A single emergency center study for obstructive urinary tract infection with sepsis

Objective@#Unlike common acute urinary tract infections, obstructive urinary tract infections caused by urinary calculus can be fatal because they can progress to sepsis and cause shock or disseminated intravascular coagulation. The evidence of patients with obstructive urinary tract infections caused by urinary tract stones visiting the emergency center is still lacking. @*Methods@#Seventy-seven patients who visited the emergency room with obstructive urinary tract infections caused by urinary calculus from January 2016 to December 2018 were enrolled in this study and divided into two groups: sepsis group and non-sepsis group. @*Results@#The lymphocyte count, platelet count, neutrophil-lymphocyte ratio, serum creatinine, and C-reactive protein were significantly different in the sepsis-positive and negative groups. Percutaneous nephrostomy was also significantly higher in the sepsis-positive group. The area under the receiver operating characteristic curve was calculated to evaluate the ability of the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio to predict a septic urinary tract infection. The neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were 0.659 and 0.550, respectively. Multivariate logistic regression analysis showed that diabetic patients, percutaneous nephrostomy, and serum creatinine were associated with septic obstructive urinary tract infection. @*Conclusion@#In patients with an obstructive urinary tract infection who were referred to the emergency center, diabetic patients and those with high blood urea nitrogen and creatinine levels are at high risk of sepsis. In such cases, rapid diagnosis and treatment, such as percutaneous nephrostomy, are necessary.

National survey of awareness and training experience of automated external defibrillator

OBJECTIVE: Public concerns and awareness of automated external defibrillators (AEDs) are essential for improving the survival outcomes of out-of-hospital cardiac arrest (OHCA) in the community. On the other hand, the proportion of OHCA, in which AED is used in a prehospital setting, is very low in Korea. The aim of this study was to identify the barriers and training issues of AEDs. METHODS: A nationwide population-based survey was conducted to analyze the current public trends in AED awareness, training, and intention to use in 2017 (n=506). The barriers and training issues of AEDs were then documented. For trend analysis, previous tri-temporal surveys were obtained in 2007, 2011, and 2015. RESULTS: Public awareness of AEDs has increased: from 5.8% in 2007, to 30.6% in 2011, 82.6% in 2015, and 79.4% in 2017 (P<0.001). The training experience of AEDs has increased over time: from 0.5% in 2007 to 8.2% in 2011 and 33.2% in 2017. Thirty-two percent of respondents knew how and where to find the AEDs, but only 12.5% were able to certainly locate their public-access AED near their residency or work places. The reasons for being unwilling to use the AED included not knowing how to use (65.0%), fear of causing harm to the victim (21.3%), and legal liability (11.7%). CONCLUSION: Not knowing the location of AED and how to use it, and being unaware of the Good Samaritan Law were the major barriers to public access defibrillation. Further research is urgently needed if AEDs are to be increased and more lives saved.

A single emergency center study on the Canadian Syncope Risk Score applied to a patients visited with syncope in Korea

OBJECTIVE: Syncope is mostly benign, but it can also be caused by a life-threatening situation. In Korea, no studies have investigated application of the Canadian Syncope Risk Score (CSRS) to patients with syncope; therefore, this study was started to evaluate the usefulness of CSRS. METHODS: A total of 222 patients who visited the emergency room with syncope for one year from January 2016 to December 2016 were enrolled in this study. Patients were divided into two groups, a serious adverse events (SAE) group and a non-serious adverse events group. The scores of the nine CSRS variables were added and the CSRS was then calculated after the addition. RESULTS: The CSRS score for patients with SAE ranged from 0 to 8. The CSRS score was 18.6%, 31.7%, 55.6%, and 58.8% for 0, 1, 2, and 3, respectively. In the case of CSRS 0 and 1, 17 patients (81.0%) and 11 patients (84.6%) were non-cardiac. In the case of CSRS 2, 7 were non-cardiac (70.0%). In the case of CSRS 3, 6 cases (60.0%) were cardiogenic and 4 cases (40.0%) were non-cardiogenic. The area under the receiver operating characteristic curve of CSRS to predict SAE was 0.71. Setting the CSRS cutoff value to 0, we found that sensitivity and specificity of predicting SAE was 67.19% and 67.09%, respectively. CONCLUSION: CSRS may be difficult to predict for acute intracranial disease or acute hemorrhagic disease requiring transfusion; therefore, it is necessary to supplement it further.

