Emergency physicians' role in telemedicine care during the coronavirus disease pandemic: Experiences from Taiwan.

Taiwan's response to the coronavirus disease pandemic received international recognition. Among various epidemic control measures, telemedicine services are provided for people under home quarantine. Although this service presents no policy, cost or equipment problems, the medical needs of people under home quarantine are diverse. Further, there are no clear guidelines regarding which specialists should be included in a multidisciplinary team. Moreover, many physicians are unwilling to participate in telemedicine, creating a big challenge for hospitals providing these services. Emergency physicians (EPs) have unique experiences in crisis management and can provide a number of effective public health measures. We advocate that EPs should be the first specialists to contact patients in a multidisciplinary team. Currently, there is a lack of literature on this subject, and Taiwan's epidemic control experience is used as an example to prove our viewpoint and provide recommendations for future EPs.

Locational effect on automated external defibrillator use and association of age with on-site return of spontaneous circulation.

BACKGROUND: Emergency medical services (EMSs) are used by approximately 383,000 patients with out-of-hospital sudden cardiac arrest (SCA) in the United States. Hence, it is crucial to implement automated external defibrillator (AED) programs to prepare responders for an SCA emergency. Taiwanese pass legislature to enforce AED installation in 8 mandatory areas since 2013. Our study investigated the efficacy of the policy regarding AED installation. MATERIALS AND METHODS: We collected data of patients who had sudden cardiac arrest (SCA) in pre-hospital settings, and received resuscitative efforts, including cardiopulmonary resuscitation or defibrillation with AEDs. The data were from July 11, 2013 to July 31, 2015. In total, 209 adult patients were documented by on-site caregivers of different facilities, and a report was mailed to the central health and welfare unit. RESULTS: Schools, large-scale gathering places, and special institutions used AEDs the most, accounting for 33 (15.3%) cases. From non-mandatory AED areas, long-term care facilities had the maximum cases of AED use (32 cases; 14.9%). With commuting stations as a reference, long-distance transport had the lowest odds ratio (OR) of 0.481 (95% confidence interval [CI], 0.24-0.962). The OR for schools, large-scale gathering places, and special institutions was 4.474 (95% CI: 2.497-8.015). Regarding failure of return of spontaneous circulation (ROSC), the OR for the ≥80-year age group was higher than that for the 20-39-year age group. CONCLUSIONS: The policy regarding the legislation to install AEDs in mandatory areas improved AED accessibility. Elderly patients aged ≥80 years have a higher rate of ROSC failure.

Excess mortality reduction given a "reduce patient mortality at all costs" scenario for mass burn casualties.

OBJECTIVE: The aim of this study was to estimate the effect on medical resource use and mortality of full financial support from the government for treatment costs after a mass burn casualty event in Taiwan. METHODS: All patients with burn injuries from the event were included (n = 483). Each burn patient from this incident was matched to a separate burn patient identified from the National Health Insurance database. Medical care usage and mortality were compared between groups at 1-, 3-, 6-, 9-, and 12-month intervals. RESULTS: Regarding outpatient expenditure, burn patients from the mass casualty event had significantly higher levels of medical expenditure compared with their control counterparts at all intervals and levels of medical institution. For inpatient expenditure, patients from the mass casualty event only had higher expenditure for the first month, and excess procedures used by these patients mainly consisted of nonvital procedures such as rehabilitation training. The mortality rate was only slightly lower for this group of burn patients compared with their control counterparts. CONCLUSIONS: Full financial support by the government in terms of medical treatment may engender only marginal additional benefits in terms of mortality if burn treatment procedures are already well established in the country.

Hurdle Poisson Regression Model for Identifying Factors Related to Noncompliance and Waiting Time for Confirmatory Diagnosis in Colorectal Cancer Screening.

OBJECTIVES: Population-based colorectal cancer (CRC) screening programs that use a fecal immunochemical test (FIT) are often faced with a noncompliance issue and its subsequent waiting time (WT) for those FIT positives complying with confirmatory diagnosis. We aimed to identify factors associated with both of the correlated problems in the same model. METHODS: A total of 294,469 subjects, either with positive FIT test results or having a family history, collected from 2004 to 2013 were enrolled for analysis. We applied a hurdle Poisson regression model to accommodate the hurdle of compliance and also its related WT for undergoing colonoscopy while assessing factors responsible for the mixture of the two outcomes. RESULTS: The effect on compliance and WT varied with contextual factors, such as geographic areas, type of screening units, and level of urbanization. The hurdle score, representing the risk score in association with noncompliance, and the WT score, reflecting the rate of taking colonoscopy, were used to classify subjects into each of three groups representing the degree of compliance and the level of health awareness. CONCLUSION: Our model was not only successfully applied to evaluating factors associated with the compliance and the WT distribution, but also developed into a useful assessment model for stratifying the risk and predicting whether and when screenees comply with the procedure of receiving confirmatory diagnosis given contextual factors and individual characteristics.

