Modification of HEART Pathway for Patients With Chest Pain: A Korean Perspective

Background and Objectives@#The History, Electrocardiography, Age, Risk factors, and Troponin (HEART) pathway was developed to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department. @*Methods@#We modified the HEART pathway by replacing the Korean cut-off of 25 kg/m2 with the conventional threshold of 30 kg/m2 in the definition of obesity among risk factors. The primary outcome was a MACE within 30 days, which included acute myocardial infarction, primary coronary intervention, coronary artery bypass grafting, and all-cause death. @*Results@#Of the 1,304 patients prospectively enrolled, MACE occurred in 320 (24.5%). The modified HEART pathway identified 37.3% of patients as low-risk compared with 38.3% using the HEART pathway. Of the 500 patients classified as low-risk with HEART pathway, 8 (1.6%) experienced MACE, and of the 486 low-risk patients with modified HEART pathway, 4 (0.8%) experienced MACE. The modified HEART pathway had a sensitivity of 98.8%, a negative predictive value (NPV) of 99.2%, a specificity of 49.0%, and a positive predictive value (PPV) of 38.6%, compared with the original HEART pathway, with a sensitivity of 97.5%, a NPV of 98.4%, a specificity of 50.0%, and a PPV of 38.8%. @*Conclusions@#When applied to Korean population, modified HEART pathway could identify patients safe for early discharge more accurately by using body mass index cut-off levels suggested for Koreans.

Association between initial fibrinogen levels and adverse outcomes in emergency department patients with primary postpartum hemorrhage

Objective@#This study evaluates the association between the initial fibrinogen levels and adverse outcomes in emergency department (ED) patients with primary postpartum hemorrhage (PPH). @*Methods@#This retrospective observational study was performed between January 2004 and December 2021 in the ED of a university-affiliated tertiary referral center. Primary PPH patients with fibrinogen level assessments in the ED were included. Patients were classified into two groups: the adverse outcome group-defined as patients receiving massive transfusion (transfusion of ≥10 units of packed red blood cells within the initial 24 hours), uterine artery embolization or emergency hysterectomy, intensive care unit admission, and in-hospital mortality-and the non-adverse outcome group. @*Results@#Of the 481 patients included in the study, 276 (57.4%) had adverse outcomes. The median fibrinogen level in patients with adverse outcomes was lower than in patients without adverse outcomes-149.5 mg/dL (range, 66.8-228.8) vs. 288.0 mg/dL (range, 215.0-349.0), respectively; P<0.001. The area under the receiver operating characteristic curve of the initial fibrinogen level for adverse outcomes was 0.811 (95% confidence interval, 0.773-0.849; P<0.001). The occurrence of adverse outcomes increased with decreasing fibrinogen levels (P<0.001). When the cutoff value of the initial fibrinogen level was 400 mg/dL, the sensitivity and negative predictive values for predicting adverse outcomes were 98.6% and 84.6%, respectively. When the cutoff value of the initial fibrinogen level was 100 mg/dL, the specificity and positive predictive values were 96.6% and 92.8%, respectively. @*Conclusion@#The initial fibrinogen levels on ED admission are associated with adverse outcomes.

The predictive value of procalcitonin for septic shock in sepsis patients

Objective@#This study examined the difference in procalcitonin between sepsis and septic shock. @*Methods@#The single-center retrospective cohort study was conducted from July 2017 to June 2018 at an emergency department (ED) of a university hospital. The inclusion criteria were patients over 18 years old who visited the ED with an infection. The exclusion criteria were the patients without organ failure by sepsis-3 definition, those with missing serum lactate data, and those discharged without workup. The sepsis patients were divided into those with and without septic shock, and the two groups were compared with biomarkers, including procalcitonin. @*Results@#Of the 406 patients who visited the ED with an infection, 36 were excluded because they did not have sepsis or an unknown infection. Finally, 369 patients were enrolled, and 61.5% fitted the septic shock definition. A comparison of the septic shock and non-shock sepsis groups showed that a history of chronic liver disease, malignancy, pulse rate, prothrombin time, blood urea nitrogen, aspartate and alanine transaminase, troponin-I, Sequential Organ Failure Assessment score and procalcitonin levels were significantly higher in the septic shock group. In multivariate analysis, however, procalcitonin was an independent predictor for septic shock (adjusted odd ratio, 1.05; 95% confidential interval, 1.01-1.09). The area under the receiver operating characteristic curve was 0.729, and the cutoff value was 4.0 ng/mL. @*Conclusion@#The procalcitonin levels were higher in the septic shock group than in the non-shock sepsis group. This could help predict septic shock independently. Further prospective multicenter research is needed to determine if procalcitonin can predict the severity of sepsis.

