Severe Systemic Reactions Following Bee Sting Injuries in Korea

Purpose@#Most bee sting injuries are benign, although sometimes they can result in life threatening outcomes, such as anaphylaxis and death. The purpose of this study was to investigate the epidemiologic status of bee sting injuries in Korea and to identify risk factors associated with severe systemic reactions (SSRs). @*Materials and Methods@#Cases were extracted from a multicenter retrospective registry for patients who had visited emergency departments (EDs) for bee sting injuries. SSRs were defined as hypotension or altered mental status upon ED arrival, hospitalization, or death. Patient demographics and injury characteristics were compared between SSR and non-SSR groups. Logistic regression was performed to identify risk factors for bee sting-associated SSRs, and the characteristics of fatality cases were summarized. @*Results@#Among the 9673 patients with bee sting injuries, 537 had an SSR and 38 died. The most frequent injury sites included the hands and head/face. Logistic regression analysis revealed that the occurrence of SSRs was associated with male sex [odds ratio (95% confidence interval); 1.634 (1.133–2.357)] and age [1.030 (1.020–1.041)]. Additionally, the risk of SSRs from trunk and head/ face stings was high [2.858 (1.405–5.815) and 2.123 (1.333–3.382), respectively]. Bee venom acupuncture [3.685 (1.408–9.641)] and stings in the winter [4.573 (1.420–14.723)] were factors that increased the risk of SSRs. @*Conclusion@#Our findings emphasize the need for implementing safety policies and education on bee sting-related incidents to protect high-risk groups.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

Purpose@#Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the “boarding restriction protocol” that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding. @*Materials and Methods@#The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated. @*Results@#The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4–1587.1) minutes to 630.2 (398.0–1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5–482.8) minutes to 344.7 (213.4–519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5–1149.0) minutes to 204.1 (98.7–545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period. @*Conclusion@#The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays

Characteristics of frequent emergency department users in Korea: a 4-year retrospective analysis using Korea Health Panel Study data

Objective@#We aimed to investigate the characteristics of frequent emergency department (ED) users in Korea. @*Methods@#We analyzed the Korea Health Panel Study data of a sampled population from the 2005 Population Census of Korea data, and adults (age ≥18 years) who visited the ED at least once a year between 2014 and 2017 were included in the study. People who visited three or more times a year were classified as frequent users. We compared demographic, socioeconomic, and health-related factors between nonfrequent and frequent users. We used a multivariable logistic regression analysis to determine factors related to frequent ED visits. We also compared the characteristics of ED use in both nonfrequent and frequent users. @*Results@#A total of 5,090 panels were included, comprising 6,853 visits. Frequent users were 333 (6.5% of all panels), and their ED visits were 1,364 (19.9% of all ED visits). In the multivariable regression analysis, medical aid coverage (adjusted odds ratio [aOR] of the National Health Service coverage, 0.55; 95% confidence interval [CI], 0.40–0.75), unemployment (aOR of employment, 0.72; 95% CI, 0.56–0.91), prior ward admission in a year (aOR, 2.14; 95% CI, 1.67–2.75), and frequent outpatient department use (aOR, 1.72; 95% CI, 1.35–2.20) were associated with frequent use. Moreover, frequent users visited the ED of public hospitals more often than than nonfrequent users (19.2% vs. 9.8%). Medical problems rather than injury/poisoning were the more common reasons for visiting the ED (84.5% vs. 71.2%). @*Conclusion@#We found that frequent ED users were likely to be those with socioeconomic disadvantage or with high demand for medical service. Based on this study, further studies on interventions to reduce frequent ED use are required for better ED services.

Comparison among frailty screening tools in the emergency department: a systematic review