The utilization of automated external defibrillators in Taiwan.

BACKGROUND: Increasing attention to care of patient succumbed to out-of-hospital cardiac arrest (OHCA) and evidence for improved survival have resulted in many countries to encourage the use automated external defibrillators (AEDs) by legislation. In Taiwan, the amendment of the Emergency Medical Services Act mandated the installation of AEDs in designated areas in 2013. Since then, 6151 AEDs have been installed and registered in mandated and non-mandated locations. The purpose of this study was to investigate the utilization of AEDs at mandated and non-mandated locations. METHODS: This paper analyzed 217 cases in whom AEDs was used between July 11, 2013 and July 31, 2015. Descriptive statistics were used to analyze the data. RESULTS: The highest frequency of AEDs used was in long-term care facilities, accounting for 34 (15.7%) cases. The second and third highest was in schools and commuting stations. The highest utilization rate of registered AED was in long-term care facilities (73.9%), the second was in residential areas, and the third was in hot spring areas. Employees at the designated locations or medical personnel operated the AED in 143 cases (84.6%), and bystanders, relatives, friends or others operated the AEDs in 26 cases (15.4%). On-site Return of Spontaneous Circulation (ROSC) after applying AEDs occurred in 76 cases (45.8%). CONCLUSION: Long-term care facilities had the highest utilization of AEDs and government should pay more attention to enforce the installing of AEDs in these places. The government also needs to promote the education public on how to search the AEDs locations.

Impact of Comorbidity on Fatality Rate of Patients with Middle East Respiratory Syndrome.

To date, 1841 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported worldwide, with 652 deaths. We used a publically available case line list to explore the effect of relevant factors, notably underlying comorbidities, on fatal outcome of Middle East respiratory syndrome (MERS) cases up to the end of October 2016. A Bayesian Weibull proportional hazards regression model was used to assess the effect of comorbidity, age, epidemic period and sex on the fatality rate of MERS cases and its variation across countries. The crude fatality rate of MERS cases was 32.1% (95% credibility interval (CI): 29.9%, 34.3%). Notably, the incremental change of daily death rate was most prominent during the first week since disease onset with an average increase of 13%, but then stabilized in the remaining two weeks when it only increased 3% on average. Neither sex, nor country of infection were found to have a significant impact on fatality rates after taking into account the age and comorbidity status of patients. After adjusting for age, epidemic period, MERS patients with comorbidity had around 4 times the risk for fatal infection than those without (adjusted hazard ratio of 3.74 (95% CI: 2.57, 5.67)).

Lessons from the MOHW compensation pilot program on birth incidents: First step and looking forward.

OBJECTIVE: In Taiwan, the number of medical disputes and litigation has increased dramatically over the past 20 years. The seriousness of medical disputes continuing grows in clinical practice, especially in obstetricians. This study provided a possible solution to the medical dispute litigation issue. MATERIALS AND METHODS: The Ministry of Health and Welfare (MOHW) compensation program for birth incidents has been implemented since 2012 and it provided pecuniary compensation for mothers, newborns, and fetuses who got injured or died in birth-related medical incidents. We analyzed the amount and distribution of compensation, and assessed the effect of compensation on the number of medical dispute litigation. RESULTS: From 2012 to 2015, a total of 348 applications was received, 322 of which were examined by the committee. Among the examined cases, 278 were approved for compensation. The total amount of compensation had reached 266.16 million NTD (8.32 million USD). For the medical dispute litigation, a dramatic decrease in number was observed after the implementation of this compensation pilot program. CONCLUSION: Prompt compensation provided instant economic and spiritual support for patients and families. Pecuniary compensation could be an alternative choice of justice, which might encourage the injured to receive economic compensation, instead of filing a lawsuit against the physician or hospital institution. As a result, the number of dispute litigation has decreased. This indicates that the compensation program is an efficient way to improve medical dispute litigation difficulties.

Nationwide "Hospital Emergent Capability Accreditation by Level-Stroke" Improves Stroke Treatment in Taiwan.