Association Between Body Weight Changes and Subsequent Development of Out-of-Hospital Cardiac Arrest: A Population-Based Nested Case-Control Study

Background@#Body weight is a modifiable demographic factor. Although the association of body mass index (BMI) categories with sudden cardiac death was reported, dynamic changes of BMI and the risk of cardiac arrest remain unknown. This study aimed to evaluate the association between the out-of-hospital cardiac arrest (OHCA) occurrence within a year and the percent changes of BMI preceding the OHCA. @*Methods@#This population-based nested case-control study used the National Health Insurance Service Data of Korea. In all, 24,465 patients with non-traumatic OHCA between 2010 and 2018, who underwent national health check-up twice (one within a year and the other within 2–4 years before OHCA) and 32,434 controls without OHCA, were matched for age and sex. The association between the risk of OHCA and BMI percent change stratified by sex was investigated. @*Results@#All the BMI percent changes of ≥ 5% significantly increased the OHCA occurrence with a reverse J-shaped association. Compared to individuals with a stable weight, those with severe (> 15%) BMI decrease had the highest odds ratio (OR) of 4.29 (95% confidence intervals [CIs], 3.72–4.95) for OHCA occurrence followed by those with moderate (10–15%) weight loss (OR, 2.80; 95% CI, 2.55–3.08) and those with severe (> 15%) weigh gain (OR, 2.24; 95% CI, 1.96–2.57), respectively. The impact of weight loss on the cardiac arrest occurrence was more prominent in men, while the impact of weight gain was more prominent in women. @*Conclusion@#Significant weight changes increase the risk of OHCA within a year with a reverse J-shaped association. Significant weight loss might be a warning sign for OHCA especially for men.

Corticosteroid outcome may be dependent of duration of use in severe COVID-19

Background/Aims@#For patients hospitalized with coronavirus disease 2019 (COVID-19) who require supplemental oxygen, the evidence of the optimal duration of corticosteroid is limited. This study aims to identify whether long-term use of corticosteroids is associated with decreased mortality. @*Methods@#Between February 10, 2020 and October 31, 2021, we analyzed consecutive hospitalized patients with COVID-19 with severe hypoxemia. The patients were divided into short-term (≤ 14 days) and long-term (> 14 days) corticosteroid users. The primary outcome was 60-day mortality. We performed propensity score (PS) analysis to mitigate the effect of confounders and conducted Kaplan-Meier curve analysis. @*Results@#There were 141 (52%) short-term users and 130 (48%) long-term corticosteroid users. The median age was 68 years and the median PaO2/FiO2 at admission was 158. Of the patients, 40.6% required high-flow nasal cannula, 48.3% required mechanical ventilation, and 11.1% required extracorporeal membrane oxygenation. The overall 60-day mortality rate was 23.2%, and that of patients with hospital-acquired pneumonia (HAP) was 22.9%. The Kaplan-Meier curve for 60- day survival in the PS-matched cohort showed that corticosteroid for > 14 days was associated with decreased mortality (p = 0.0033). There were no significant differences in bacteremia and HAP between the groups. An adjusted odds ratio for the risk of 60-day mortality in short-term users was 5.53 (95% confidence interval, 1.90–18.26; p = 0.003). @*Conclusions@#For patients with severe COVID-19, long-term use of corticosteroids was associated with decreased mortality, with no increase in nosocomial complications. Corticosteroid use for > 14 days can benefit patients with severe COVID-19.

