Electronic medical record implementation in the emergency department in a low-resource country: Lessons learned.

OBJECTIVE: There is paucity of information regarding electronic medical record (EMR) implementation in emergency departments in countries outside the United States especially in low-resource settings. The objective of this study is to describe strategies for a successful implementation of an EMR in the emergency department and to examine the impact of this implementation on the department's operations and patient-related metrics. METHODS: We performed an observational retrospective study at the emergency department of a tertiary care center in Beirut, Lebanon. We assessed the effect of EMR implementation by tracking emergency departments' quality metrics during a one-year baseline period and one year after implementation. End-user satisfaction and patient satisfaction were also assessed. RESULTS: Our evaluation of the implementation of EMR in a low resource setting showed a transient increase in LOS and visit-to-admission decision, however this returned to baseline after around 6 months. The bounce-back rate also increased. End-users were satisfied with the new EMR and patient satisfaction did not show a significant change. CONCLUSIONS: Lessons learned from this successful EMR implementation include a mix of strategies recommended by the EMR vendor as well as specific strategies used at our institution. These can be used in future implementation projects in low-resource settings to avoid disruption of workflows.

Does time to angiography affect the survival of trauma patients with embolization to the pelvis? A retrospective study across trauma centers in the United States.

INTRODUCTION: Traumatic pelvic injuries can result in rapid exsanguination. Bleeding control interventions include stabilization, angiography, and possible embolization. Previous studies yielded conflicting results regarding the benefit of a shorter time to embolization. OBJECTIVES: The aim of this study is to examine the impact of the time to angioembolization on the survival of patients presenting with pelvic injuries using a national database. MATERIALS AND METHODS: This was an observational retrospective study that used the National Trauma Data Bank 2017 dataset. Adult patients with pelvic injuries and who received angiography with embolization to the pelvis were included. Univariate and bivariate analyses (survival to hospital discharge yes/no) were done. This was followed by a multivariable logistic regression analysis to assess the impact of time to angiography on survival to hospital discharge after adjusting for potential confounders. RESULTS: A total of 1,057 patients were included. They were predominantly of male gender (69.3 %) with a median age of 50 years (IQR = [31-64]). The mean time to pelvic angiography was 264.0 ± 204.4 min. The overall survival rate at hospital discharge was 72.0 %. Time to angiography was not significantly associated with survival to hospital discharge before and after adjusting for clinically and statistically significant confounders (aOR = 1.000; 95 %CI=[0.999 - 1.001]; p = 0.866). CONCLUSION: Time to angiography was not associated with survival to hospital discharge of patients with pelvic injuries who required embolization. Further research examining specific patterns of injuries and assessing the impact of early angioembolization is needed.

Epidemiology of adult injuries: A multi-center study in greater Beirut.

INTRODUCTION: Injury accounts for nearly 4 million deaths and 63 million disabilities annually. The injury burden is disproportionally large in low- and middle-income countries (LMICs), including Lebanon. This study aims to examine the characteristics and patterns of adult injuries presenting at multiple emergency departments (ED) in Lebanon and further identifies factors associated with hospital admission. MATERIALS AND METHODS: A retrospective cross-sectional study was conducted on adult patients (aged≥16) who presented with an injury to one of the five participating EDs from June 2017 to May 2018. Pan-Asia Trauma Outcomes Study (PATOS) variables were adopted for data collection. A descriptive analysis was performed, followed by bivariate and multivariate logistic regression to identify injury risk factors for hospital admission. RESULTS: A total of 3,716 patients' records were included. Most injuries were sustained by males (62.7%), patients aged between 16 and 35 years (16-25: 28%; 26-35: 22.7%), and above 65 years (15.6%). Most injuries were unintentional (94.9%). Falls were highly prevalent across all age groups (38.8%), more proclaimed among the older adults' population (56-65:52.8%; ≥66:73.7%), followed by struck-by object (23.6%) and transport injuries (10.1%). Upper and lower extremity injuries were common across all ages. Most patients (80.9%) were treated and discharged at the ED, 11.4% were admitted to the hospital, 4.3% were transferred to other trauma care facilities, and 2 patients died in the ED. Factors positively associated with hospital admission included: older age (≥ 56 years); private insurance; spine and lower extremity injuries; fractures, cuts/open wounds, concussion, and organ injuries (p-value≤0.05; OR>1). CONCLUSION: Injury is a neglected public health problem in many LMICs, including Lebanon. While youth and the elderly are most affected, injuries occur across all age groups. This study lays the foundation for establishing a population-based injury surveillance system, crucial for designing tailored injury prevention programs to reduce injury-related deaths and disabilities.