General Characteristics for Poisoning-Induced Transient or Sustained Hyperammonemia

PURPOSE: In patients with altered mentality caused by drugs or unknown causes, ammonia is checked to facilitate differential diagnosis or diagnose hepatic coma. This helps early prevention and treatment of brain damage due to hyperammonemia. This study was conducted to evaluate clinical characteristics of intoxicated adult patients with hyperammonemia. METHODS: We evaluated 95 patients with hyperammonemia among intoxicated patients above the age of 15 who visited our ED from January 2013 to December 2015. We analyzed the demographic characteristics and type of poisoning substance, reason for ingestion, toxicological characteristics such as elapsed time from ingestion to hospital visit, lab, clinical progression and complications. Data were evaluated using the student's t test or Mann-Whitney U test for continuous variables, and Chi-square test and Fisher's exact test for frequency analysis of categorical variables. RESULTS: When compared to healthy individuals, patients with hyperammonemia showed statistical significance on their SOFA score (p=0.016) and poison severity score (p<0.001). Additionally, patients with hyperammonemia showed significantly different initial serum AST level (p=0.012) and maximum serum AST level during the hospital stay (p=0.026) when compared to healthy individuals. Moreover, individuals with sustained hyperammonemia compared to transient hyperammonemia showed clinically significant SOFA scores (p<0.001), poison severity scores (p=0.007), mortality rates in the ICU (p=0.021), as well as different duration of hospital stay (p=0.037), serum creatinine level (p=0.002), erythrocyte sedimentation rate (p=0.025), and serum myoglobin (p=0.015). CONCLUSION: Most poisoning-induced hyperammonemia cases were transient and recovered without special treatment. Therefore, hyperammonemia is almost non-specific among poisoning patients.

The Poisoning Information Database Covers a Large Proportion of Real Poisoning Cases in Korea

The poisoning information database (PIDB) provides clinical toxicological information on commonly encountered toxic substances in Korea. The aim of this study was to estimate the coverage rate of the PIDB by comparing the database with the distribution of toxic substances that real poisoning patients presented to 20 emergency departments. Development of the PIDB started in 2007, and the number of toxic substances increased annually from 50 to 470 substances in 2014. We retrospectively reviewed the medical records of patients with toxic exposure who visited 20 emergency departments in Korea from January to December 2013. Identified toxic substances were classified as prescription drug, agricultural chemical, household product, animal or plant, herbal drug, or other. We calculated the coverage rate of the PIDB for both the number of poisoning cases and the kinds of toxic substances. A total of 10,887 cases of intoxication among 8,145 patients was collected. The 470 substances registered in the PIDB covered 89.3% of 8,891 identified cases related to poisoning, while the same substances only covered 45.3% of the 671 kinds of identified toxic substances. According to category, 211 prescription drugs, 58 agricultural chemicals, 28 household products, and 32 animals or plants were not covered by the PIDB. This study suggested that the PIDB covered a large proportion of real poisoning cases in Korea. However, the database should be continuously extended to provide information for even rare toxic substances.

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.

Enhanced Strategies through National Tri-temporal Analysis of Public Capacity Prepared for Laypersons' Cardiopulmonary Resuscitation

