study examined the effects of chest compression only CPR training on the retention of correct CPR knowledge. METHODS: In December 2016, an interview survey to target the study population was conducted by trained interviewers, using a structured questionnaire. The respondents' general characteristics, status of CPR education, and knowledge and willingness regarding CPR were investigated. Pearson's chi-square tests and multivariate logistic regression analyses were used to determine which education-related factors affected the correct skill knowledge of performing CPR. RESULTS: Among the respondents, there are 80 persons (17.4%) who answered correctly in the questions regarding the skills of performing CPR. The respondents who had a willingness to perform CPR to family and strangers were 90.2% and 44.9% respectively. Through multivariable analysis, the factors related to correct skill knowledge in performing CPR in the didactic with practice group were people who had undergone CPR training within 2 years (odds ratio [OR], 2.293; 95% confidence interval [CI], 1.311–4.009), and person who had undergone chest compression only CPR training (OR, 2.044; 95% CI, 1.033–4.042). CONCLUSION: Chest compression only type of CPR training and the experience of CPR education within 2 years were associated with accurate skill knowledge of performing CPR.

Relationship between emergency department crowding and initial management, mortality of severe trauma patients

OBJECTIVE: This study examined whether emergency department (ED) crowding influences the timing of the initial assessment and treatment in severe trauma patients, as well as their mortality rates. METHODS: This retrospective, observational study was conducted between January 2015 and October 2016, and included adult severe trauma patients who presented to the ED. The emergency department occupancy rate (EDOR) was used to measure ED crowding. The patients were divided into four groups using the EDOR quartile. The timeliness of the initial assessment and treatment in the four groups as well as the mortality rates were compared. RESULTS: This study investigated 307 patients. The timing of the first computed tomography (CT) and laboratory test order, CT and laboratory test result acquisition, first transfusion, and patient transfer from the ED to the operating room were similar in the four groups. Multivariable logistic regression analysis did not show a significant difference in mortality between the groups. CONCLUSION: ED crowding was not associated with delays in the initial assessment and treatment of severe trauma patients, or in their mortality rates.

Validation of critical administration threshold and massive transfusion for mortality prediction in patients with adult severe trauma

OBJECTIVE: A massive transfusion (MT) of 10 or more units of packed red blood cells (PRCs) focuses on the summation volumes over 24 hours. This traditional concept promotes survivor bias and fails to identify the “massively” transfused patient. The critical administration threshold (≥3 units of PRCs per hour, CAT+) has been proposed as a new definition of MT that includes the volume and rate of blood transfusion. This study examined the CAT in predicting mortality in adult patients with severe trauma, compared to MT. METHODS: Retrospective data of adult major trauma patients (age≥15 years, Injury Severity Score [ISS]≥16) from a regional trauma center collected between May 2016 and June 2017 were used to identify the factors associated with trauma-related death. Univariate associations were calculated, and multiple logistic regression analysis was performed to determine the parameters associated with in-hospital mortality. RESULTS: A total of 540 patients were analyzed. The median ISS was 22, and the hospital mortality rate was 30.9% (n=92). Forty-two (7.8%) and 23 (4.3%) patients were CAT+ and traditional MT+, respectively. Severe brain injury, CAT+, acidosis, and elderly age were significant variables in multivariate analysis. CAT+ was associated with a fourfold increased risk of death (odds ratio, 4.427; 95% confidence interval, 1.040–18.849), but MT+ was not associated (odds, 1.837; 95% confidence interval, 0.376–8.979). CONCLUSION: The new concept of CAT for transfusion was a more useful validation concept of mortality in adult severe trauma patients on admission than traditional MT. Encompassing both the rate and volume of transfusion, CAT is a more sensitive tool than common MT definitions.