A study on changes in lung function, neutralizing antibodies, and symptoms of adult patients hospitalized with COVID-19

Background/Aims@#To identify changes in symptoms and pulmonary sequelae in patients with coronavirus disease 2019 (COVID-19). @*Methods@#Patients with COVID-19 hospitalized at seven university hospitals in Korea between February 2020 and February 2021 were enrolled, provided they had ≥ 1 outpatient follow-up visit. Between January 11 and March 9, 2021 (study period), residual symptom investigations, chest computed tomography (CT) scans, pulmonary function tests (PFT), and neutralizing antibody tests (NAb) were performed at the outpatient visit (cross-sectional design). Additionally, data from patients who already had follow-up outpatient visits before the study period were collected retrospectively. @*Results@#Investigation of residual symptoms, chest CT scans, PFT, and NAb were performed in 84, 35, 31, and 27 patients, respectively. After 6 months, chest discomfort and dyspnea persisted in 26.7% (4/15) and 33.3% (5/15) patients, respectively, and 40.0% (6/15) and 26.7% (4/15) patients experienced financial loss and emotional distress, respectively. When the ratio of later CT score to previous ones was calculated for each patient between three different time intervals (1–14, 15–60, and 61–365 days), the median values were 0.65 (the second interval to the first), 0.39 (the third to the second), and 0.20 (the third to the first), indicating that CT score decreases with time. In the high-severity group, the ratio was lower than in the low-severity group. @*Conclusions@#In COVID-19 survivors, chest CT score recovers over time, but recovery is slower in severely ill patients. Subjects complained of various ongoing symptoms and socioeconomic problems for several months after recovery.

Clinical outcomes of and risk factors for secondary infection in patients with severe COVID-19: a multicenter cohort study in South Korea

Background/Aims@#Secondary infection with influenza virus occurs in critically ill patients and is associated with substantial morbidity and mortality; however, there is limited information about it in patients with severe coronavirus disease 2019 (COVID-19). Thus, we investigated the clinical outcomes of and risk factors for secondary infections in patients with severe COVID-19. @*Methods@#This study included patients with severe COVID-19 who were admitted to seven hospitals in South Korea between February 2020 to February 2021. Multivariate logistic regression analyses were performed to assess factors associated with the risk of secondary infections. @*Results@#Of the 348 included patients, 104 (29.9%) had at least one infection. There was no statistically significant difference in the 28-day mortality (17.3% vs. 12.3%, p = 0.214), but in-hospital mortality was higher (29.8% vs. 15.2%, p = 0.002) in the infected group than in the non-infected group. The risk factors for secondary infection were a high frailty scale (odds ratio [OR], 1.314; 95% confidence interval [CI], 1.123 to 1.538; p = 0.001), steroid use (OR, 3.110; 95% CI, 1.164 to 8.309; p = 0.024), and the application of mechanical ventilation (OR, 4.653; 95% CI, 2.533 to 8.547; p < 0.001). @*Conclusions@#In-hospital mortality was more than doubled in patients with severe COVID-19 and secondary infections. A high frailty scale, the use of steroids and application of mechanical ventilation were risk factors for secondary infection.

Acute exacerbation of COPD increases the risk of hip fractures: a nested case-control study from the Korea National Health Insurance Service

Background/Aims@#Hip fracture and acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) could increase mortality in patients with COPD. There are no data on the relationship between AE-COPD and hip fracture, which may significantly affect the prognosis of patients with COPD. Therefore, we conducted this study to determine the effects of AE-COPD on hip fractures in patients with COPD. @*Methods@#This retrospective, nested, case-control study included 253,471 patients with COPD (≥ 40 years of age) identified from the Korea National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) from 2002 to 2015. Among 176,598 patients with COPD, 1,415 patients with hip fractures were identified. Each case was matched to one control for age (within 10 years), sex, and year of COPD diagnosis. We estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hip fractures associated with AE-COPD using conditional logistic regression analysis, adjusting for underlying diseases and smoking history. @*Results@#In patients with AE-COPD, the risk of hip fracture was 2.50 times higher, regardless of systemic corticosteroid use and underlying disease (aOR, 2.50; 95% CI, 1.67 to 3.75). The risk of hip fracture increased if there was one episode of AE in the year before hip fractures (aOR, 2.25; 95% CI, 1.66 to 3.05). Moreover, the risk of hip fracture also increased in patients with more than two episodes of AE the year before hip fractures (aOR, 2.57; 95% CI, 1.61 to 4.10). @*Conclusions@#AE-COPD increases the risk of hip fracture regardless of underlying diseases, including osteoporosis, and treatment with systemic corticosteroids.