PURPOSE: Bystander cardiopulmonary resuscitation (CPR) and dissemination of its training are essential to improve the survival outcomes of sudden cardiac death. The purpose of this study was to investigate the tri-temporal trend analysis of the national CPR capacity variables and preparedness in a community. METHODS: This nationwide population-based study used structured questionnaire by a telephone survey for CPR in 2007 (n=1,029), in 2011 (n=1,000), and in 2015 (n=1,000). We used stratified cluster sampling to assess the impact of age, gender, and geographic regions. The contents in the questionnaire consisted of CPR awareness, self-efficacy for bystander CPR, prior training status, and willingness of public CPR training. RESULTS: The proportion of CPR awareness and its recent training experience (<2 years) increased from 89.0% and 14.6%, respectively, in 2007 to 88.5% and 18.7% in 2011, and finally to 94.8% and 30.6% in 2015 (both p for trend<0.001). More than 95% of respondents had agreed to mandatory CPR training acquiring a driver's license or CPR education in school. The awareness of Good Samaritan Law was increased from 20.5% in 2011 to 28.7% in 2015; however, the overall values were lower than the other CPR-related awareness and preparedness. CONCLUSION: In Korea, the trends of national CPR capacity index have been increasing during the past decade. However, the public awareness of the Good Samaritan Law was still low. We suggest that promoting the Good Samaritan Law should be the next step in preparing public CPR training in the future.

National Survey of Training Methodology between Experience and Needs for Laypersons' Cardiopulmonary Resuscitation

PURPOSE: The purpose of this study was to perform a comparative analysis of training methodology between accessibility and needs for cardiopulmonary resuscitation (CPR) in the community. METHODS: This population-based nationwide study used a structured questionnaire via telephone survey in 2011-2012. The study was conducted by stratified cluster sampling to assess the impact of age, gender, and geographic regions (n=1,000). The contents of the questionnaire consisted of awareness, prior training status, and willing methodology of public CPR training. RESULTS: Thirty-eighty percent of respondents (n=381) had previously been taught CPR. Military service, education facility/ school, and workplace were 3 major resources of public CPR training among previously educated subjects (45%, 23%, and 9%, respectively). Seventy-two percent of trainees had been taught less than an hour and only 60% were trained using an individual manikin for CPR practice. Fifty-nine percent (n=593) had willingness to participate in CPR education and 40% of subjects wished to learn in a hospital or health care facility. Place of CPR training showed a major difference between previous experiences and willing groups in the community. Women and elders were more likely to learn CPR. Almost all respondents wanted short-duration learning (<1 hour), however, it was similar in the groups. CONCLUSION: In the scope of the public, training site showed a significant discrepancy between previous accessibility and needs of layperson. They prefer a highly accessible location and method with relatively short-practice programs.

Degree of Satisfaction with Indirect Medical Oversight Programs to 119 Rescue Services

PURPOSE: The purpose of this study was to identify the degree of satisfaction with indirect medical oversight programs and its determinants. METHODS: Gumi 119 rescuers participated in indirect medical oversight programs, including Emergency Medical Services (EMS) record review, weekly visiting education, and monthly EMS conference from March 2012 to February 2013. Data were collected using a mail survey with a self-administered questionnaire. The degree of satisfaction with the programs was categorized according to two groups (1=satisfied, 2=unsatisfied). Then the Mann-Whitney U test and Fisher's exact test were performed in order to find statistically significant factors influencing satisfaction. RESULTS: Cronbach alpha of questionnaires was 0.869. Among the 59 questionnaires, 55(93.2%) were returned. No differences in sex, age, career, EMS record review, monthly conference, linkage with direct medical direction, and improvement of confidence in ER medical team were observed between the two groups. Qualification, weekly visiting program, and improvement in reliability to hospital showed statistical significance (p=0.017, 0.040 and 0.001, respectively). CONCLUSION: The level of qualification of 119 rescuers and weekly visiting education at the fire department by doctors has had a significant influence on satisfaction with indirect medical oversight.

Degree of Satisfaction with Indirect Medical Oversight Programs to 119 Rescue Services

PURPOSE: The purpose of this study was to identify the degree of satisfaction with indirect medical oversight programs and its determinants. METHODS: Gumi 119 rescuers participated in indirect medical oversight programs, including Emergency Medical Services (EMS) record review, weekly visiting education, and monthly EMS conference from March 2012 to February 2013. Data were collected using a mail survey with a self-administered questionnaire. The degree of satisfaction with the programs was categorized according to two groups (1=satisfied, 2=unsatisfied). Then the Mann-Whitney U test and Fisher's exact test were performed in order to find statistically significant factors influencing satisfaction. RESULTS: Cronbach alpha of questionnaires was 0.869. Among the 59 questionnaires, 55(93.2%) were returned. No differences in sex, age, career, EMS record review, monthly conference, linkage with direct medical direction, and improvement of confidence in ER medical team were observed between the two groups. Qualification, weekly visiting program, and improvement in reliability to hospital showed statistical significance (p=0.017, 0.040 and 0.001, respectively). CONCLUSION: The level of qualification of 119 rescuers and weekly visiting education at the fire department by doctors has had a significant influence on satisfaction with indirect medical oversight.