Association between public cardiopulmonary resuscitation education and the willingness to perform bystander cardiopulmonary resuscitation: a metropolitan citywide survey

OBJECTIVE: Bystander cardiopulmonary resuscitation (CPR) is an important factor associated with improved survival rates and neurologic prognoses in cases of out-of-hospital cardiac arrest. We assessed how factors related to CPR education including timing of education, period from the most recent education session, and content, affected CPR willingness. METHODS: In February 2012, trained interviewers conducted an interview survey of 1,000 Daegu citizens through an organized questionnaire. The subjects were aged ≥19 years and were selected by quota sampling. Their social and demographic characteristics, as well as CPR and factors related to CPR education, were investigated. Chi-square tests and multivariate logistic regression analyses were used to evaluate how education-related factors affected the willingness to perform CPR. RESULTS: Of total 1,000 cases, 48.0% were male. The multivariate analyses revealed several factors significantly associated with CPR willingness: didactic plus practice group (adjusted odds ratio [AOR], 3.38; 95% confidence interval [CI], 2.3 to 5.0), group with more than four CPR education session (AOR, 7.68; 95% CI, 3.21 to 18.35), interval of less than 6 months from the last CPR education (AOR, 4.47; 95% CI 1.29 to 15.52), and education with automated external defibrillator (AOR, 5.98; 95% CI 2.30 to 15.53). CONCLUSION: The following were associated with increased willingness to perform CPR: practice sessions and automated electrical defibrillator training in public CPR education, more frequent CPR training, and shorter time period from the most recent CPR education sessions.

Descending necrotizing mediastinitis after a trigger point injection

Descending necrotizing mediastinitis (DNM) is a rare form of mediastinal infection. Most cases are associated with esophageal rupture. DNM after a trigger point injection in the upper trapezius has not been described previously. We present a case of DNM after a trigger point injection in the upper trapezius. A 70-year-old man visited the emergency department with chest discomfort and fever after a trigger point injection in the left upper trapezius. Chest computed tomography showed evidence of DNM, and antibiotic therapy was immediately administered intravenously. Because of the risk of sudden death, poor prognosis due to underlying disease, and his age, he declined surgical treatment and died of septic shock. Although trigger point injections are generally considered safe, caution should be used in patients with an underlying disease or in the elderly. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical management are essential to improve the prognosis.

Association of Public CPR Education with Willingness to Perform Bystander CPR: A Metropolitan City Wide Survey

PURPOSE: Bystander cardiopulmonary resuscitation (CPR) is an important factor in improving the survival rate and neurologic prognosis for out-of-hospital cardiac arrest patients. Here, we aimed to establish factors related to CPR education, such as timing of education, interval from the most recent education session, and contents, that may influence CPR willingness. METHODS: In February 2012, an interview survey of 1,000 Daegu citizens was conducted via organized questionnaire, administered by trained interviewers. Subjects were aged 19 years or older and selected by a quota sampling technique. Social and population characteristics, factors related to CPR, and factors related to CPR education, were investigated. The chi-square test and multivariate logistic regression analysis were used to evaluate education-related factors that may affect the willingness to perform CPR. RESULTS: The adjusted odds ratio (OR) for CPR willingness was 3.38 (95% confidence interval [CI], 2.3–5.0) among the respondents in the didactic plus practice group. The adjusted OR for CPR willingness was 7.68 (95% CI, 3.21–18.35) among the respondents receiving over 4 CPR education sessions. The adjusted OR for CPR willingness, in accordance with the time interval from the last CPR education session, was 4.47 (95% CI, 1.29–15.52) for intervals under 6 months and 3.80 (95% CI, 1.91–7.56) for intervals between 6 months and 1 year. If automated external defibrillator (AED) training was included in CPR education, the adjusted OR for CPR willingness was 5.98 (95% CI, 2.30–15.53). CONCLUSION: Including practice sessions and AED training in public CPR education, more frequent CPR revision and short time intervals in between CPR education sessions are associated with greater willingness to perform CPR.