BACKGROUND AND PURPOSE: Recombinant tissue plasminogen activator (rtPA) is one of the proven therapies that improve the outcome of patients with acute ischemic stroke (AIS). In 2009, the Ministry of Health and Welfare, Executive Yuan, Republic of China, launched the project "Hospital Emergent Capability Accreditation by Level-Stroke (HECAL-Stroke)" to improve AIS treatment in Taiwan. The current study was performed to determine whether the project launched by the government was effective in promoting rtPA therapy among AIS patients. METHODS: All participating hospitals were verified and designated as "heavy duty (HD)," "moderate duty (MoD)," or "medium duty (MeD)" according to the stroke center criteria. Four annual indices (rates of treatment, protocol adherence, in-time treatment, and complications) were recorded from 2009 to 2014 as outcome measures. The data were analyzed using the χ2 test for significance. RESULTS: The number of certified hospitals progressively increased from 74 to 112 during the 6-year period and finally consisted of 33 HD, 9 MoD and 70 MeD hospitals in 2014. The annual intravenous rtPA treatment rate increased significantly from 3.0% in 2009 to 4.5% in 2014. The protocol adherence rates were 95.7% in the HD group, 92.4% in the MoD group and 72.8% in the MeD group. The annual in-time treatment rate significantly improved from 26.0% in 2009 to 60.1% in 2014. The overall symptomatic intracranial hemorrhagic rate after rtPA treatment was 8.6%. CONCLUSIONS: Initiation of the HECAL-Stroke project by the government significantly improved rtPA treatment in Taiwan.

Experience of distributing 499 burn casualties of the June 28, 2015 Formosa Color Dust Explosion in Taiwan.

OBJECTIVE: To describe the experience of distributing 499 burn casualties of an unexpected event and determine whether patient transfer is associated with patient outcomes measured 2 weeks after the incident. METHODS: All 499 patients injured in the event were included. For the 138 patients transferred to other hospitals after primary distribution, we evaluated whether the transfers were associated with patient severity. Furthermore, we used multinomial logistic regression to investigate the association of patient transfer with patient outcomes after controlling for age, gender, total burn surface area (TBSA), final hospital level, wound infection, and patient pneumonia. RESULTS: We determined that on-site triage differed significantly from hospital triage (p<0.001). Furthermore, the secondary distribution enabled the transfer of a high number of patients to medical centers based on the availability of beds; however, such transfers were not associated with patient outcomes (p>0.05). Factors associated with patient outcomes were wound infection and TBSA (p<0.001). CONCLUSIONS: In case of inadequate burn centers, satisfactory patient outcomes can be achieved by the immediate treatment of patients, despite the treating hospitals being lower-level hospitals. Regardless of the hospital level, immediate treatment of burn patients is crucial to reducing mortality.

Residents' perception of duty hour limits through teaching hospital accreditation status-experience in Taiwan.

Residents' work overload is a rising issue in Taiwan. Duty hours of the residents in the United States have been limited by the Accreditation Council for Graduate Medical Education Common Program Requirements since 2003; similar standards were not implemented in Taiwan until 2013. Taiwanese duty hour standards are the work hour limits adopted as part of the required teaching hospital accreditation status. In January 2015, the Ministry of Health and Welfare conducted a national survey for all house officers in Taiwan. We collected data including those on demographics and perceptions of residents regarding duty hour limits. Most respondents reported positive perceptions of the duty hour standards. They felt that these limits will improve resident education, quality of life, and patient safety. The strong incentive to follow the regulations (through teaching hospital accreditation) could help protect residents (and patients) from unsafe working conditions. However, further studies on the influence of shortened duty hour on professional development are necessary for future improvement.

Gastric-type adenocarcinoma in situ of uterine cervix: cytological and histopathological features of two cases.

Benign, premalignant, and malignant endocervical glandular lesions occasionally show a gastric phenotype. We report 2 cases of gastric-type adenocarcinoma in situ (AIS) of the endocervix, not associated with lobular endocervical glandular hyperplasia or gastric-type adenocarcinoma. Cytologically, both showed endocervical glands with slightly enlarged nuclei, distinctive nucleoli, pseudostratified strips, and intracytoplasmic golden yellow mucin. Histologically, both lesions were situated in preexisting endocervical glands and presented columnar cells with voluminous pale eosinophilic cytoplasm and evident nuclear atypia. In case 1, the lesion was located at the mid-zone of the endocervical canal and, in case 2, at the outer endocervical canal with extension to the transformation zone and prominent intestinal metaplasia. In both, the cells showed voluminous cytoplasm containing gastric-type mucin, stained red by combined alcian blue/periodic acid-Schiff stain. Immunohistochemically, both lesions were positive for HIK1083 and p53, while negative for p16 and ER. Human papilloma virus (HPV) DNA was not detected by polymerase chain reaction. Our cases illustrate that gastric-type AIS can occur without lobular endocervical glandular hyperplasia. The lesions can occur in the outer cervical canal and present extensive intestinal differentiation. Awareness of this rare type of endocervical glandular lesion is important since they are pathogenetically different from the more common HPV-associated lesions and may become more prevalent in the HPV-eradicating era.