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).

Application of Poisoning aBIG score for Prediction of Fatal Severity in Acute Adult Intoxications

PURPOSE: The objective of this study was to develop a new scoring tool that is comprehensively applicable and predicts fatality within 24 h of intoxication. METHODS: This was a cohort study conducted in two emergency medical centers from 2011 to 2012. We identified factors associated with severe/fatality. Through a discriminant analysis, we devised the aBIG (age, Base deficit, Infection, and Glasgow coma scale) score. To compare the ability of aBIG to predict intoxication severity with that of previous scoring systems such as APACHE II, MODS, SAPS IIe, and SOFA, we determined the receiver operating characteristic curves of each variable in predicting severe-to-fatal toxicity. RESULTS: Compared with the mild/moderate toxicity group (n=211), the severe/fatal group (n=143) had higher incidences of metabolic acidosis, infection, serious mental change, QTc prolongation and hepato-renal failure. Age, base deficit, infection-WBC count, and Glasgow Coma Scale were independently associated with severe/fatal poisoning. These variables were combined into the poisoning "aBIG" score [0.28xAge group+0.38xWBC count/10(3)+0.52xBase deficit+0.64x(15-GCS)], which were each calculated to have an area under the curve of 0.904 (95% confidence interval: 0.868-0.933). The aBIG poisoning score had an equivalent level of severity predictability as APACHE II and a superior than MODS, SOFA, and SAPS IIe. CONCLUSION: We developed a simplified scoring system using the four variables of age, base deficit, infected leukocytosis, and GCS. The poisoning aBIG score was a simple method that could be performed rapidly on admission to evaluate severity of illness and predict fatal severity in patients with acute intoxications.

Application of Poisoning aBIG score for Prediction of Fatal Severity in Acute Adult Intoxications

PURPOSE: The objective of this study was to develop a new scoring tool that is comprehensively applicable and predicts fatality within 24 h of intoxication. METHODS: This was a cohort study conducted in two emergency medical centers from 2011 to 2012. We identified factors associated with severe/fatality. Through a discriminant analysis, we devised the aBIG (age, Base deficit, Infection, and Glasgow coma scale) score. To compare the ability of aBIG to predict intoxication severity with that of previous scoring systems such as APACHE II, MODS, SAPS IIe, and SOFA, we determined the receiver operating characteristic curves of each variable in predicting severe-to-fatal toxicity. RESULTS: Compared with the mild/moderate toxicity group (n=211), the severe/fatal group (n=143) had higher incidences of metabolic acidosis, infection, serious mental change, QTc prolongation and hepato-renal failure. Age, base deficit, infection-WBC count, and Glasgow Coma Scale were independently associated with severe/fatal poisoning. These variables were combined into the poisoning "aBIG" score [0.28xAge group+0.38xWBC count/10(3)+0.52xBase deficit+0.64x(15-GCS)], which were each calculated to have an area under the curve of 0.904 (95% confidence interval: 0.868-0.933). The aBIG poisoning score had an equivalent level of severity predictability as APACHE II and a superior than MODS, SOFA, and SAPS IIe. CONCLUSION: We developed a simplified scoring system using the four variables of age, base deficit, infected leukocytosis, and GCS. The poisoning aBIG score was a simple method that could be performed rapidly on admission to evaluate severity of illness and predict fatal severity in patients with acute intoxications.

