Out-of-hospital cardiac arrest outcomes according to the time of day: a citywide multicenter retrospective observational study

Objective@#The characteristics and prognosis of out-of-hospital cardiac arrest (OHCA) patients can vary due to a variety of factors, including the time of the day. We tried to identify the characteristics and prognosis of OHCA in a Korean metro city based on the time of the day. @*Methods@#This citywide retrospective observational study was conducted from January 1, 2015, to November 31, 2020, in Daegu, Korea on patients over 18 years of age who were suspected of having a medical etiology of OHCA. We evaluated the characteristics and outcomes of OHCA, according to the time of day, divided into dawn (00:00-05:59), morning (06:00-11:59), afternoon (12:00-17:59), and night (18:00-23:59). The outcome variables were survival to hospital discharge and favorable neurological outcomes. @*Results@#The median age of the total of 4,783 OHCA patients in the study was 72.0 years of which 3,096 (64.7%) were males. The number of patients who survived was 317 (7.8%) and 301 (6.3%) were discharged with favorable neurological outcomes. There were 672 (14.0%) patients admitted at dawn, 1,607 (33.6%) in the morning, 1,379 (28.8%) in the afternoon, and 1,125 (23.5%) at night. After adjusting for the possible confounding variables, compared with the morning group, the survival to hospital discharge was low in the afternoon and the night (adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.48-0.98 and aOR, 0.48; 95% CI, 0.32-0.74). In addition, favorable neurological outcomes were also low in the afternoon and the night compared with the morning (aOR, 0.59; 95% CI, 0.40-0.85 and aOR, 0.62; 95% CI, 0.41-0.93). @*Conclusion@#Diurnal differences in OHCA outcomes were observed. Identification of the diurnal OHCA characteristics will be necessary to devise an appropriate regional emergency medical services strategy.

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.

Mortality prognostic factors of COVID-19 in the emergency department during outbreak in Daegu, Korea: a multicenter retrospective study

Objective@#We aimed to investigate the characteristics and prognostic factors of coronavirus disease 2019 (COVID-19) patients in the emergency departments (EDs) in Daegu, Korea, the region with the second regional outbreak worldwide. @*Methods@#We conducted a retrospective observational multicenter study using a population-based COVID-19 registry of EDs. We included the demographic, clinical and laboratory data. Cox proportional hazard regression analysis was performed to identify the prognostic factors of mortality. @*Results@#A total of 241 patients were included in this study. In the Cox hazard regression model (hazard ratio [95% confidence interval]), age (65-79 years: 3.531 [1.529-8.156], ≥80 years: 5.335 [2.229-12.770]), respiratory rate (RR) (>20 breaths/min: 2.025 [1.205-3.403], ≤11 breaths/min: 111.292 [30.845-401.555]), lymphocyte counts 23 mg/dL (2.047 [1.233-3.399]), aspartate aminotransferase (AST) levels>40 IU/L (1.785 [1.009-3.158]) and neutrophil counts>6.3×109/L (1.638 [1.014-2.644]) were associated with mortality. @*Conclusion@#Age, RR, lymphocyte counts, BUN levels, AST levels and neutrophil counts were prognostic factors in COVID-19 patients in the ED. These factors can help effectively treat and reduce mortality through optimized management of COVID-19 patients, in places with limited emergency medical resources such as massive regional outbreaks.

Public awareness and willingness to use automated external defibrillators in a metropolitan city

Objective@#Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys. @*Methods@#Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs. @*Results@#Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10–1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43–2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13–1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26–5.93). @*Conclusion@#To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

Cervical epidural hematoma with Brown-Sequard syndrome caused by an epidural injection: a case report

Epidural hematoma with Brown-Sequard syndrome caused by an epidural injection is a rarely found condition in the emergency department (ED). We report an unusual case of Brown-Sequard syndrome in a 55-year-old man who presented at the ED with right-sided weakness and contralateral loss of pain and temperature sensation after a cervical epidural injection for shoulder pain. Cervicla spine magnetic resonance imaging showed an epidural hematoma from C4 to C6. After admission, his right hemiparesis and contralateral sensory loss improved within eight days, and surgical decompression was not required. Diagnosing spinal lesions in the ED is challenging, especially in patients with acute neurological signs requiring immediate evaluation for stroke. In this case, definite hemiparesis and some contralateral sensory loss were noted. Therefore, a potential spinal lesion was suspected rather than a stroke. This case emphasized the importance of conducting a focused neurological examination after history taking.

Public awareness and willingness to use automated external defibrillators in a metropolitan city

Objective@#Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys. @*Methods@#Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs. @*Results@#Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10–1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43–2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13–1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26–5.93). @*Conclusion@#To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

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.

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.