Which Trauma Severity Scores Are Useful in Predicting Pediatric Mortality?

BACKGROUND AND OBJECTIVES: Trauma is the leading cause of death in children. Several trauma severity scores exist: the shock index (SI), age-adjusted SI (SIPA), reverse SI (rSI), and rSI multiplied by Glasgow Coma Score (rSIG). However, it is unknown which is the best predictor of clinical outcomes in children. Our goal was to determine the association between trauma severity scores and mortality in pediatric trauma. DESIGN AND METHODS: A multicenter retrospective study was performed using the 2015 US National Trauma Data Bank, including patients 1 to 18 years old and excluding patients with unknown emergency department dispositions. The scores were calculated using initial emergency department parameters. Descriptive analysis was carried out. Variables were stratified by outcome (hospital mortality). Then, for each trauma score, a multivariate logistic regression was conducted to determine its association with mortality. RESULTS: A total of 67,098 patients with a mean age of 11 ±5 years were included. Majority of the patients were male (66%) and had an injury severity score <15 (87%). Eighty-four percent of patients were admitted: 15% to the intensive care unit and 17% directly to the operating room. The mortality at hospital discharge was 3%.There was a statistically significant association between SI, rSI, rSIG, and mortality ( P < 0.05). The highest adjusted odds ratio for mortality corresponded to rSIG, followed by rSI then SI (8.51, 1.9, and 1.3, respectively). CONCLUSION: Several trauma scores may help predict mortality in children with trauma, the best being rSIG. Introduction of these scores in algorithms for pediatric trauma evaluations can impact clinical decision-making.

Beirut Blast: The Experiences of Acute Care Hospitals.

Mass Casualty Incidents recently increased in intensity and frequency at an unprecedented rate globally. On August 4, 2020, a massive blast hit the Port of Beirut severely damaging its healthcare sector. This study aims to provide a comprehensive understanding of the impact of the Beirut blast on acute care hospitals in the Beirut area, with a focus on understanding healthcare professionals' (HCPs) responses and encountered challenges. A qualitative research design method was adopted to evaluate the experiences of HCPs at acute hospitals located within 5 kilometers of the blast epicenter. 9 hospitals participated in the study. 11 semi-structured interviews were conducted with key informant HCPs using a designed interview guide. HCPs reported severe infrastructural damages in their corresponding hospitals, and 2 were completely non-functional post-blast. Other than physical injuries sustained by HCPs, the blast imposed substantial strains on their mental health, exacerbated by the ongoing socio-economic crises in Lebanon. Moreover, the findings revealed critical challenges which hindered hospitals' emergency responses at the level of communication, coordination, and human resources, as well as supplies. Participants urged for the need to conduct proper triage, arrange emergency operating centers, and deploy outdoor treatment tents among others, to effectively respond to future disasters. The Beirut blast overwhelmed the Lebanese healthcare system and challenged its level of emergency preparedness. This generated evidence to address the deficiencies and strengthen the existing hospitals' emergency response plans. Future efforts should include prioritizing hospitals' emergency preparedness to ensure the provision of care at increased capacity following the impact of a large-scale disaster.

Factors associated with survival in adult trauma patients undergoing angiography with and without embolization across trauma centers in the United States.

