Outcomes of direct and indirect medical intensive care unit admissions from the emergency department of an acute care hospital: a retrospective cohort study.

OBJECTIVES: This study aimed to determine if the risk of adverse outcomes (in-hospital and 60-day mortality, intensive care unit (ICU) and total hospital length of stay (LOS)) was greater for medical ICU (MICU) or high dependency unit (HDU) patients indirectly admitted from the emergency department (ED) than for directly admitted patients. SETTING: This study was conducted at a large public acute care hospital in Singapore. PARTICIPANTS: In this retrospective cohort study, hospital records of patients who were admitted directly from the ED, or initially admitted to the general wards from the ED and subsequently transferred to the MICU/HDU within 24 h, were reviewed. Patients were included if they were: (A) discharged from the MICU/HDU in 2009 and were admitted from the ED and (B) transferred to the MICU/HDU within 24 h of presentation at the ED. Data from 706 patients were analysed; 58.4% were men with a median age of 61 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The following outcomes were compared: in-hospital mortality, 60-day mortality, LOS at the MICU/HDU, as well as total hospital LOS. RESULTS: Of the 706 patients, 491 (69.5%) were directly admitted to the MICU/HDU. After adjusting for demographics, comorbidities, interventions at the ED and clinical parameters at the ED (heart rate, respiration, oxygen saturation, mean arterial pressure), as well as the Apache II score on arrival at the MICU/HDU, indirectly admitted patients had a higher risk of in-hospital mortality (OR=3.07, 95% CI 1.39 to 6.80), death within 60 days (OR=3.09, 95% CI 1.40 to 6.83) and risk of staying >1 day at the MICU/HDU (OR=2.54, 95% CI 1.48 to 4.36). There was no significant difference in total in-hospital LOS. CONCLUSIONS: Indirectly admitted MICU/HDU patients had generally poorer outcomes. As the magnitude of effect may vary across settings, context-specific studies may be useful for improving outcomes.

Review of studies and guidelines on fasting and procedural sedation at the emergency department.

AIM: Procedural sedation and analgesia allows urgent procedures to be performed safely by preserving patients' airway reflexes. Fasting, which is required before deeper levels of sedation, and where the airway reflexes are not preserved, is difficult to impose in emergencies. This paper aims to synthesise evidence on the need for pre-procedure fasting to minimise aspiration among adults undergoing procedural sedation and analgesia for emergency procedures. METHODS: Overviews, guidelines with graded recommendations and primary studies on aspiration and pre-procedure fasting in procedural sedation and analgesia were retrieved from Medline, Cochrane, and Center for Reviews and Dissemination Databases. Terms searched were procedural sedation, fasting, emergency and sedation. RESULTS: One primary study and one guideline were included. The American College of Emergency Physicians Clinical Policies Subcommittee on Procedural Sedation and Analgesia issued a recommendation based on 'preliminary, inconclusive or conflicting evidence, or on panel consensus'. The recommendation states: 'recent food intake is not a contraindication for administering procedural sedation and analgesia...'. The primary study conducted by Bell in an emergency department in Australia compared patients who last ate or drank more than 6 and 2 h from induction, respectively, with those who last ate or drank within 6 and 2 h. There were no cases of aspiration in both groups. Out of 118 patients who fasted, 1 (0.8%) vomited, as did one of 282 patients (0.4%) who did not fast. CONCLUSIONS: Aspiration risk is expected to be lower in procedural sedation and analgesia than in general anaesthesia. Current guidelines rely on expert consensus due to the lack of primary studies. Contextualisation of existing guidelines are quick and efficient strategies for developing locally relevant tools.

Venous thromboembolism at the National Healthcare Group, Singapore.

INTRODUCTION: Venous thromboembolism (VTE), including its most serious clinical subtype, pulmonary embolism (PE), is a potentially preventable disease. While current assessment tools do not include ethnicity as a risk factor, studies suggest that Asians have lower risk of VTE compared to Caucasians. This study aims to describe 2006 in-hospital and projected population based incidence rates of VTE and PE in Singapore. MATERIALS AND METHODS: Data on 2006 admissions at 3 major NHG hospitals, cases of VTE and their demographics were obtained from the ODS, a large administrative database of the National Healthcare Group (NHG). Demographic characteristics of the 2006 Singapore resident population were obtained from the 2006 Singapore Statistics website. RESULTS: In 2006, there were 860 cases of VTE out of 98,121 admissions in these 3 hospitals. Overall and secondary VTE age adjusted in-hospital burden was 73 and 54 per 10,000 patients, respectively. Caucasians and Eurasians had VTE rates in excess of 100 per 10,000 while Chinese, Malays and Indians each had rates below 100 per 10,000. Assuming that 42.5% of the 2006 Singapore population was served by NHG, the estimated population-based incidence of VTE and PE is 57 and 15 per 100,000, respectively. CONCLUSIONS: As patterns across ethnic groups point to lower VTE rates among Asians compared to Caucasians and Eurasians, analytic studies should be considered to test this hypothesis. There may be a need to develop locally applicable risk assessment tools which can be used to support local guidelines for VTE prophylaxis, thus leading to more acceptable and cost-effective care.

Global trends in cardiology and cardiothoracic surgery--an opportunity or a threat?

Coronary heart disease is currently the leading cause of death globally, and is expected to account for 14.2% of all deaths by 2030. The emergence of novel technologies from cardiothoracic surgery and interventional cardiology are welcome developments in the light of an overwhelming chronic disease burden. However, as these complementary yet often competing disciplines rely on expensive technologies, hastily prepared resource plans threaten to consume a substantial proportion of limited healthcare resources. By describing procedural and professional trends as well as current and emerging technologies, this review aims to provide useful knowledge to help managers make informed decisions for the planning of cardiovascular disease management. Since their inception, developments in both specialties have been very rapid. Owing to differences in patient characteristics, interventions and outcomes, results of studies comparing cardiothoracic surgery and interventional cardiology have been conflicting. Outcomes for both specialties continue to improve through the years. Despite the persistent demand for coronary artery bypass surgery (CABG) as a rescue procedure following percutaneous coronary intervention (PCI), there is a widening gap between the numbers of PCI and CABG. Procedural volumes seem to have affected career choices of physicians. Emerging technologies from both disciplines are eagerly awaited by the medical community. For long-term planning of both disciplines, conventional health technology assessment methods are of limited use due to their rapid developments. In the absence of established prediction tools, planners should tap alternative sources of evidence such as changes in disease epidemiology, procedural volumes, horizon scan reports as well as trends in disease outcomes.