Objective@#It is important to identify high-risk elderly patients in the emergency department (ED), and various screening tools should be used. This study aimed to find the most appropriate tool by comparing frailty screening tools used in the ED. @*Methods@#The authors searched PubMed, EMBASE, Cochrane library, and KoreaMed databases for medical literature. Two or more frailty screening tools were studied. Sensitivities and values of the area under the receiver operating characteristic curve of each tool used in individual studies were compared. @*Results@#After the screening process, six studies using 12 tools were selected. Most of the tools had low sensitivities. The sensitivities were 90% or more in case of the Clinical Frailty Scale (CFS) and Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7). Seniors at Risk (ISAR) tools for frailty screening, Vulnerable Elders Survey (VES-13) and Geriatric (G8) tools were identified for predicting postoperative mortality, and CFS, Fried and Stable, Unstable, Help to walk, Bedbound (SUHB) tools were used for determining bad composite outcomes. The areas under the curve values predicting outcome were as follows: 0.63-0.67 for death, 0.52-0.64 for postoperative death, 0.52-0.68 for postoperative adverse outcome, 0.55-0.64 for poor prognosis, 0.65-0.69 for activity daily living disability, 0.66-0.78 for functional decline, 0.58-0.61 for hospitalization, 0.57-0.59 for fall, and 0.77-0.91 for frailty screening. @*Conclusion@#It was difficult to select the most appropriate tool among the 12 frailty tools included in this review. However, Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL), Study of Osteoporotic Fracture (SOF), CFS, VES-13, and PRISMA-7 were relatively useful in the ED.

The impact of emergency department expansion on crowding and patient flow

Objective@#Overcrowding in the emergency department (ED) has been a long-standing global problem, but has yet to be resolved. This study was undertaken to investigate whether expansion of the ED can affect overcrowding. @*Methods@#This was a retrospective study comparing two 10-month periods: before (September 2015 to June 2016) and after (September 2017 to June 2018) the ED expansion in an urban tertiary hospital. The ED expansion included expansion of the ambulatory area and establishment of a 25-bedded emergency ward dedicated to patients admitted through the ED. @*Results@#Comparing the two study periods, we noted an increase in the number of patients visiting the ED, from 77,078 to 87,027. Moreover, the proportion of patients who returned home untreated significantly decreased from 11.5% to 0.9% (P<0.001). The number of adult patients increased from 40,814 to 60,720; in particular, the number of ambulatory patients increased from 18,648 to 42,944. Conversely, waiting time for X-ray and computed tomography increased (10.0 to 17.0 minutes, and 35.0 to 48.0 minutes, respectively). Other areas with increased time duration include median ED length of stay of total patients (193.0 minutes to 205.8 minutes), and time from consultation to admission decision (122.3 to 161.4 minutes). However, the boarding time decreased from 239.2 to 190.9 minutes. @*Conclusion@#The ED expansion allowed more patients to be treated, and the boarding time of admitted patients was reduced through operation of the emergency ward. However, due to increase in the number of visiting patients, the time required for medical treatment increased concurrently.

Gender and Intentionality Disparities in the Epidemiology and Outcomes of Falls from Height in Korean Adults

PURPOSE@#This study investigated the characteristics of adult patients who had fallen from a height and presented to an emergency room (ER) according to gender and intentionality, with the goal of reducing the harm caused by these injuries.@*METHODS@#A retrospective analysis was conducted of fall-from-height patients aged ≥19 years from the in-depth surveillance study of injured patients visiting ERs conducted under the supervision of the Korea Centers for Disease Control and Prevention from 2011 to 2016. Patterns were analyzed according to gender and intentionality.@*RESULTS@#There were 29,838 men (68.5%) and 13,734 women (31.5%), with mean ages of 50.3±15.7 years and 57.2±19.9 years, respectively. The most common height of the fall was ≥1 m to 4 m in men (n=15,863; 53.2%) and <1 m in women (n=7,293; 53.1%). The most common location where the fall occurred was the workplace for men (n=10,500 male; 35.2%) and residential facilities for women (n=7,755; 56.5%). Most falls from height were unintentional (n=41,765; 97.1% vs. n=1,264; 2.9% for intentional falls). Suicide was the most frequent reason for intentional falls, and the age group of 19–30 years predominated in this category (n=377; 29.9%). For intentional falls, the most common interval before presentation to the ER was 0–6 hours (n=370; 29.3%) and the most common height was ≥4 m (n=872; 69.0%).@*CONCLUSIONS@#Among men, falls from height most often occurred from ≥1 m to 4 m, at the workplace, and during the course of paid work, whereas among women, they were most common from <1 m, in residential facilities, and during daily activities. Intentional falls most often occurred with the purpose of suicide, in the age group of 19–30 years, with an interval of 0–6 hours until treatment, from ≥4 m, and in residential facilities. Alcohol consumption was more common in intentional falls.

