Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand.

BACKGROUND: The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality. METHODS: A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included. RESULTS: A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was 'cannot control symptoms' (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality. CONCLUSION: The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Interhospital transportation of a COVID-19 patient undergoing veno-venous extracorporeal membrane oxygenation by helicopter.

Some coronavirus disease 2019 (COVID-19) patients develop rapidly progressive acute respiratory distress syndrome and require veno-venous extracorporeal membrane oxygenation (V-V ECMO). A previous study recommended the transfer of ECMO patients to ECMO centers. However, because of the pandemic, a limited number of ECMO centers are available for patient transfer. The safe long-distance interhospital transport of these patients is a concern. To minimize transportation time, helicopter use is a suitable choice. We report the first case of a COVID-19 patient on V-V ECMO, transferred to our ECMO center by helicopter. A 45-year-old man with rheumatoid arthritis history, treated with immunosuppressants, presented with fever and sore throat. He was diagnosed with COVID-19 following a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test result and was subsequently prescribed favipiravir. However, his respiratory failure progressively worsened. On day 10 of hospitalization at the previous hospital, he was intubated, and we received a request for ECMO transport on the next day. The ECMO team, who wore personal protective equipment (N95 respirators, gloves, gowns, and face shields), initiated V-V ECMO in the referring hospital and safely transported the patient by helicopter. The flight time was 7 min. He was admitted to the intensive care unit of our hospital and received tocilizumab. He was discharged on hospital day 31 with no significant sequelae. In this case report, we discuss important factors for the safe and appropriate interhospital transportation of COVID-19 patients on ECMO as well as staff and patient safety during helicopter transportation.

Role of Point-of-Care Testing in Reducing Time to Treatment Decision-Making in Urgency Patients: A Randomized Controlled Trial.

INTRODUCTION: Shortening emergency department (ED) visit time can reduce ED crowding, morbidity and mortality, and improve patient satisfaction. Point-of-care testing (POCT) has the potential to decrease laboratory turnaround time, possibly leading to shorter time to decision-making and ED length of stay (LOS). We aimed to determine whether the implementation of POCT could reduce time to decision-making and ED LOS. METHODS: We conducted a randomized control trial at the Urgency Room of Siriraj Hospital in Bangkok, Thailand. Patients triaged as level 3 or 4 were randomized to either the POCT or central laboratory testing (CLT) group. Primary outcomes were time to decision-making and ED LOS, which we compared using Mann-Whitney-Wilcoxon test. RESULTS: We enrolled a total of 248 patients: 124 in the POCT and 124 in the CLT group. The median time from arrival to decision was significantly shorter in the POCT group (106.5 minutes (interquartile [IQR] 78.3-140) vs 204.5 minutes (IQR 165-244), p <0.001). The median ED LOS of the POCT group was also shorter (240 minutes (IQR 161.3-410) vs 395.5 minutes (IQR 278.5-641.3), p <0.001). CONCLUSION: Using a point-of-care testing system could decrease time to decision-making and ED LOS, which could in turn reduce ED crowding.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study.

STUDY OBJECTIVE: Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED. METHODS: This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs. RESULTS: Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose. CONCLUSION: High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

Outcomes of Emergency Medical Service Usage in Severe Road Traffic Injury during Thai Holidays.