Long-term benefits of chest compression-only cardiopulmonary resuscitation training using real-time visual feedback manikins: a randomized simulation study

Objective@#Cardiopulmonary resuscitation (CPR) education with a feedback device is known to result in better CPR skills compared to one without the feedback device. However, its long-term benefits have not been established. The purpose of this study was to evaluate the long-term CPR skill retention after training using real-time visual manikins in comparison to that of non-feedback manikins. @*Methods@#We recruited 120 general university students who were randomly divided into the real-time feedback group (RTFG) and the non-feedback group. Of them, 95 (RTFG, 48; non-feedback group, 47) attended basic life support and automated external defibrillation training for 1 hour. For comparison of retention of CPR skills, the two groups were evaluated based on 2-minute chest compression performed immediately after training and at 3, 6, and 9 months. The CPR parameters between the two groups were also compared using a generalized linear model. @*Results@#At immediately after training, the performance of RTFG was better in terms of average chest compression depth (51.9±1.1 vs. 45.5±1.1, p<0.001) and a higher percentage of adequate chest compression depth (51.0±4.1 vs. 26.9±4.2, p<0.001). This significant difference was maintained until 6 months after training, but there was no difference at 9 months after training. However, there was no significant difference in the chest compression rate and the correct hand position at any time point. @*Conclusion@#CPR training with a real-time visual feedback manikin improved skill acquisition in chest compression depth, but only until 6 months after the training. It could be a more effective educational method for basic life support training in laypersons.

Comparing the neurologic outcomes of patients with out-of-hospital cardiac arrest according to prehospital advanced airway management method and transport time interval

Objective@#The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database. @*Methods@#We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome. @*Results@#Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65–2.87 for SGAs; OR, 1.31; CI, 0.30–5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31–1.07 for SGAs; OR, 0.63; CI, 0.12–3.26 for ETI). @*Conclusion@#Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.

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.

Determining the correlation between outdoor heatstroke incidence and climate elements in Daegu metropolitan city / 영남의대학술지

BACKGROUND@#Heatstroke is one of the most serious heat-related illnesses. However, establishing public policies to prevent heatstroke remains a challenge. This study aimed to investigate the most relevant climate elements and their warning criteria to prevent outdoor heatstroke (OHS).@*METHODS@#We investigated heatstroke patients from five major hospitals in Daegu metropolitan city, Korea, from June 1 to August 31, 2011 to 2016. We also collected the corresponding regional climate data from Korea Meteorological Administration. We analyzed the relationship between the climate elements and OHS occurrence by logistic regression.@*RESULTS@#Of 70 patients who had heatstroke, 45 (64.3%) experienced it while outdoors. Considering all climate elements, only mean heat index (MHI) was related with OHS occurrence (p=0.019). Therefore, the higher the MHI, the higher the risk for OHS (adjusted odds ratio, 1.824; 95% confidence interval, 1.102–3.017). The most suitable cutoff point for MHI by Youden’s index was 30.0°C (sensitivity, 77.4%; specificity, 73.7%).@*CONCLUSION@#Among the climate elements, MHI was significantly associated with OHS occurrence. The optimal MHI cutoff point for OHS prevention was 30.0°C.

Determining the correlation between outdoor heatstroke incidence and climate elements in Daegu metropolitan city / 영남의대학술지

BACKGROUND: Heatstroke is one of the most serious heat-related illnesses. However, establishing public policies to prevent heatstroke remains a challenge. This study aimed to investigate the most relevant climate elements and their warning criteria to prevent outdoor heatstroke (OHS).METHODS: We investigated heatstroke patients from five major hospitals in Daegu metropolitan city, Korea, from June 1 to August 31, 2011 to 2016. We also collected the corresponding regional climate data from Korea Meteorological Administration. We analyzed the relationship between the climate elements and OHS occurrence by logistic regression.RESULTS: Of 70 patients who had heatstroke, 45 (64.3%) experienced it while outdoors. Considering all climate elements, only mean heat index (MHI) was related with OHS occurrence (p=0.019). Therefore, the higher the MHI, the higher the risk for OHS (adjusted odds ratio, 1.824; 95% confidence interval, 1.102–3.017). The most suitable cutoff point for MHI by Youden’s index was 30.0°C (sensitivity, 77.4%; specificity, 73.7%).CONCLUSION: Among the climate elements, MHI was significantly associated with OHS occurrence. The optimal MHI cutoff point for OHS prevention was 30.0°C.

Application of a Dual-Dispatch System for Out-of-Hospital Cardiac Arrest Patients: Will More Hands Save More Lives?