Usefulness of New Berlin Definition of Polytrauma for Mortality Prediction in Adult Patients with Major Trauma

PURPOSE: The terminology that represented major trauma was vague, inconsistent, and lacked validation. The objective of this study is to investigate the new definition of polytrauma in adult patients of major trauma. METHODS: A retrospective data of adult major trauma patients [Age≥15, 16≤Injury Severity Score (ISS)<75] from a regional trauma center were collected in period between July 2011 and December 2013 and divided into two groups: polytrauma and non-polytrauma. We compared the demographic, laboratory characteristics, and outcomes in patients with major trauma, polytrauma and non-polytrauma. Univariate associations were calculated, and a multiple logistic regression analysis was used to determine the parameters associated with in-hospital mortality and early death. RESULTS: A total of 662 patients met the inclusion criteria for major trauma. Of these, 150 (22.7%) met the new polytrauma definition. In the major trauma group, the mean ISS was 22, in-hospital mortality rate was 23.4%, and early death rate was 20.7%. In the polytrauma group, ISS was 27, in-hospital mortality rate was 44.7%, and early death rate was 38.7%. In the non-polytrauma group, ISS was 20, in-hospital mortality rate was 17.2%, and early death rate was 15.4%. Of the five physiologic parameters (systolic blood pressure≤90 mmHg, Glasgow Coma Scale≤8, base deficit≥6, international normalized ratio≥1.4/activated partial thromboplastin time≥40 seconds, age≥70 years), the lowest in-hospital mortality was found when one parameter was involved (2.5%), and the highest mortality was found when all parameters were involved (100%). CONCLUSION: Based on “The new Berlin definition”, polytrauma was associated more with in-hospital mortality and early death than non-polytrauma in adults. The five physiologic parameters were correlated with in-hospital mortality.

Usefulness of Initial Red Cell Distribution Width for Predicting Mortality in Severe Trauma Patients Admitted to the Emergency Department

PURPOSE: This study investigated the association between the initial red cell distribution width (RDW) and mortality in patients with severe trauma. METHODS: We conducted a retrospective analysis between January and December 2014. Severe adult trauma patients (age≥18, Injury Severity Score≥16), who were treated in our emergency department, were included in this study. We classified patients into four groups in accordance with their RDW (group 1: RDW≤12.3%, group 2: 12.4%≤RDW≤12.6%, group 3: 12.7%≤RDW≤13.2%, group 4: 13.3%≤RDW). They were compared based on the characteristics of their groups. We also compared the baseline characteristics of patients who survived and did not survive. Univariate and multivariate Cox proportional hazard analyses were performed to determine the association between mortality and each variable. RESULTS: We enrolled 364 severe trauma adult patients. The mortality rate was 8.9%, 16.2%, 12.6%, and 20.4% for RDW groups 1, 2, 3, and 4, respectively; there was no statistical significance. The RDW of patients who survived (n=311) and did not survive (n=53) were 12.7% (12.4-13.3%) and 12.9% (12.5-13.6%), respectively, but this was also not statistically significant (p=0.075). Univariate Cox proportional hazard analysis showed a significant difference between the mortality and initial RDW, but a multivariate analysis did not show an independent association between initial RDW and mortality (hazard ratio, 0.729; confidence interval, 0.508-1.047; p=0.087). Moreover, multivariate analysis did not also show a significant difference between RDW quartile groups according to route of hospital visit. CONCLUSION: There was no independent association between the initial RDW and mortality in patients with severe trauma.

Characteristics and Risk Factors of Pediatric Eye Injury Patients in Emergency Department: Multicenter Cross-Sectional Study

PURPOSE: This study was conducted in order to determine the characteristics and risk factors of pediatric eye injury patients in the emergency department and to offer strategies for prevention of pediatric eye injury. METHODS: This prospective study was conducted by use of a standardized eye injury survey of patients under the age of 16 years who were treated for ocular injury at nine emergency medical centers, from March to September of 2010. The following data were collected; general characteristics of the study population, type and location of injury, causative activities, and materials of injury. Risk factors associated with open-globe injury were analyzed by logistic regression. RESULTS: A total of 1,151 patients were enrolled in the study; 75% were male. The highest incidence was observed between the age of 11 and 16 years (34.5%); 79.2% of patients had closed globe injury. The most common type of injury was contusion (65.4%) in closed globe injury and penetration (5.1%) in open-globe injury. Eye injury occurred most commonly at home (48.6%), followed by school/institution (19.4%). The most common causative activity and material were play (42.4%) and person/animal/plant (17%). Application of eye protective equipment (odds ratio: 24.33; 95% CI: 11.32~52.29) was found to be a statistically significant factor for occurrence of an open-globe injury. CONCLUSION: Establishment of safety measures considering gender and age is important since characteristics of pediatric eye injury differ based on such risk factors. The risk of open-globe eye injury increased with application of personal protective equipment, therefore, public education and promotion to use protective equipment of adequate level would be considered important.