INTRODUCTION: Thailand has the highest mortality from road traffic injury (RTI) in the world. There are usually higher incident rates of RTI in Thailand over long holidays such as New Year and Songkran. To our knowledge, there have been no studies that describe the impact of emergency medical service (EMS) utilization by RTI patients in Thailand. We sought to determine the outcomes of EMS utilization in severe RTIs during the holidays. METHODS: We conducted a retrospective review study by using a nationwide registry that collected RTI data from all hospitals in Thailand during the New Year holidays in 2008-2015 and Songkran holidays in 2008-2014. A severe RTI patient was defined as one who was admitted, transferred to another hospital, or who died at the emergency department (ED) or during referral. We excluded patients who died at the scene, those who were not transported to the ED, and those who were discharged from the ED. Outcomes associated with EMS utilization were identified by using multiple logistic regression and adjusted by using factors related to injury severity. RESULTS: Overall we included 100,905 patients in the final analysis; 39,761 severe RTI patients (39.40%; 95% confidence interval [CI] 95% CI [39.10%-39.71%]) used EMS transportation to hospitals. Severe RTI patients transported by EMS had a significantly higher mortality rate in the ED and during referral than that those who were not (2.00% vs. 0.78%, p < 0.001). Moreover, EMS use was significantly associated with increased mortality rate in the first 24 hours of admission to hospitals (1.38% for EMS use vs. 0.57% for no EMS use, p < 0.001). EMS utilization was a significant predictor of mortality in EDs and during referral (adjusted odds ratio [OR] 2.19; 95% CI [1.88-2.55]), and mortality in the first 24 hours of admission (adjusted OR 2.31; 95% CI [1.95-2.73]). CONCLUSION: In this cohort, severe RTI patients transported by EMS had a significantly higher mortality rate than those who went to hospitals using private vehicles during these holidays.

The feasibility of the 1-h high-sensitivity cardiac troponin T algorithm to rule-in and rule-out acute myocardial infarction in Thai emergency patients: an observational study.

BACKGROUND: The 3-h high-sensitivity cardiac troponin T (hs-cTnT) algorithm is the most commonly used scheme to diagnose acute myocardial infarction. The 1-h hs-cTnT algorithm has recently been approved by the European Society of Cardiology as an alternative algorithm for earlier diagnosis. If the hs-cTnT test cannot discriminate the diagnosis of the patient at 1 h, the patient is defined as observational group. Their test must be repeated at 3 h. A high prevalence of this group may indicate a low clinical utility of the 1-h hs-cTnT algorithm. This study was aimed to estimate the proportion of the observational group in Thai emergency department (ED) patients and also the time to rule-in/out between both the algorithms. METHODS: A historical control study was conducted in patients with chest pain for 1-12 h at the ED of Siriraj Hospital, Bangkok, Thailand. The study compared two groups: one prospective group of all patients evaluated with the 1-h hs-cTnT algorithm between June and September 2017 and one historical control group evaluated with the 3-h hs-cTnT algorithm between January and March 2017. RESULTS: A total of 130 patients were included (3-h hs-cTnT algorithm group n = 65 and 1-h hs-cTnT algorithm group n = 65). Twelve patients [18.5% (95% CI 10.0-30.1)] were categorized as observational group in the 1-h hs-cTnT algorithm group. The mean rule-in/out times in the 3-h hs-cTnT algorithm and 1-h hs-cTnT algorithm groups were 238 min (SD 63.3) and 134 min (SD 68.5), respectively (both p < 0.001). The time to disposition was also shortened in the 1-h hs-cTnT algorithm group (p <  0.001). Multivariable regression analysis performed to identify and adjust for confounders among patient characteristics revealed no significant confounders. CONCLUSIONS: The use of the 1-h hs-cTnT algorithm in the ED resulted in an acceptable proportion in the observational group and a decreased time to rule-in/out compared with the 3-h hs-cTnT algorithm.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Emergency Department Patients With Cardiogenic Pulmonary Edema: A Randomized Controlled Trial.

STUDY OBJECTIVE: High-flow nasal cannula is a new method for delivering high-flow supplemental oxygen for victims of respiratory failure. This randomized controlled trial compares high-flow nasal cannula with conventional oxygen therapy in emergency department (ED) patients with cardiogenic pulmonary edema. METHODS: We conducted an open-label randomized controlled trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years or older with cardiogenic pulmonary edema were randomly assigned to receive either conventional oxygen therapy or high-flow nasal cannula. The primary outcome was the respiratory rate 60 minutes postintervention. RESULTS: We enrolled 128 participants (65 in the conventional oxygen therapy and 63 in the high-flow nasal cannula groups). Baseline high-flow nasal cannula and conventional oxygen therapy mean respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5). Mean respiratory rates at 60 minutes postintervention were lower in the high-flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3; 95% confidence interval 1.9 to 4.6). No significant differences were found in the admission rate, ED and hospital lengths of stay, noninvasive ventilation, intubation, or mortality. CONCLUSION: In patients with cardiogenic pulmonary edema in the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.