Association between the emergency department length of stay and severity-standardized survival among severe emergency patients

Objective@#The length of stay in the emergency department (ED) is a major contributor to ED overcrowding, which in turn negatively affects the quality of emergency care. Several efforts have been made to reduce the ED length of stay (ED-LOS), including a mandatory target to limit ED-LOS within certain parameters. However, the association between ED-LOS and treatment results is yet to be clarified. The authors investigated the influence of ED-LOS on patient survival by comparing severity-adjusted survival. @*Methods@#This study was a retrospective analysis of data registered in 2018 in the National Emergency Department Information System (NEDIS). Cases registered by the regional and local emergency centers were included for analysis. The standardized W scores (Ws) based on the Emergency Department Initial Evaluation Score were used to assess treatment outcomes represented by severity-standardized survival, and the correlation between the Ws and the ED-LOS was analyzed. @*Results@#A total of 2,281,526 cases were included for analysis. The overall mortality comprised 52,284 cases (2.3%) and the median ED-LOS was 165 minutes (interquartile range, 96-301). Although a longer ED-LOS was associated with poorer outcomes overall, the association was not apparent when an analysis of cases eligible for ED-LOS evaluation in the national evaluation program was carried out. Moreover, in the analysis of severe cases with a predicted survival probability of less than 0.9, an ED-LOS shorter than 6 hours was associated with significantly poorer severity-adjusted survival. @*Conclusion@#The study revealed that the current ED-LOS criteria used in the national evaluation program were not associated with better survival.

A quick Sequential Organ Failure Assessment–negative result at triage is associated with low compliance with sepsis bundles: a retrospective analysis of a multicenter prospective registry

Objective@#We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED). @*Methods@#Prospective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed. @*Results@#Among the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29–0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52–0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49–0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33–2.08) was higher in patients with qSOFA scores <2 points. @*Conclusion@#A qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.

Pulse pressure during the initial resuscitative period in patients with septic shock treated with a protocol-driven resuscitation bundle therapy

Background/Aims@#Maintaining a mean arterial pressure (MAP) ≥ 65 mmHg during septic shock should be based on individual circumstances, but specific target is poorly understood. We investigated associations between time-weighted average (TWA) hemodynamic parameters during the initial resuscitative period and 28-day mortality. @*Methods@#Prospectively collected data were obtained from a septic shock patient registry, according to the Sepsis-3 definition, between 2016 and 2018. The TWA systolic blood pressure, diastolic blood pressure, MAP, shock index, and pulse pressure (PP) during the first 6 hours after shock recognition were compared. Multivariable regression analysis was performed to assess associations between these parameters and 28-day mortality. @*Results@#Of 340 patients with septic shock, 92 died. Only the median TWA PP differed between the survivors and non-survivors (39.2 mmHg vs. 43.0 mmHg, p = 0.020), whereas the other indexes did not. When PP was divided into quartiles ( 48 mmHg), the mortality rate was higher in the highest quartile (41.2%). Multivariable logistic analysis revealed that PP (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.012 to 1.622; p = 0.039) and PP of > 48 mmHg (OR, 2.25; 95% CI, 1.272 to 3.981; p = 0.005) were independently associated with 28-day mortality. @*Conclusions@#PP was significantly associated with 28-day mortality in patients with septic shock and MAP maintained at > 65 mmHg during the first 6 hours. Further studies are warranted to optimize strategies for maintaining PP and MAP at > 65 mmHg during the early resuscitative period.

Association between the emergency department length of stay time and in-hospital mortality according to 28 diagnosis groups in patients with severe illness diagnosis codes

Objective@#The purpose of this study was to analyze the effects of emergency department length of stay (ED LOS) on the prognosis of patients classified in 28 severe illness diagnosis code groups. @*Methods@#We used data from the National Emergency Department Information System (NEDIS) from 2016 to 2017. Patients with severe illness diagnosis codes as per the discharge diagnosis reports of the emergency department were included and classified into 28 diagnosis code groups. We used multiple logistic regression analysis on the various diagnosis groups to determine whether 6 hours of ED LOS was a factor influencing mortality. @*Results@#Of the 18,217,034 patients in the NEDIS data, 553,918 patients were hospitalized with a severe illness code at regional or local emergency medical centers. The average ED LOS was 389 minutes in the non-survivor group and 420 minutes in the survivor group. After adjusting for confounders, ED LOS >6 hours was associated with lower mortality (odds ratio, 0.737; 95% confidence interval, 0.715-0.759). The association of ED LOS >6 hours with lower mortality was found in the diagnosis groups for acute myocardial infarction, intracranial hemorrhage, major trauma, aortic dissection, gastrointestinal bleeding/foreign bodies, intoxication, acute kidney injury, and post-resuscitation status. @*Conclusion@#In the analysis for the 28 severe disease illness code groups, ED LOS of more than 6 hours was not a factor that adversely affects the in-hospital mortality.

