Do-not-attempt resuscitation policy reduced in-hospital cardiac arrest rate and the cost of care in a developing country.

We aim to study the characteristics and outcomes of patients with a Do-Not-Attempt Resuscitation and to determine its impact on the Cost of In-Hospital Cardiac Arrest. A retrospective study of all adult patients admitted to the hospital from June 2021 to May 2022 who had a Do-Not-Resuscitate order. We abstracted patients' socio-demographics, physiologic parameters, primary diagnosis, and comorbidities from the electronic medical records. We calculated the potential economic cost using the median ICU length of stay for the admitted IHCA patients during the study period. There were 28,866 acute admissions over the study period, and 788 patients had DNR orders. The median (IQR) age was 71 (55-82) years, and 50.3% were males. The most prevalent primary diagnosis was sepsis, 426 (54.3%), and cancer was the most common comorbidity. More than one comorbidities were present in 642 (80%) of the cohort. Of the DNR patients, 492 (62.4%) died, while 296 (37.6%) survived to discharge. Cancer was the primary diagnosis in 65 (22.2%) of those who survived, compared with 154 (31.3%) of those who died (P = 0.002). Over the study period, 153 patients had IHCA and underwent CPR, with an IHCA rate of 5.3 per 1,000 hospital admissions. Without a DNR policy, an additional 492 patients with cardiac arrest would have had CPR, resulting in an IHCA rate of 22.3 per 1000 hospital admissions. Most DNR patients in our setting had sepsis complicated by multiple comorbidities. The DNR policy reduced our IHCA incidence by 76% and prevented unnecessary post-resuscitation ICU care.

The epidemiology and outcomes of adult in-hospital cardiac arrest in a high-income developing country.

Aim: In-Hospital Cardiac Arrest (IHCA) is a significant burden on healthcare worldwide. Outcomes of IHCA are worse in developing countries compared with developed ones. We aimed to study the epidemiology and factors determining outcomes in adult IHCA in a high income developing country. Methods: We abstracted prospectively collected data of adult patients admitted to our institution over a three-year period who suffered a cardiac arrest. We analysed patient demographics, arrest characteristics, including response time, initial rhythm and code duration. Pre-arrest vital signs, primary diagnoses, discharge and functional status, were obtained from the patients' electronic medical records. Results: A total of 447 patients were studied. The IHCA rate was 8.6/1000 hospital admissions. Forty percent (40%) achieved ROSC with an overall survival to discharge rate of 10.8%, of which 59% had a good functional outcome, with a cerebral performance category score of 1 or 2. Fifty-four percent (54%) of patients had IHCA attributed to causes other than cardiac or respiratory. Admission Glasgow Coma Scale (GCS), shockable rhythm and short code duration were significantly associated with survival (p < 0.001). Conclusion: A combination of patient and system-related factors, such as the underlying cause of cardiac arrest and a lack of DNAR policy, may explain the reduced survival rate in our setting compared with developed countries.

Effect of off-hour versus work-hour thrombolysis for acute ischemic stroke on emergency department patients' outcome: a retrospective study.

OBJECTIVE: Early management of patients with acute ischemic stroke is crucial regardless of the time of presentation. The aim of the study was to evaluate the effect of off-hours management of patients with ischemic stroke that underwent thrombolytic therapy in the emergency department. METHODS: This is a single-center retrospective study included ischemic stroke patients who received thrombolysis in the emergency department from January 2009 to April 2017. Patients who presented between 08:00 and 17:00 Monday to Friday were in the 'work-hour group (group 1)' versus others who were considered 'off-hours (group 2)'. Primary endpoint was 3-month mortality. Secondary endpoints included the National Institutes of Health Stroke Scale and dramatic recovery rate at 24 h, intracranial hemorrhage, systemic hemorrhage and modified Rankin Scale at the 3 months. Symptom-to-needle time, door-to-computed tomography time, and door-to-needle time were also compared between groups. RESULTS: A total of 399 ischemic stroke patients were included in the analysis, 137 (34%) during work-hours and 262 (66%) during off-hours. The mortality rate was not different at 3 months between groups: 24 (17.5%) in the work-hours group versus 38 (14.5%) in the off-hours group [odds ratio 1.25; 95% confidence interval (CI), 0. 72-2.19]. There were no differences between groups on secondary endpoints. The mean time of symptom-to-needle was significantly higher during off-hours (mean difference: 18.4 min; 95% CI, 7.81-29.0). CONCLUSIONS: In this study, there were no significant differences in mortality and functional outcomes at 3 months between patients who underwent off-hour or work-hour thrombolysis in the emergency department.

Establishment of an Undergraduate FOAM Initiative: International Emergency Medicine (iEM) Education Project for Medical Students.