Use of smart glasses for ultrasound-guided peripheral venous access: a randomized controlled pilot study

OBJECTIVE: Smart glasses can provide sonographers with real-time ultrasound images. In the present study, we aimed to evaluate the utility of smart-glasses for ultrasound-guided peripheral venous access.METHODS: In this randomized, crossover-design, simulation study, 12 participants were recruited from the emergency department residents at a university hospital. Each participant attempted ultrasound-guided peripheral venous access on a pediatric phantom at intervals of 5 days with (glasses group) or without (non-glasses group) the use of smart glasses. In the glasses group, participants confirmed the ultrasound image through the lens of the smart glasses. In the non-glasses group, participants confirmed the ultrasound image through the display viewer located next to the phantom. Procedure time was regarded as the primary outcome, while secondary outcomes included the number of head movements for the participant, number of skin punctures, number of needle redirections, and subjective difficulty.RESULTS: No significant differences in procedural time were observed between the groups (non-glasses group: median time, 15.5 seconds; interquartile range [IQR], 10.3 to 27.3 seconds; glasses group: median time, 19.0 seconds; IQR, 14.3 to 39.3 seconds; P=0.58). The number of head movements was lower in the glasses group than in the non-glasses group (glasses group: median, 0; IQR, 0 to 0; non-glasses group: median, 4; IQR, 3 to 5; P<0.01). No significant differences in the number of skin punctures or needle restrictions were observed between the groups.CONCLUSION: Our results indicate that smart-glasses may aid in ensuring ultrasound-guided peripheral venous access by reducing head movements.

Severe Injuries from Low-height Falls in the Elderly Population

BACKGROUND: Falls from low-height can cause severe injuries in the elderly population. This study was conducted to determine characteristics of injuries from low-height falls. METHODS: We retrospectively review surveillance data on injured patients who presented to six emergency departments from January 2011 to December 2015. Study subjects were divided into severe group and non-severe group based on severity of injury. The general and clinical characteristics were compared between the two groups and analyzed factors related with severe injuries. RESULTS: Of 1,190 elderly patients, severe group comprised 82 patients (7%). The severe group was 2 years younger than the non-severe group. In the severe group, 61% was men and 34% in the non-severe group. In the non-severe, the injuries more commonly occurred at residential facilities and indoors than those in the severe group. Paid work during injury occurrence was 15%, and the more patients presented with non-alert consciousness in the severe group. The most common regions of major injury were head and neck in the severe group. CONCLUSION: Paid work, non-alert consciousness, and major injury to head and neck are relating factors to severe injuries in the elderly population.

Epidemiological and Clinical Characteristics of Elderly Fall Patients Visit to the Emergency Department: A Comparison by Gender

PURPOSE@#This study was to analyze clinical and epidemiological characteristics of elderly patients who were admitted to the emergency department (ED) due to falls by separating male and female.@*METHODS@#We retrospectively analyzed the fall patients aged 65 years or older from the data of the in-depth surveillance study of injured patients visit to the ED under the supervision of the Korea Centers for Disease Control and Prevention (KCDC) from 2011 to 2016 by separating male and female.@*RESULTS@#A total of 361,588 elderly fall patients were analyzed and, among them, 14,429 (37.3%) were males and 24,208 (62.7%) were females. Male and female showed similar frequency of damage happening season. However, they showed falling accident mostly on winter. The time of injury occurrence is mostly from 12:00 to 18:00 with 4,949 (34.3%) male and 8,564 (35.4%) female. Most falls occurred in daily activities, accounting for 7,614 (52.8%) in males and 14,957 (61.8%) in females, respectively. Unintentional damage accounted for the most part and 7,395 (51.2%) of male and 15,343 (63.4%) of female were injured indoors. Head and neck were the most common site of injuring, with 8,392 (58.2%) in males and 7,851 (32.4%) in females. According to ED examination outcomes, most of the patients were discharged, while the majority of the hospitalized patients were admitted to the general patient room.@*CONCLUSIONS@#The elderly falls occurred mostly from 12:00 to 18:00, during winter and to elderly women. Also, they happened unintentionally indoors in everyday life, mostly. Proved clinical, epidemiological characteristics from this research will be used as useful indicator at validity research of development of prevent program of falling accident for elderly people.