INTRODUCTION: Interventional angiography is increasingly utilized in trauma management for various injuries. Despite published guidelines by the Eastern Association for the Surgery of Trauma on the use of angiography, limited data exist on factors associated with outcomes in angiography procedures. This study examines factors associated with survival to hospital discharge in trauma patients undergoing angiography with or without embolization across US trauma centers. MATERIALS AND METHODS: This retrospective observational study used the National Trauma Data Bank 2017 dataset and included adult trauma patients who underwent conventional angiography with or without embolization. A bivariate analysis was done to compare patients' characteristics by outcome (survived/died), followed by a multivariable logistic regression analysis to determine factors associated with survival to hospital discharge after adjusting for important confounders. RESULTS: In the included sample of 4242 patients, median age was 41 years and male gender was predominant (72.6%). Overall mean time to angiography was 263.77 ± 750.19 min. Factors positively associated with survival included treatment at large facilities with over 401 beds (OR = 2.170; 95% CI, [1.277-3.685]), helicopter ambulance/fixed-wing transport (OR = 1.736; 95% CI, [1.325-2.275]), mild Glasgow Coma Scale (OR = 7.621; 95% CI, [5.868-9.898]) and moderate Glasgow Coma Scale (OR = 3.127; 95% CI, [2.080-4.701]), SBP ≥ 90 (OR = 1.516; 95% CI [1.199-1.916]), and spleen as embolization site (OR = 1.647; 95% CI [1.119-2.423]). CONCLUSION: This nationwide study identified variables associated with survival in trauma patients who underwent angiography. These variables can serve in creating standardized risk stratification tools that could be incorporated into evidence-based guidelines for angiography candidates.

Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study.

OBJECTIVE: Little is known about survival outcomes after traumatic cardiac arrest in Asia, or the association of Utstein factors with survival after traumatic cardiac arrests. This study aimed to describe the epidemiology and outcomes of traumatic cardiac arrests in Asia, and analyze Utstein factors associated with survival. METHODS: Traumatic cardiac arrest patients from 13 countries in the Pan-Asian Resuscitation Outcomes Study registry from 2009 to 2018 were analyzed. Multilevel logistic regression was performed to identify factors associated with the primary outcomes of survival to hospital discharge and favorable neurological outcome (Cerebral Performance Category (CPC) 1-2), and the secondary outcome of return of spontaneous circulation (ROSC). RESULTS: There were 207,455 out-of-hospital cardiac arrest cases, of which 13,631 (6.6%) were trauma patients aged 18 years and above with resuscitation attempted and who had survival outcomes reported. The median age was 57 years (interquartile range 39-73), 23.0% received bystander cardiopulmonary resuscitation (CPR), 1750 (12.8%) had ROSC, 461 (3.4%) survived to discharge, and 131 (1.0%) had CPC 1-2. Factors associated with higher rates of survival to discharge and favorable neurological outcome were arrests witnessed by emergency medical services or private ambulances (survival to discharge adjusted odds ratio (aOR) = 2.95, 95% confidence interval (CI) = 1.99-4.38; CPC 1-2 aOR = 2.57, 95% CI = 1.25-5.27), bystander CPR (survival to discharge aOR = 2.16; 95% CI 1.71-2.72; CPC 1-2 aOR = 4.98, 95% CI = 3.27-7.57), and initial shockable rhythm (survival to discharge aOR = 12.00; 95% CI = 6.80-21.17; CPC 1-2 aOR = 33.28, 95% CI = 11.39-97.23) or initial pulseless electrical activity (survival to discharge aOR = 3.98; 95% CI = 2.99-5.30; CPC 1-2 aOR = 5.67, 95% CI = 3.05-10.53) relative to asystole. CONCLUSIONS: In traumatic cardiac arrest, early aggressive resuscitation may not be futile and bystander CPR may improve outcomes.

Trauma center designation level and survival of patients with chest wall instability.

INTRODUCTION: Chest wall instability is a potentially life-threatening condition that should be evaluated at a trauma center. While patients with chest wall instability are sent to different trauma center levels, the impact of this on outcomes has not been evaluated yet. This study examines survival to hospital discharge of patients with chest wall instability treated at different trauma center levels. METHODS: This is an observational retrospective cohort study analyzed data from National Trauma Data Bank (NTDB) 2017 dataset. The study sample consisted of adult patients who presented with chest wall instability or deformity and for whom the ED disposition was recorded. Descriptive analysis was carried out. Hospital information, patients' demographic and clinical characteristics, and dispositions were compared based on the main independent variable "trauma designation level. This was followed by LASSO regression to determine the impact of the trauma designation level on patients' survival after controlling for most of the extracted factors from NTDB to conduct this study. RESULTS: The study sample consisted of 1172 patients sustaining chest wall instability or deformity. Most patients were males (78.2%) and had a median age of 52 years. Most were taken to level I (51.5%) or level II (43.2%) trauma centers. The overall survival to hospital discharge was 78.2%. After adjusting for confounders, no difference in patients' survival was noticed between those taken to level II [OR = 1.000; 95% confidence interval (CI): 0.976-1.025] or III [OR = 1.000; 95% CI: 0.993-1.007] trauma centers and those taken to level I centers. CONCLUSION: Survival rates for patients having chest wall instability were similar when transported to level II or level III versus level I centers. This finding can help guide pre-hospital field triage criteria for this specific type of injury and highlights the need for more outcome research in organized trauma systems.