Characteristics analysis of patients being re-transferred among patients who transferred to emergency medical center

Objective@#This study investigates the characteristics of patients who were re-transferred from other hospitals to regional or local emergency medical centers. @*Methods@#Data from 2016 to 2017 was obtained from the National Emergency Department Information System (NEDIS). The study population was classified as ‘transferred group’ and ‘direct visit group.’ The transferred group was further subdivided into the ‘re-transfer group’ (patients transferred out to another hospital) and ‘single transfer group’ (patients not transferred out). Multiple logistic regression analysis was performed to identify factors associated with re-transfer. @*Results@#The re-transfer rate (3.7%) of the ‘transferred group’ was higher than the transfer rate (1.3%) of the ‘direct visit group’. Multiple regression analysis revealed that older age, male (adjusted odds ratio [aOR], 1.082; 95% confidence interval [CI], 1.606-1.105), medical aid (aOR, 1.231; 95% CI, 1.191-1.105), injury origin (aOR, 1.063; 95% CI, 1.006-1.122), and Korean Triage and Acuity Scale level 1 or 2 (aOR, 1.214; 95% CI, 1.182-1.247), are associated with re-transfer. The Korean Standard Classification of Diseases group having the highest re-transfer rate was determined to be the neoplasm disease group. @*Conclusion@#Data from the current study reveals that factors associated with an increased likelihood of re-transfer were high severity, old age, medical aid, and neoplasm diagnosis. Considering these characteristics of re-transferred patients, it is necessary to improve the transfer system to reduce re-transfers. However, further research is required, including the reasons for the transfer.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Detection of Severe Acute Respiratory Syndrome Coronavirus 2 in the Pleural Fluid

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be detected via a nasopharyngeal swab and in sputum, blood, urine, and feces. However, there is only limited data on the real-time reverse transcriptase polymerase chain reaction (RT-PCR) results of coronavirus disease 2019 (COVID-19) patients with pleural fluid. We report a case of COVID-19 with SARS-CoV-2 detected in both sputum and pleural fluid. A 68-year-old male patient came to the hospital with a chief complaint of dyspnea. He was diagnosed with lung cancer. A biopsy was performed, and a pneumothorax was found. As a result, a chest tube was placed into the right pleural space. During his hospital stay, the patient was confirmed as COVID-19 positive. We identified the presence of SARS-CoV-2 through real-time RTPCR assay from the pleural fluid. Although pleural effusion is an uncommon finding in the COVID-19, care should be taken to avoid exposure when handling the pleural fluid sample.

Emergency department utilization and risk factors for mortality in older patients: an analysis of Korean National Emergency Department Information System data

Objective@#With trends in population aging an increasing number of older patients are visiting the emergency department (ED). This study aimed to identify the characteristics of ED utilization and risk factors for in-hospital mortality in older patients who visited EDs. @*Methods@#This nationwide observational study used National Emergency Department Information System data collected during a 2-year period from January 2016 to December 2017. The characteristics of older patients aged 70 years or older were compared with those of younger patients aged 20 to 69 years. Risk factors associated with in-hospital mortality were analyzed by multivariable logistic regression. @*Results@#A total of 6,596,423 younger patients and 1,737,799 older patients were included. In the medical and nonmedical older patient groups, significantly higher proportions of patients were transferred from another hospital, utilized emergency medical services, had Korean Triage and Acuity Scale scores of 1 and 2, required hospitalization, and required intensive care unit admission in the older patient group than in the younger patient group. ED and post-hospitalization mortality rates increased with age; in particular, older medical patients aged 90 or older had an in-hospital mortality rate of 9%. Older age, male sex, transfer from another hospital, emergency medical service utilization, a high Korean Triage and Acuity Scale score, systolic blood pressure 20/min, heart rate >100/min, body temperature <36°C, and altered mental status were associated with in-hospital mortality. @*Conclusion@#Development of appropriate decision-making algorithms and treatment protocols for high risk older patients visiting the ED might facilitate appropriate allocation of medical resources to optimize outcomes.