Factors associated with satisfaction with pediatric emergency department services in Korea: analysis of Korea Health Panel Data 2010 to 2012

OBJECTIVE: We aimed to investigate the factors related to satisfaction with the pediatric emergency department service in Korea. METHODS: This study examined data from the Korea Health Panel Data from 2010 to 2012. Pediatric patients who visited the emergency department at least once between 2010 and 2012 in Korea were included. Data were collected on patient satisfaction with the emergency department service, and factors related to the patient characteristics, emergency department service process, and medical institution. We compared the dissatisfied and satisfied groups, and calculated the odds ratios for satisfaction according to each variable. RESULTS: A total of 1,505 emergency department visits from 947 pediatric patients during the 3-year period were analyzed. We estimated that about 79.5% of patients in the population were satisfied. The odds of expressing satisfaction were higher among males than in females, and among patients who were hospitalized after emergency department treatment compared to those who were transferred to another hospital. Conversely, the odds of expressing satisfaction were lower among patients who had a chronic disease, a financial source other than National Health Insurance, experienced hospitalization within 1 year. CONCLUSION: Our study results might be helpful for establishing a satisfactory pediatric emergency medical service system. In the future, further prospective studies evaluating the causal relationships between the relevant factors and patient satisfaction are warranted.

Usefulness of Predictors for Hepatotoxicity in Acetaminophen Poisoning Patient

PURPOSE: The purpose of this study was to determine whether hepatotoxicity could be predicted early using biochemical markers in patients with acetaminophen (AAP) poisoning and to assess the usefulness of predictive factors for acute liver injury or hepatotoxicity. METHODS: This study was a retrospective observational study involving a medical records review. The participants were patients who were admitted to the emergency department (ED) with AAP overdose at two hospitals over a 10-year period. Demographic data, age, time from ingestion to visit, initial AAP level, initial hepatic aminotransferases, and initial prothrombin time were recorded. Acute liver injury was defined as a peak serum ALT >50 U/L or double the admission value, and hepatotoxicity was defined as a peak ALT >1,000 U/L. Receiver operating characteristic curve analyses were performed to compare the prognostic performance among variables. RESULTS: A total of 97 patients were admitted to the ED with AAP overdose, of whom 26 had acute liver injury and 6 had hepatotoxicity. Acute liver injury was associated with the time interval after taking the drug, and hepatotoxicity was associated with the initial PT and the ALT level. The scoring system proposed by the authors has a significant ability to predict both acute liver injury and hepatotoxicity. CONCLUSION: To predict the prognosis of AAP poisoning patients, the time interval after taking AAP was important, and initial prothrombin time and ALT level were useful tests. Also a scoring system combining variables may be useful.

Epidemiologic Characteristics of Intentional Poisoning: Emergency Department Based Injury in-depth Surveillance During 2011–2015

PURPOSE: The purpose of this study was to investigate the epidemiologic characteristics of patients who visited emergency departments (EDs) after intentional poisoning in Korea. METHODS: This study retrospectively analyzed the data of of 23 hospitals during a five-year period, between 2011 and 2015. We included patients who inflicted injury to themselves - attempt of suicide - by means of poisoning. RESULTS: A total of 18,121 patients visited an ED after intentional poisoning. Among them, 58.3% were females; however, there were more males among those aged 60 years or older. The mortality rate for males was 8.6%, which was 3.1 times higher than that for females with 2.8%. The most common poison was pesticides (35.4%) in males and sedative-hypnotics (44.0%) in females. The most common causative agent of death was pesticide in both sexes (75.2% and 65.3%, respectively). Since the production of paraquat was discontinued in 2011, the number of deaths from pesticide poisoning has decreased. The mortality rate declined in both males and females, from 12.6% and 4.5% in 2011 to 7.1% and 2.1% in 2015, respectively. CONCLUSION: In this study, we analyzed the epidemiologic characteristics of intentional poisoning, especially the frequency of suicide attempts by gender and age group, the cause of suicide, and the causative agent. This can be used as basic data for establishing policies to reduce and prevent suicide attempts by poisoning.

Prognostic Factor Analysis Including Electrocardiogram Change in Patientss with Subarachnoid Hemorrhage