BACKGROUND: Recovery after out-of-hospital cardiac arrest (OHCA) is difficult, and emergency medical services (EMS) systems apply various strategies to improve outcomes. Multi-dispatch is one means of providing high-quality cardiopulmonary resuscitation (CPR), but no definitive best-operation guidelines are available. We assessed the effects of a basic life support (BLS)-based dual-dispatch system for OHCA. METHODS: This prospective observational study of 898 enrolled OHCA patients, conducted in Daegu, Korea from March 1, 2015 to June 30, 2016, involved patients > 18 years old with suspected cardiac etiology OHCA. In Daegu, EMS started a BLS-based dual-dispatch system in March 2015, for cases of cardiac arrest recognition by a dispatch center. We assessed the association between dual-dispatch and OHCA outcomes using multivariate logistic regressions. We also analyzed the effect of dual-dispatch according to the stratified on-scene time. RESULTS: Of 898 OHCA patients (median, 69.0 years; 65.5% men), dual-dispatch was applied in 480 (53.5%) patients. There was no difference between the single-dispatch group (SDG) and the dual-dispatch group (DDG) in survival at discharge and neurological outcomes (survival discharge, P = 0.176; neurological outcomes, P = 0.345). In the case of less than 10 minutes of on-scene time, the adjusted odds ratio was 1.749 (95% confidence interval [CI], 0.490–6.246) for survival discharge and 6.058 (95% CI, 1.346–27.277) for favorable neurological outcomes in the DDG compared with the SDG. CONCLUSION: Dual-dispatch was not associated with better OHCA outcomes for the entire study population, but showed favorable neurological outcomes when the on-scene time was less than 10 minutes.

Delphi study to evaluate the emergency medical system operation fund support projects

OBJECTIVE: This study aimed to achieve expert consensus for the evaluation of Emergency medical system operation fund (EMSOF) support projects using the Delphi method in Korea. METHODS: The Delphi study was performed in June 2018. Experts who are members of the policy committee of the Korean Society of Emergency Medicine (KSEM) participated in the study. Respondents were asked to express their level of agreement of appropriateness for the following 6 categories for 21 projects: project contents, amount of support, indicators, performance, overall evaluation, and need to maintain. With a possible score of 9 points, the project categories were classified into 3 groups, inappropriate, moderate and appropriate, based on the median score of the respondents' ratings in each question. RESULTS: Sixteen of the 18 policy committee members participated in the survey. Their average professional work years were 8.2 years. All 21 projects were evaluated as appropriate for content. Amount of support and indicators were evaluated as moderate. Only 5 out of the 21 projects were evaluated as having appropriate indicators. No projects were evaluated as ineffective. Comprehensive evaluation of the projects was evaluated as moderate, and no project was evaluated as inappropriate in fund support. CONCLUSION: Overall, the contents of the EMSOF assistance project were rated high; however, there was a disagreement on the amount of support and evaluation indicators for each project. The results of this study are expected to be used as basic data to improve the use of EMSOF.

Does the placement of automated external defibrillators affect first responders' willingness to perform cardiopulmonary resuscitation in high-rise residential buildings?

OBJECTIVE: The increasing number of people living in high-rise apartments may result in a delayed response from emergency medical technicians called out for an out-of-hospital cardiac arrest, making the role of apartment managers as the first responders extremely important. This study investigated whether automated external defibrillator (AED) placement influences the willingness of apartment managers to perform cardiopulmonary resuscitation (CPR) and use an AED. METHODS: A cross-sectional target population-based survey was conducted in Daegu, July 2016. Questionnaires were sent to apartment managers working in apartments with more than 500 households. The general characteristics of the respondents, status of CPR education, and knowledge about and willingness to perform CPR and use an AED were investigated. RESULTS: Of the 1,445 respondents, 758 (52.5%) worked in apartments with AEDs, of which 77.8% and 70.8% were willing to perform CPR and use an AED, respectively, compared with 68.1% and 60.0% of respondents who worked in apartments without AEDs. After adjusting for potential confounders, AED placement was associated with the willingness to perform CPR (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04–1.71) and use an AED (OR, 1.39; 95% CI, 1.10–1.75). Prior CPR training and accurate knowledge of CPR skills were also associated with the willingness to perform CPR and use an AED. CONCLUSION: Placing AEDs in high-rise apartment buildings and providing refresher CPR education for maintaining CPR skills will be necessary to support apartment managers in their role as first responders.

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.

Probability of Early Retirement Among Emergency Physicians / 예방의학회지

OBJECTIVES: Early retirement occurs when one's job satisfaction suffers due to employment mismatch resulting from factors such as inadequate compensation. Medical doctors report high levels of job stress and burnout relative to other professionals. These levels are highest among emergency physicians (EPs), and despite general improvements in their working conditions, early retirement continues to become more common in this population. The purpose of this study was to identify the factors influencing EPs intention to retire early and to develop a probability equation for its prediction. METHODS: A secondary analysis of data from the 2015 Korean Society of Emergency Physicians Survey was performed. The variables potentially influencing early retirement were organized into personal characteristics, extrinsic factors, and intrinsic factors. Logistic regression analysis was performed to identify risk factors and to develop a probability equation; these findings were then arranged in a nomogram. RESULTS: Of the 377 survey respondents included in the analysis, 48.0% intended to retire early. Risk factors for early retirement included level of satisfaction with the specialty and its outlook, slanderous reviews, emergency room safety, health status, workload intensity, age, and hospital type. Intrinsic factors (i.e., slanderous reviews and satisfaction with the specialty and its outlook) had a stronger influence on early retirement than did extrinsic factors. CONCLUSIONS: To promote career longevity among EPs, it is vital to improve emergency room safety and workload intensity, to enhance medical professionalism through a stronger vision of emergency medicine, and to strengthen the patient-doctor relationship.