INTRODUCTION: Our goal was to describe the structure, process, platforms, and piloting period activities of the International Emergency Medicine (iEM) Education Project, which is a Free Open Access Medical Education (FOAM) initiative designed for medical students. METHODS: This was a descriptive study. We analyzed the activity data of iEM Education Project platforms (website and image, video, audio archives) in the piloting period (June 1, 2018-August 31, 2018). Studied variables included the total and monthly views, views by country and continents, the official languages of the countries where platforms were played, and their income levels. RESULTS: Platforms were viewed or played 38,517 times by users from 123 countries. The total views and plays were 8,185, 11,896, and 18,436 in June, July, and August, respectively. We observed a monthly increasing trend in all platforms. Image archive and website were viewed the most. All platforms were dominantly viewed from Asia and North America, high- and upper-middle-income countries, and non-English speaking countries. However, there were no statistically significant differences between continents, income levels, or language in platforms, except for the website, the project's main hub, which showed a strong trend for difference between income levels (Kruskal-Wallis, P = 0.05). Website views were higher in high-income countries compared with low- and lower-middle income countries (Mann Whitney U test, P = 0.038 and P = 0.021, respectively). CONCLUSION: The iEM Education Project was successfully established. Our encouraging initial results support the international expansion and increased collaboration of this project. Despite targeting developing countries with limited resources in this project, their engagement was suboptimal. Solutions to reach medical students in these countries should be investigated.

Predictors of mortality in ST-elevation MI patients: A prospective study.

We aimed to define factors predicting mortality in patients having ST elevation myocardial infarction (STEMI) who had Primary Percutaneous Coronary Intervention (PCI) in our setting.This is a prospective study on patients presenting to the emergency department with STEMI who underwent PCI during a 12-month period. Physiological parameters were calculated using the vital signs and age of patients. Time-based factors in the institutional protocol were collected. Univariate analysis was performed to define significant factors that affected mortality. Significant factors were then entered into a logistic regression model. Factors significantly affecting mortality were defined. Receiving operating characteristic curve was applied to define the best predictors of mortality.A total of 167 consecutive patients were studied; 128 (76.6%) were males. The mean (SD) age of the patients was 61.9 (12.8) years. The logistic regression model showed that significant factors were age (P = .002), Modified Shock Index, MSI (P = .028), systolic blood pressure (P = .028), and time between consultation and activation of catheter laboratory (P = .047). The cut-off points with best prediction of mortality were age of 71.5 years, systolic blood pressure of less than 95 mmHg, MSI of 0.85, and a time more than 3.5 minutes between consultation and activation of catheter laboratory.Our study shows that significant predictors of 30-days mortality of STEMI were age, systolic blood pressure on presentation, MSI, and the time between consultation and catheter laboratory activation. Improving prehospital resuscitation and activation of the catheter laboratory by emergency physicians may reduce mortality in our setting.

Elevated lactate level and shock index in nontraumatic hypotensive patients presenting to the emergency department.

BACKGROUND: The aim of our study was to evaluate the effect of lactate level (LL) and shock index (SI) on the outcome in nontraumatic hypotensive patients in the emergency department, and also to show the significance of the combined usage of these two parameters. METHODS: This is a prospective, observational study. Elevated and normal LL (ELL and NLL), elevated and normal SI (ESI and NSI), and a combination of these two parameters (lactate-SI group 1: ELL and ESI, lactate-SI group 2: ELL or ESI, and lactate-SI group 3: NLL and NSI) were evaluated for primary (mortality) and secondary outcome measures. RESULTS: A total of 131 patients who fulfilled the inclusion criteria were analysed. Of the patients with ELL, 34.78% were mechanically ventilated (P<0.001), 31.88% received vasoactive drugs (P<0.001), and 68.1% were hospitalized (P<0.01). The mortality rate among patients with ELL was 50.72% (P<0.001). Of the patients with ESI, 39.42% died (P<0.01). Use of mechanical ventilation in the emergency department was higher in lactate-SI group 1 [36.1%, P<0.0001, sensitivity: 100.0%, negative predictive value (NPV): 100.0%]. Vasoactive drug use was higher in lactate-SI group 1 (32.8%, P<0.0001, sensitivity: 100.0%, NPV: 100.0%). Lactate-SI group 1 showed a higher hospitalization rate (67.8%, P>0.05). In-hospital mortality in lactate-SI group 1 was higher (54.1%, P<0.0001, sensitivity: 100.0%, NPV: 100.0%). CONCLUSION: The combination of both parameters is effective in predicting these outcome measures with higher sensitivities and NPVs. Further studies on the subject are required.