Accuracy of medical directors for indirect medical oversight on prehospital care

Objective@#This study aimed to evaluate the accuracy of the assessment of medical directors for indirect medical oversight on prehospital care. @*Methods@#Medical directors assessed the same prehospital care run sheets with six cases of cardiac arrest, four cases of withholding or interruption of cardiopulmonary resuscitation (CPR) and six cases of severe trauma patients. Demographics of the medical directors and the accuracy of their assessment for the prehospital care run sheets were investigated. @*Results@#Board certified emergency physician was 14 of the total 21 medical directors (58%). Eleven medical directors were educated for the medical director course of the Korean council of emergency medical services physicians. The accuracy of the assessment of the medical directors was 50% in the assessment of electrocardiogram using an automated external defibrillator (AED) in cardiac arrest. Pulse check, respiration check, AED monitoring and the reason of interruption for CPR were lower than 60% for withholding or interruption of CPR. The lowest accurate assessment of medical directors was the appropriate treatment for trauma, with 36.5% in severe trauma. @*Conclusion@#Lower accuracy in some assessments of the medical directors for indirect medical oversight on prehospital care was identified. Education and quality control are needed for medical directors to provide high-quality indirect medical oversight.

Changes in Relative Importance of the 5-Level Triage System, Korean Triage and Acuity Scale, for the Disposition of Emergency Patients Induced by Forced Reduction in Its Level Number: a Multi-Center Registry-based Retrospective Cohort Study

BACKGROUND: The 5-level triage tool, the Korean Triage and Acuity Scale (KTAS), was developed based on the Canadian Triage and Acuity Scale and has been used for triage in all emergency medical institutions in Korea since 2016. This study evaluated the association between the decrease in level number and the change in its relative importance for disposition in the emergency department (ED). METHODS: Using the registry of the National Emergency Department Information System (NEDIS) ver. 3.1, data regarding consecutive emergency patients from March 2017 to October 2017 were reviewed retrospectively. Reconfiguring KTAS levels, a total of 15 multinomial logistic regression models (KTAS_0 to KTAS_14), including the KTAS, its variants, and covariates were constructed to determine significant factors affecting ED disposition. The relative importance of each model was obtained using a dominance analysis. RESULTS: A total of 79,771 patients were included in the analysis. In the model KTAS_0, the KTAS and 8 covariates were found to be significantly related to ED disposition. The KTAS and the decision maker of each ED visit, whether it was the physician or others, had the largest relative importance, 34.8% and 31.4%, respectively (P < 0.001). In other models of KTAS variants, including 4-level, 3-level and 2-level, the rates of the KTAS decreased to 31.8% (interquartile range [IQR], 28.9–34.2), 26.4% (IQR, 23.2–31.0), and 18.7% (IQR, 7.5–24.9), respectively (P = 0.016). On the other hand, the rates for covariates tended to be larger for smaller triage levels and so there was a significant interaction effect between the KTAS and the covariates according to the triage level (P < 0.001). CONCLUSION: The 5-level triage tool, the KTAS, had the largest relative importance among the predictors affecting ED disposition only at its original level. Therefore, it is recommended that no attempt should be made to reduce the number of levels in the triage tool.

Factors associated hospital admission in patients with low acuity visiting emergency department

OBJECTIVE: Patients with low acuity who need hospitalization may be at risk if they do not receive proper treatment in overcrowded emergency rooms. This study was conducted to investigate factors affecting the hospitalization of patients with low acuity of Korean Triage and Acuity Scale (KTAS). METHODS: This study was a retrospective chart review analysis of patients aged 15 years or older who had triaged as KTAS 4 and 5 grades when visiting a local emergency medical center from January 1, 2016 to December 31, 2017. Multivariate logistic analysis was performed to analyze the effects of age, sex, reasons for visiting, visiting route, ambulance utilization, KTAS grade and major category on patient admission. RESULTS: A total of 10,540 patients were enrolled and the odds ratio (OR) increased with age from those aged over 34 years (P < 0.001). Patients that triaged as KTAS grade 5 (adjusted OR, 1.57; 95% confidence interval [CI], 1.36–1.82), had a condition caused by disease (adjusted OR, 2.31; 95% CI, 2.00–2.68), and visited by using an ambulance (public: adjusted OR, 1.05; 95% CI, 0.91–1.22; private: adjusted OR, 4.60; 95% CI, 3.85–5.49) were more likely to be hospitalized. Individuals in the “general” major category were more likely to be hospitalized than those falling into other major categories (P < 0.001). CONCLUSION: The factors influencing the hospitalization of patients with low acuity were age, reasons for visiting, visiting route, ambulance utilization, KTAS grade and major category on patient admission.

Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization

OBJECTIVE: To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization. METHODS: We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR. RESULTS: Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (P < 0.001). CONCLUSION: Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.