PURPOSE: The prognostic factors of subarachnoid hemorrhage (SAH) are still not completely known. Several studies suggested that electrocardiogram (ECG) changes can act as a predictor of outcome in SAH patients. The purpose of this study was to describe the prognostic factors, including ECG changes, which are predictive of unfavorable outcome in non-traumatic SAH patients. METHODS: We retrospectively selected patients from our prospectively collected database of 202 SAH patients who visited the emergency medical center. The outcome was assessed using the Glasgow Coma Scale at six months after the occurrence of SAH. RESULTS: In the univariate analysis, a high score in one of the conventional systems (Hunt and Hess system, World Federation of Neurosurgical Societies [WFNS] scale, and Fisher grade), advanced age, accompanying intracranial hemorrhage or intraventricular hemorrhage, ECG changes (ST depression or Tall T), and a history of hypertension were associated with unfavorable outcome. The multivariate analysis showed three prognostic factors (ECG changes, age and high score in the conventional system) for unfavorable outcome. Using this result, three novel models corresponding to the three conventional systems were constructed to predict an unfavorable outcome in such patients. The area under the curve for model 1 (containing the WFNS scale) was 0.912, that of model 2 (containing the HH system) was 0.913, and that of model 3 (containing the Fisher system) was 0.885. Compared with the WFNS, HH or Fisher grade alone, each model exhibited superior accuracy. CONCLUSION: ECG can be described as an independent predictor of poor outcome, and the novel models which contain the ECG changes were found to be more accurate in predicting an unfavorable outcome in SAH patients compared with the conventional scoring system.

Health Behavior and Factors Associated with Depression in North Korean Adolescent Defectors in South Korea: The Korea Youth Risk Behavior Web-Based Survey, 2011–2014 / 가정의학회지

BACKGROUND: The number of North Korean adolescent defectors entering South Korea has been increasing. The health behavior, including mental health-related behavior, and factors associated with depression in North Korean adolescent defectors residing in South Korea were investigated. METHODS: Data obtained from the Korea Youth Risk Behavior Web-Based Survey (2011–2014) dataset were utilized. In total, 206 North Korean adolescent defectors were selected, and for the control group, 618 matched South Korean adolescents were selected. Frequency analysis was used to determine the place of birth and nationality of the parents, chi-square tests were used to compare the general characteristics of the North and South Korean subjects, and multivariate logistic regressions were conducted to compare the health behavior of the two sets of subjects. To determine the factors associated with depression in the North Korean subjects, a logistic regression was performed. RESULTS: The North Korean adolescents reported higher current smoking (adjusted odds ratio [aOR], 2.54; 95% confidence interval [CI], 1.48 to 4.35), current drinking (aOR, 1.85; 95% CI, 1.15 to 2.99), and drug use rates (aOR, 10.99; 95% CI, 4.04 to 29.88) than did the South Korean adolescents. The factors associated with depression in the North Korean adolescents were current smoking (aOR, 6.99; 95% CI, 1.62 to 30.06), lifetime drinking experience (aOR, 5.32; 95% CI, 1.51 to 18.75), and perceived stress (aOR, 4.74; 95% CI, 1.74 to 12.90). CONCLUSION: There were differences in health behavior between the North and South Korean adolescents. A specialized approach for North Korean adolescent defectors is required to promote proper health behavior and adaptation to South Korean society.

Body Mass Index and Mortality according to Gender in a Community-Dwelling Elderly Population: The 3-Year Follow-up Findings from the Living Profiles of Older People Surveys in Korea / 가정의학회지

BACKGROUND: Body mass index is widely regarded as an important predictor of mortality. The purpose of this study was to investigate the relationship between body mass index and mortality and to compare community-dwelling elderly people in South Korea according to sex. METHODS: Data were collected from the 2008 and 2011 Living Profiles of Older People Surveys, which comprised 10,613 community-living South Korean men and women aged 65 years or older. The participants were stratified into five groups according to body mass index as defined by the World Health Organization guidelines. The sociodemographic characteristics of participants and mortality rates were compared across the body mass index groups. RESULTS: The highest survival rates were observed in men with a body mass index of 25.0–29.9 kg/m². A similar trend was observed in women, but it was not statistically significant. After adjusting for covariates, this association was also found in men across all BMI index groups, but not in women. CONCLUSION: This study supports previous findings that overweight or mild obesity is associated with the lowest mortality and suggests that the current categories of obesity require revision. Furthermore, the absence of statistically significant findings in the female cohort suggests that body mass index is not a suitable predictor of mortality in women and that an alternative is required.