Associations between Sleep Quality, Daytime Sleepiness, with Perceived Errors during Nursing Work among Hospital Nurses / 農村醫學 地域保健

OBJECTIVES: The objective of this study was to identify the influence of shift work on sleep quality, daytime sleepiness, and perceived errors during nursing work among hospital nurses. METHODS: The study subjects were 209 hospital nurses working in two general hospitals in South Korea. The data were collected through self-administered questionnaires in May 2013. Sleep quality was measured using Korea Pittsburgh Sleep Quality Index (PSQI-K), daytime sleepiness was measured using Epworth Sleepiness Scale (ESS), and perceived errors in past 6 months during nursing duty hours with the tool developed in this study. RESULTS: The sleep quality was significantly worse among rotating shift nurses when compared to fixed day duty nurses. However, the odds ratio (OR) of 1.92 [95% confidence interval(CI): 0.58-6.37] adjusted for sociodemographic variables, health behaviors, and working environment in logistic regression was not significant. There was no significant difference in the daytime sleepiness between rotating shift nurses and fixed day duty nurses in both simple and multivariable analyses. There were significantly more perceived errors in rotating shift nurses than fixed day duty nurses. However, the OR of 1.26 (95% CI: 0.38-4.21) adjusted for sociodemographic variables, health behaviors, working environment, sleep quality, and daytime sleepiness in logistic regression was not significant. Depression (OR=3.31, 95% CI: 1.11-9.84) and daytime sleepiness(OR=1.18, 95% CI: 1.07-1.30) were significantly associated with perceived errors in logistic regression. CONCLUSION: This study suggested shift work among hospital nurses had no independent influence of sleep quality, daytime sleepiness, and perceived errors. However, daytime sleepiness had independent influence of perceived errors. More studies are warranted to achieve more reliable conclusion.

The Association of Trust, Social Participation with Self-Rated Health Status: Mediating Effect of Depression / 農村醫學 地域保健

OBJECTIVES: This study was performed to investigate the relationship between individual-level social capital and depression. And, we assessed if depressive symptom mediates the relationship between social capital and self-rated health status. METHODS: Data from the 2011 Community Health Survey were analyzed for this study. We used chi-square tests and analyzed a four step approach in which several regression analyses were conducted and significance of the coefficients was examined at each step. RESULTS: In men, the results of controlling mediating factor (depression): social participation was not significantly associated with self-rated health status(p=0.082), the finding supports that social participation was fully mediated by depression. In women, the relationship between social capital(trust, social participation) and self-rated health status was partially mediated by depression. CONCLUSIONS: In order to increase self rated health status, not only improvement in trust and social participation are needed but effort to reduce depression must be combined.

Inadequate Post-hoc Statistical Power Analysis in Journal of the Korean Society of Emergency Medicine

PURPOSE: Negative studies provide valuable information. However, conducting studies with inadequate power is unethical and an inefficient use of resources. Moreover, inaccurate interpretations from underpowered studies result in false conclusions that alter clinical interventions and deter further research. The purpose of this study was to determine the prevalence of negative studies with inadequate power in the Journal of the Korean Society of Emergency Medicine (JKEM). METHODS: We assessed all papers in JKEM from 2009 to 2012. We sought published evidence that a post-hoc power analysis had been performed in association with the main hypothesis of the paper. All clinical research studies containing the phrase "no difference" were identified. Data necessary for power calculation were extracted from applicable studies. RESULTS: There were a total of 351 papers in which a statistical comparison was undertaken. Out of 351 original articles, 170(48.4%) were negative studies that contained enough information for analysis. Out of 126 negative studies in JKEM, only 21((16.7%) had performed a power analysis demonstrating adequate sample size. In addition, only 6.3% of dichotomous variable articles and 10.3% of continuous variable articles had adequate power. Levels of adeadequate power in negative studies did not improve over time (p=0.148). CONCLUSION: Many negative studies in JKEM are inconclusive because they lack the adequate power to detect even large differences between groups. Therefore, it is imperative to consider power when interpreting the literature. When designing future research, power calculations should be performed to ensure sufficient patient recruitment to attain clinically meaningful results.

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.