Validity of the Newly Developed Five Level Pediatric Triage System Implemented in a Children's Hospital Emergency Department

PURPOSE: Korean Acuity and Triage Scale (KTAS) has been used nationally since 2016 for triage in emergency departments. After the newly developed triage tool was applied, there have been few studies of the validity of pediatric KTAS. The purpose of this study was to evaluate the validity of KTAS in children under the age of 15 who visited a single children's hospital. METHODS: This retrospective study was conducted on 7,011 pediatric patients under the age of 15 who visited a single child hospital between January 1 and December 31, 2016, the difference in the admission rate, intensive care unit admission rate, length of stay in the emergency department, and total hospital cost in emergency department were analyzed using the KTAS level. RESULTS: The number of patients triaged as KTAS IV was highest with 48.2%. The length of stay was longest in KTAS I and shortest in KTAS V. The medical cost in emergency department was highest in KTAS I and lowest in KTAS V. All dependent variables except for the intensive care unit admission rate showed significant differences according to the KTAS level. CONCLUSION: When the KTAS of the newly developed five level triage system was applied to pediatric patients, there were statistically significant difference in hospitalization, length of stay in emergency department, and total cost to the emergency department according to the KTAS level. Therefore, it will be necessary to evaluate the validity of KTAS through multicenter studies including hospitals with various characteristics.

The Usefulness of the mPTS (modified pediatric trauma score) and Newly Developed Extended mPTS as a High Risk Pediatric Trauma Patients Screening Tool: Support of Two Tiered Trauma Team Activation System

PURPOSE: A secondary triage tool for pediatric trauma patients, “modified pediatric trauma score (mPTS)” was introduced to predict high risk trauma. METHODS: Pediatric trauma patients (≤15 years) presenting to the Pusan National University Hospital trauma center emergency department were analyzed retrospectively. The patients were classified into high risk and low risk groups. The high risk group was assigned an Injury Severity Score ≥12, death, intensive care unit admission, or urgent intervention (intubation, closed thoracostomy, emergency angiography and embolization, emergency surgery). The airway, blood pressure, fractures, level of consciousness, and external wounds were evaluated and the mPTS was calculated. RESULTS: One hundred seventy-seven patients were enrolled in this study. The mPTS had a sensitivity, specificity, positive predictive value, and negative predictive value of 88%, 54%, 60%, and 85%, respectively. Overtriage and undertriage was 39% and 14%, respectively. The mPTS missed 6 high risk patients and all 6 patients were abdominal injury patients. The mPTS was modified to include an abdominal physical examination and/or focused assessment with sonography for trauma. The newly developed scoring system was called the extended mPTS (E-mPTS). The E-mPTS had a sensitivity of 98% and negative predictive value of 98%. The safe level of overtriage (38%) was maintained. CONCLUSION: mPTS was applied to the patients and the undertriage rate was too high. The extended mPTS improved undertriage to 2% while maintaining the overtriage rate at a safe level. The E-mPTS is expected to have a resource saving effect when used as a pediatric trauma team activation standard.

Pneumoperitoneum due to Gastroesophageal Junction Rupture after Prolonged Cardiopulmonary Resuscitation with Supraglottic Airway

Gastric rupture after cardiopulmonary resuscitation (CPR) is a rare complication. In most cases, it is associated with bystander-provided CPR, bag-mask ventilation, and difficult airway management. To the best of our knowledge, there has been only one previous case report in the literature regarding gastric rupture after CPR via supraglottic airway. We present a case of a gastroesophageal junction rupture secondary to CPR with supraglottic airway. Healthcare providers should consider that gastric rupture can be a complication from performing CPR.

Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition

OBJECTIVE: We compared training using a voice advisory manikin (VAM) with an instructor-led (IL) course in terms of acquisition of initial cardiopulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines. METHODS: This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and distributed them randomly into two groups: the IL group (n=41) and the VAM group (n=37). In the IL-group, participants were trained in “single-rescuer, adult CPR” according to the American Heart Association's Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes. RESULTS: The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; P=0.396). CONCLUSION: Both methods, the IL training using a practice-while-watching video and the VAM training, facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Feature of Visiting Patients to a Wide Regional Emergency Center According to Insurance Status

PURPOSE: In Korea, emergency department overcrowding in large hospitals have caused social concern. Moreover, patients with low socioeconomic status visit the emergency department more frequently. This kind of visitation also causes a burden on the national budget, but emergent patient should be treated in emergency department regardless of economic state. So, on establishment of policy about the patient with low socioeconomic status, the frequency of emergency visitation alone is difficult to obtain a sufficient basis for policy-making. METHODS: We retrospectively analyzed adult patients with a disease who visited the Pusan Wide-regional Emergency Center in 2015. Korean Triage and Acuity Scale level I, II or III were defined as emergency, and level IV or V was defined as non-emergency. The ratio of emergency and non-emergency was compared in the National Health Insurance and Medicaid database. RESULTS: The number of patients with National Health Insurance was 16,208 (90.3%) and with Medicaid was 1,737 (9.7%). Among those with National Health Insurance, there were 12,720 (78.5%) emergency cases and 3,488 (21.5%) non-emergency cases. Among those with Medicaid, 1,379 (79.4%) emergency cases and 358 (20.6%) non-emergency cases. Between National Health Insurance and Medicaid, there was no statistically significant difference in the ratio of emergency and non-emergency (p=0.380) CONCLUSION: Accessibility of emergency and non-emergency patients with National Health Insurance and Medicaid to Pusan Wide-regional Emergency Center was not different.