Body Mass Index and Mortality according to Gender in a Community-Dwelling Elderly Population: The 3-Year Follow-up Findings from the Living Profiles of Older People Surveys in Korea / 가정의학회지

BACKGROUND: Body mass index is widely regarded as an important predictor of mortality. The purpose of this study was to investigate the relationship between body mass index and mortality and to compare community-dwelling elderly people in South Korea according to sex. METHODS: Data were collected from the 2008 and 2011 Living Profiles of Older People Surveys, which comprised 10,613 community-living South Korean men and women aged 65 years or older. The participants were stratified into five groups according to body mass index as defined by the World Health Organization guidelines. The sociodemographic characteristics of participants and mortality rates were compared across the body mass index groups. RESULTS: The highest survival rates were observed in men with a body mass index of 25.0–29.9 kg/m². A similar trend was observed in women, but it was not statistically significant. After adjusting for covariates, this association was also found in men across all BMI index groups, but not in women. CONCLUSION: This study supports previous findings that overweight or mild obesity is associated with the lowest mortality and suggests that the current categories of obesity require revision. Furthermore, the absence of statistically significant findings in the female cohort suggests that body mass index is not a suitable predictor of mortality in women and that an alternative is required.

Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease

PURPOSE: Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). MATERIALS AND METHODS: This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). RESULTS: Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). CONCLUSION: After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.

The Effect of Clinical Pathway for Patient with Postpartum Hemorrhage in the Emergency Department

PURPOSE: Postpartum hemorrhage (PPH) is a major cause of maternal death. The aim of this study is to analyze the effect of clinical pathway (CP) and off-hours effects in PPH patients who visit the emergency department. METHODS: A retrospective study of PPH patients who visited the emergency department between December 1, 2005 and February 28, 2014 was conducted. A multidisciplinary team was designed for PPH in August 1, 2009. We compared time to intervention, volume of transfusion, length of stay (LOS), and uterus preservation rate between the before CP group and after CP group. RESULTS: A total of 143 post CP groups were compared with 101 before CP visits. Time to operation was less compared with the pre CP group (77 min (22-140) vs 47.5 min (13-114) p=0.011). Volume of transfusion and admission to intensive care units (ICU) were increased in the post CP group. (2 (0-16) vs 2 (0-25) p=0.045, 20 (19.8%) vs 54 (37.8%) p=0.003) LOS of ICU was lower than in the pre CP group and uterus preservation was higher than in the pre CP group. (0 day (0-43) vs 0 day (0-6) p=0.015, 82 (81.2%) vs 129 (90.2%) p=0.042) Time to angiographic embolization was less in the post-CP group with on-duty visits than in post-CP with off hours visits. (38.50 min (16-112) vs 71.0 min (28-633), p=0.025) CONCLUSION: A clinical pathway for PPH is associated with improvement of uterine preservation rate and reduced LOS of ICU. However this CP could not eliminate off-hour effects from time to intervention.

Hematological Parameters Predicting Complications of Caustic Ingestion: A Retrospective Study

PURPOSE: In addition to chemical burn of the alimentary tract, caustic ingestion can cause severe complications including esophageal perforation, airway edema, esophageal stricture, and death. Hematological parameters have been reported to be useful inflammatory markers predicting prognoses in various clinical situations where oxidative stress is increased. We hypothesized that hematological parameters might be useful for prediction of complications after caustic ingestion. METHODS: We performed a retrospective analysis of patients admitted to our Emergency Department after caustic ingestion. The numbers of leukocytes, neutrophils, lymphocytes, and monocytes, and the neutrophil-lymphocyte ratio were compared between uncomplicated and complicated patient groups. Receiver operating characteristic curve analysis was performed for parameters that differed between the two groups. Subgroup analysis was performed according to the substance ingested, thus acid or alkali. RESULTS: Thirty-seven patients were included in our study and eight had complications. Leukocyte, neutrophil counts, and the neutrophil-lymphocyte ratio of the complicated group were higher than those of the uncomplicated group. The areas under the receiver operating characteristic curves of leukocyte counts, neutrophil counts, and the neutrophil- lymphocyte ratio, were 0.819, 0.832, and 0.750, respectively. The cut-off values of these parameters for prediction of complications were 12 060/uL, 9607/uL, and 2.72, respectively. In subgroup analysis, the leukocyte and neutrophil counts, and the neutrophil-lymphocyte ratio of complicated patients who had ingested alkali were higher than those of the uncomplicated group. CONCLUSION: Leukocyte counts, neutrophil counts, and the neutrophil-lymphocyte ratio might serve as useful predictors of complications after ingestion of caustic substances.

Performance of Reperfusion Therapy and Hospital Mortality in ST-Elevation Myocardial Infarction Patients with Non-Chest Pain Complaints

PURPOSE: ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains. MATERIALS AND METHODS: This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated. RESULTS: Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality. CONCLUSION: STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.