Pulse pressure during the initial resuscitative period in patients with septic shock treated with a protocol-driven resuscitation bundle therapy

Background/Aims@#Maintaining a mean arterial pressure (MAP) ≥ 65 mmHg during septic shock should be based on individual circumstances, but specific target is poorly understood. We investigated associations between time-weighted average (TWA) hemodynamic parameters during the initial resuscitative period and 28-day mortality. @*Methods@#Prospectively collected data were obtained from a septic shock patient registry, according to the Sepsis-3 definition, between 2016 and 2018. The TWA systolic blood pressure, diastolic blood pressure, MAP, shock index, and pulse pressure (PP) during the first 6 hours after shock recognition were compared. Multivariable regression analysis was performed to assess associations between these parameters and 28-day mortality. @*Results@#Of 340 patients with septic shock, 92 died. Only the median TWA PP differed between the survivors and non-survivors (39.2 mmHg vs. 43.0 mmHg, p = 0.020), whereas the other indexes did not. When PP was divided into quartiles ( 48 mmHg), the mortality rate was higher in the highest quartile (41.2%). Multivariable logistic analysis revealed that PP (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.012 to 1.622; p = 0.039) and PP of > 48 mmHg (OR, 2.25; 95% CI, 1.272 to 3.981; p = 0.005) were independently associated with 28-day mortality. @*Conclusions@#PP was significantly associated with 28-day mortality in patients with septic shock and MAP maintained at > 65 mmHg during the first 6 hours. Further studies are warranted to optimize strategies for maintaining PP and MAP at > 65 mmHg during the early resuscitative period.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Detection of Severe Acute Respiratory Syndrome Coronavirus 2 in the Pleural Fluid

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be detected via a nasopharyngeal swab and in sputum, blood, urine, and feces. However, there is only limited data on the real-time reverse transcriptase polymerase chain reaction (RT-PCR) results of coronavirus disease 2019 (COVID-19) patients with pleural fluid. We report a case of COVID-19 with SARS-CoV-2 detected in both sputum and pleural fluid. A 68-year-old male patient came to the hospital with a chief complaint of dyspnea. He was diagnosed with lung cancer. A biopsy was performed, and a pneumothorax was found. As a result, a chest tube was placed into the right pleural space. During his hospital stay, the patient was confirmed as COVID-19 positive. We identified the presence of SARS-CoV-2 through real-time RTPCR assay from the pleural fluid. Although pleural effusion is an uncommon finding in the COVID-19, care should be taken to avoid exposure when handling the pleural fluid sample.

Emergency department utilization and risk factors for mortality in older patients: an analysis of Korean National Emergency Department Information System data

Objective@#With trends in population aging an increasing number of older patients are visiting the emergency department (ED). This study aimed to identify the characteristics of ED utilization and risk factors for in-hospital mortality in older patients who visited EDs. @*Methods@#This nationwide observational study used National Emergency Department Information System data collected during a 2-year period from January 2016 to December 2017. The characteristics of older patients aged 70 years or older were compared with those of younger patients aged 20 to 69 years. Risk factors associated with in-hospital mortality were analyzed by multivariable logistic regression. @*Results@#A total of 6,596,423 younger patients and 1,737,799 older patients were included. In the medical and nonmedical older patient groups, significantly higher proportions of patients were transferred from another hospital, utilized emergency medical services, had Korean Triage and Acuity Scale scores of 1 and 2, required hospitalization, and required intensive care unit admission in the older patient group than in the younger patient group. ED and post-hospitalization mortality rates increased with age; in particular, older medical patients aged 90 or older had an in-hospital mortality rate of 9%. Older age, male sex, transfer from another hospital, emergency medical service utilization, a high Korean Triage and Acuity Scale score, systolic blood pressure 20/min, heart rate >100/min, body temperature <36°C, and altered mental status were associated with in-hospital mortality. @*Conclusion@#Development of appropriate decision-making algorithms and treatment protocols for high risk older patients visiting the ED might facilitate appropriate allocation of medical resources to optimize outcomes.