Effectiveness of Indirect Medical Oversight on the Quality of Prehospital Emergency Care by Emergency Medical Technicians

PURPOSE: This study examined the effect of indirect medical oversight on the quality of prehospital emergency care by emergency medical technicians. METHODS: Indirect medical oversight was applied for a year and 119 rescue run sheets were retrospectively analyzed before and after the program to study the effect of an indirect medical oversight program in one city. The general characteristics of patients who visited hospitals before and after the program were analyzed, along with patient evaluation records, personal data, outbreak patterns, transfer information, direct medical oversight, and emergency medical services (EMS) mobilization reports. In addition, by comparing medical records and the 119 rescue run sheets, changes in the accuracy of 119 rescue run reports, the adequacy of patient classification, and the adequacy of medical direction were analyzed. After gathering these data, statistical analysis was performed and the level of significance was defined as p<0.05. RESULTS: After executing the indirect medical oversight, there was significant improvement in the accuracy of 119 rescue run sheets (p<0.001) and in the consistency of severity classification in 119 rescue run sheets compared with medical records (p=0.016). The adequacy of direct medical oversight request also showed improvement after the indirect medical oversight took effect (p<0.001). However, there was no statistical significance in prehospital procedures. CONCLUSION: Indirect medical oversight significantly improved the quality of emergency medical service by emergency medical technicians. However, the further application and improvement of indirect medical oversight programs are required for the development of prehospital emergency medical care.

Analysis of the Impact on Community Health after Accidental Leak of Hydrofluoric Acid

PURPOSE: The purpose of this study is to verify the influence of a massive hydrofluoric acid spill on community health through patients who claimed to have been exposed. METHODS: We analyzed 2459 patients who visited our emergency department with the claim of exposure to hydrofluoric acid, and retrospective analyses were performed. We analyzed changes in numbers of visitors per day from the day of the accidental hydrofluoric acid spill, symptoms presented by the 1924 patients, and general characteristics. Comparisons of symptoms and hematologic characteristics were made between the initially set evacuation zone(1.3 km radius parameters from the spill) and the outer zone. RESULTS: A total of 2,459 patients who claimed exposure visited our ED from 27 September 2012 to 23 October 2012, and there was a significant increase in the number of visiting patients from day 8 of the hydrofluoric acid spill. The most common complaints were a sore throat, 729(37.9%) and no specific symptom with health concern, 547(28.4%). Statistically significant findings were pulmonary symptoms (p=0.001), nasal symptoms (p=0.001), diarrhea (p=0.023), and skin symptoms (p=0.007). In hematologic study, a statistically significant difference was observed in white blood cell count (p=0.018), creatine phosphokinase (p<0.001), erythrocyte sediment rate (p=0.013), and phosphorus (p<0.001). CONCLUSION: A significant increase in the number of patients was observed one week after the accidental spill of hydrofluoric acid. The most frequent symptoms were sore throat, headache, cough, and sputum. Statistically significant increase in creatine phosphokinase level and decrease in phosphorus level were noted in patients within the evacuation zone.

Clinical Review of Elderly Patients Who Visited the Emergency Department with Altered Mental Status

PURPOSE: The number of geriatric patients admitted to the emergency department (ED) is growing as the elderly population grows. The altered mental status of the elderly is more difficult to evaluate and manage than others. The purpose of this study was to determine the etiologies of altered mental status in elderly patients visiting the ED. METHODS: A retrospective study was made of 119 patients who visited the ED of Kyungpook National University Hospital for altered mental status from January 2001 to June 2002. RESULTS: The results of this study showed that extracranial causes (67.8%) were more than intracranial causes (31.9%): metabolic (35.3%), cerebrovascular (29.4%), extracranial infection (16.0%), cardiovascular (8.4%), drugs/toxins (8.4%), and intracranial infection (2.5%). The group with underlying disease or with brain imaging done showed more intracranial causes than extracranial causes. The results showed that the age, the initial Glasgow coma scale (GCS) score, a new positive finding on a brain image, and the causes of the mental change had significant influence on improvement of the mental status and on the survival rate (p < 0.05). CONCLUSION: Initial evaluation of the underlying disease, the GCS score, an early study of brain imaging, and a search for possible metabolic causes, as well as others should be done simultaneously to deliver high quality care to elderly patient. Knowledge of the most frequent causes of altered mental status in elderly patients may assist the emergency physician in the approaching these potentially ill patients and managing their care.