Application of New Trauma Scoring Systems for Mortality Prediction in Patients with Adult Major Trauma

PURPOSE: Various scoring systems have been introduced in grading severity and predicting mortality of trauma patients. The objective of this study is to apply novel trauma scoring systems; BIG score (Base deficit (B), International normalized ratio (I), Glasgow Coma Scale (G)), Emergency Trauma Score (EMTRAS), Probability of Survival score version 12 (PS12), and MGAP (Mechanism, GCS, Age, Arterial pressure) to adults with major trauma, and to compare their performance with traditional systems; Injury Severity System (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS). METHODS: Retrospective data collected between January 2011 and June 2012 from a regional trauma center registry on adult major trauma patients (Age> or =18, ISS> or =16) were used to identify factors associated with death. Univariate associations were calculated, and a multiple logistic regression analysis was used to determine variables associated with hospital mortality. RESULTS: A total of 298 adult major trauma patients were retrieved in order to validate new trauma scoring systems. The median ISS was 22 [interquartile range (IQR) 17~25], and the hospital mortality rate was 30.9%. Traditional trauma scoring systems were each calculated to have an area under the curve of ISS 0.72 [95% confidence interval (CI): 0.67-0.77], TRISS 0.91 (95% CI: 0.88-0.94), and RTS 0.90 (95% CI: 0.86-0.93). New trauma scoring systems were calculated to have an area under the curve of EMTRAS 0.91 (95% CI: 0.87-0.94), BIG score 0.90 (95% CI: 0.86-0.93), PS12 0.91 (95% CI: 0.87-0.94), and MGAP 0.89 (95% CI: 0.85-0.93). CONCLUSION: The new trauma scoring systems (EMTRAS, BIG, MGAP) were good predictors of mortality in adult major trauma patients on admission. They performed well compared to traditional trauma scoring systems (ISS, RTS, TRISS).

Work-related Fatigue, Stress and Depression of the Emergency Department Interns

PURPOSE: An internship is a very generally a stressful period during medical training in general. Working in the Emergency Department (ED) is especially difficult and stressful because of its unique clinical environment. Our goal was to determine the level of the depression, fatigue, sleep disorders and stress of interns in the ED. METHODS: A questionnaire was distributed to 430 interns who are working or had worked in the ED. The questionnaire included questions about general characteristics and scales relating to symptoms of depression, fatigue, sleep disorder and stress. RESULTS: Of the 430 questionnaires given out, 178(41.4%) were returned. The mean age of the participants was 28.4+/-2.9, and 123(69.5%) were male. Also, 112(63.3%) participants were working at an alumni-affiliated hospital or at related hospital. The interns at an unrelated hospital experienced more discrimination than those working at an alumni-related hospital (21.5% vs. 9.8%, respectively, p=0.031). Also, female interns experienced more sexual harassment than male interns (16.7% vs. 2.4%, respectively, p=0.001). The average score for medical outcomes study MOS sleep scale, Beck Depression Inventory, Fatigue Severity Scale and Cohen Perceived Stress Scale were 16.2+/-4.0, 8.0+/-7.8, 4.3+/-1.2 and 19.4+/-5.4, respectively. The degree of participation in treating patients first hand (OR 2.33, 95% CI=1.19-4.57), experiencing discrimination (OR 3.17, 95% CI=1.15-8.73) and long working hours (OR 2.02, 95% CI=1.05-3.86) had a significant effect on stress and depression. CONCLUSION: The interns who worked at an ED had higher fatigue and stress scores compared to ordinary person. Also, participation, discrimination and working hours may be good to mention. Therefore, more research and effort is required to improve the factors that cause fatigue, stress and depression of the interns in ED.