Comparison between an Instructor-led Course and Training Using a Voice Advisory Manikin in Initial Cardiopulmonary Resuscitation Skill Acquisition

PURPOSE: Purpose: We compared the outcomes of training between the use of voice-advisory manikin (VAM) and instructor-led (IL) courses with respect to the acquisition of initial cardio-pulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines. METHODS: This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and randomly distributed them into two groups: the IL group (n=41) and the VAM group (n=37). In the IL group, participants were trained in “single-rescuer, adult CPR” in accordance with the American Heart Association's Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes. RESULTS: The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the two groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; p=0.396). CONCLUSION: Both methods the IL training using a practice-while-watching video and the VAM training facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Transient Hypoglycemia-induced Hemiparesis Mimicking Stroke: A Case Report / 대한구급학회지

Hypoglycemia is caused by poor oral intake, excessive exercise, alcohol abuse and inaccurate use of a hypoglycemic agent or insulin in patients that have history of diabetes mellitus (DM), especially in the elderly. Severe hypoglycemia has a variety of different symptoms or signs from focal neurologic deficits to severe coma, or death. It can be difficult to differentiate hypoglycemia-induced symptoms or signs, and stroke or cardiovascular disease in acute setting. Transient hypoglycemic hemiparesis is an infrequent case in the emergency department (ED), which is frequently misdiagnosed for stroke. When patients with decreased mental status or hemiparesis are admitted to the ED, a routine blood sugar test is essential. Hypoglycemic hemiparesis if unrecognized can result in permanent neurological damage. Therefore, it is important to detect hypoglycemia early and treat it appropriately.

Retention of Basic Life Support Skills Following Cardiopulmonary Resuscitation Training Based on American Heart Association Guidelines in Healthcare Professionals Working in a General Hospital

PURPOSE: Traditional cardiopulmonary resuscitation (CPR) training methods have been gradually replaced by practice-oriented methods such as the American Heart Association (AHA) basic life support (BLS) course for healthcare providers. We attempted to investigate nurses' and other healthcare professionals' retention of BLS skills over time after taking the AHA BLS course for healthcare providers. METHODS: Healthcare providers were screened for their retention of CPR skills at regular intervals up to 1 year after completing the AHA BLS course. Certified BLS instructors administered skills tests. RESULTS: The degree of skills maintained over time decreased, but not significantly (p=0.207, p=0.160). The scores of written tests decreased over time, but not significantly (p=0.082). The degree of CPR knowledge and skills main-tained was higher in the nurse group than in the healthcare professional group; this difference was statistically significant (p=0.02, <0.001, <0.001). However, regarding the degree of knowledge and skills for CPR maintained over time, there was no statistically significant difference between each group. CONCLUSION: After the AHA BLS course for healthcare providers, in-hospital healthcare professionals retain significantly less information after 3 months. We suggest that a skill review is needed within 3 months after CPR training.

Effect of the Emergency Trauma Team's Management on the Treatment of Patients with Multiple Severe Trauma

PURPOSE: We performed this study to determine how the emergency trauma team affects the treatment of patients with multiple severe trauma and to discuss the effect and the direction of the emergency trauma team's management. METHODS: We performed a retrospective analysis of 518 patients who visited our emergency department with severe trauma from August 2006 to July 2008. We divided the severe trauma patients into 2 groups : patients before and after trauma team management (Group 1 and Group 2). Then, we compared demographic characteristics, mechanisms of injury, and treatment outcomes (lengths of stay in the ED, admission ratio, and in-hospital mortality) between the 2 groups. In the same way, patients with multiple severe trauma were divided into 2 groups, that are patients before and after trauma team management (Group 3 and Group 4) and analyzed. RESULTS: There was no significant difference, except mean age, between groups 1 and 2. In group 4 patients, compared to group 3 patients, the lengths of stay in the ED were lower (p value < 0.001), and the admission ratio were higher (p value = 0.017), but there was no significant difference in the in-hospital mortality between the groups 3 and 4. CONCLUSION: When patients with multiple severe trauma visit the ED, the emergency trauma team's management can decrease the lengths of stay in the ED and increase the admission ratio, but does not produce a decrease in the in-hospital mortality rate. Further investigations of emergency trauma team management are needed to improve treatment outcomes for patients with multiple severe trauma.

Eosinophilic Enteritis Diagnosed by Laparoscopic Biopsy / 대한소화기내시경학회지

Eosinophilic gastroenteritis is a rare disease characterized by the eosinophilic infiltration of the gastro-intestinal tract without involvement of organs outside the gastrointestinal tract and may be misdiagnosed in clinical practice. The pathophysiology of eosinophilic gastroenteritis is not known well. We report a case of serosal eosinophilic enteritis presenting sterile eosinophilic ascites, peripheral eosinophilia and abdominal pain. Diagnosis was confirmed by laparoscopic biopsy of small bowel. The patient was improved dramatically with prednisolone therapy.