Urban-Rural Gap in the Prehospital Delay of Acute Stroke Patients

PURPOSE: The aim of this study was to compare the difference in acute stroke management between urban and rural areas, to investigate the factors affecting these differences, and to acquire basic information for establishing an efficient regional hub and spoke system for stroke patients. METHODS: This retrospective study was based on adult patients diagnosed with acute ischemic stroke from January 2012 to December 2012 at a regional cerebrovascular center. The term "acute" was defined as 24 hours from symptom recognized. The term "urban" was defined as the region within the boundary of a metropolitan area. The distance from the symptom onset location to the stroke center was calculated using a global positioning system. RESULTS: The rate of arriving at a stroke center within 3 hours after stroke recognition for acute ischemic stroke patients was much higher in urban areas compared to rural areas (27.5 vs. 19.2%, respectively; p-value=0.011). In stroke cases in rural areas, the distance from symptom onset location to a stroke center was determined as statistically significant through multivariate logistic regression analysis (Odds ratio (OR), 0.982; 95% Confidence interval (CI) 0.969-0.995). In contrast, the use of a public ambulance (OR, 4.258; 95% CI 2.233-8.118) and inter-hospital transfer (OR, 0.416; 95% CI 0.216-0.800) were the main prehospital delay factors in urban areas. CONCLUSION: For stroke cases in urban areas, it was important to directly visit a stroke center without transfer using a public ambulance. For rural areas, a new hub hospital and policies are necessary for reducing prehospital delay.

Acute Traumatic Coagulopathy in Severe Trauma Patients

PURPOSE: Clinical observation and research findings show that acute traumatic coagulopathy (ATC) is a major factor that must be addressed in the early care of severe trauma patients. ATC is associated with increased transfusion requirements and poor clinical outcomes. This study aimed to correlate the early predictable factors of ATC with the outcomes in severe trauma patients. METHODS: Retrospective data from the trauma registry on severe trauma patients (Injury Severity Score (ISS)> or =16) were used to identify variables independently associated with coagulopathy. Univariate associations were calculated, and a multivariable logistic regression analysis was used to determine variables independently associated with ATC. RESULTS: Patients were mostly male, aged 51.9+/-17.8 years, with an injury severity score of 24.1+/-12.4. ATC, as diagnosed in the emergency department (ED), occurred in 17% of the severe trauma patients. Using a multivariable logistic regression analysis, early predictable variables independently associated with ATC were base deficit (odds ratio (OR): 13.03; 95% confidence interval (CI): 3.47-48.93), acute liver injury (OR: 4.24; 95% CI: 1.06-17.00), and transfer from another hospital (OR: 21.00; 95% CI: 3.23-136.60). CONCLUSION: ATC is associated with mortality in severe trauma patients, and some variables associated with trauma and shock are an independent predictors of ATC. These variables contribute to the early recognition and management of coagulopathy, which may improve the outcome from trauma resuscitation.

The Current Status of Cardiopulmonary Resuscitation Training for School

PURPOSE: Cardiopulmonary resuscitation (CPR) education for school is extremely important in the community. In Korea, the curriculum for health care training including CPR has been established by law since 2009. The aim of this survey was to investigate the current status of CPR training in school from the viewpoint of program administration and their aids. METHODS: In January 2012, we conducted an interview survey with 243 health teachers regarding their educational status and confidence, current education condition for school, teaching materials, and opinion on governmental health policy. The characteristics of survey respondents were compared according to elementary, middle, and high school. According to their place of work, we focused on teaching methods and programs for implementation of adequate CPR practices. RESULTS: Half of the participants worked in elementary schools, 29% in middle schools, and 20% in high schools. Ninety-four percent of elementary respondents reported having ever run a CPR curriculum, and 51% of middle school respondents and 41% of high school respondents administered CPR education in 2011. The median time for CPR lessons was two class hours [interquartile range (IQR): 1~2]. The median number of students per lesson was 30 (IQR: 26~71). Among those who had been trained, 84% of the elementary school, 56% of middle school, and 55% of the high school had performed manikin practice. Healthcare textbooks (58%), group-used manikins (31%), visual aids (24%), and only 6% of individual practice manikins were secured for use as CPR teaching aids. CONCLUSION: Wide variations in CPR curriculums and educational materials were observed among different school levels, and the standard program administrations and equipment were insufficient. Therefore, strategies and guidelines for program administration should be established as soon as possible.