Interventional angiography utilization for adult trauma patients in Trauma Centers across the United States: An observational study using the National Trauma Data Bank.

Angiography and embolization are part of trauma management protocols for various injuries. This study examines the use of angiography and embolization use in trauma care across Trauma Centers in the United States. We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients (≥16 years) who underwent conventional angiography with or without embolization were included. A univariate analysis was carried out to describe patients' demographic and injury characteristics as well as the time to angiography, angiography details, complications, and outcome (survival to hospital discharge: yes/no). One-year period prevalence proportion of angiography procedure was determined. A total of 4242 patients were included. The 1-year period prevalence proportion of angiography procedure with or without embolization was 0.53% (95% confidence intervals: 0.527-0.529). The median age was 41 years (interquartile range: 27-58) with most patients being in the age group 16 to 64 (83.8%) and males (72.6%). Over half of the patients, 55.4% had an embolization procedure performed in addition to angiography. The mean time to angiography was 263.77 ±â€…750.19 minutes. The most common embolization sites were the pelvis (24.9%), spleen (11.8%), and liver (9%). This study described angiography and embolization utilization in adult trauma patients in Trauma Centers in the US. Its findings provide the basis for future studies to examine more closely angiography/embolization utilization in specific subpopulations, and to create standardized risk stratification tools for trauma patients who are candidates for this procedure.

Injury severity score as a predictor of mortality in adult trauma patients by injury mechanism types in the United States: A retrospective observational study.

Injury severity score (ISS) is commonly used in trauma registries to describe injury severity and to predict outcomes in trauma patients regardless of injury mechanism. This study examined the correlation between ISS and mortality in adult trauma patients presenting to emergency departments in the United States with different mechanisms of injury. A retrospective observational study was conducted using the 2014 Nationwide Emergency Department Sample. Patients' characteristics were stratified by mortality. Receiver operating characteristic (ROC) curves were generated for death against ISS for each mechanism of injury. A logistic regression model was conducted for each mechanism of injury to determine whether ISS (≥16 vs <16) is a predictor of mortality. The study sample consisted of 16,147,058 weighted adult trauma patients. Median age was 46 years. Slightly over half were females (51.9%). Falls, motor vehicle accidents and being struck by or against, were the most commonly reported mechanisms of injury (44.6%, 18.1%, and 15.3%, respectively). The overall mortality in the study population was 0.4%. The area under the ROC curve was highest in injuries sustained in accidents involving machinery (0.947; 95% confidence intervals [CI], 0.896-0.998), followed by motor vehicle traffic (MVA) (0.788; 95% CI, 0.775-0.801) and cutting or piercing (0.746; 95% CI, 0.701-0.791). Deceased patients were accurately identified by ISS 65.2% in injury by machinery, 47.7% in injury involving MVA, 39.7% in injury by firearm and 31.4% in injury by assault. After adjusting for confounders, the multivariate models in which ISS was the main independent factor performed best in predicting mortality from firearm and machinery mechanism of injuries. Although the ROC curve analysis demonstrated a moderate or high discriminatory ability to identify deceased patients in 6 out of twelve mechanisms, and the multivariate analysis revealed that ISS was a significant predictor of mortality in 9 out of 12 injury mechanisms, the sensitivities of all logistic regression models were poor. The ISS ≥ 16 threshold alone therefore should not be used to identify patients with high-mortality risk. The mortality risk assessment should be done individually and be based on clinical evaluation.

The Beirut Port Blast: spectrum of injuries and clinical outcomes at a large tertiary care center in Beirut, Lebanon.

PURPOSE: To describe injuries and outcomes of casualties of Beirut Port Blast treated at a large tertiary care center in Beirut, Lebanon. METHODS: A retrospective observational study assessing the spectrum of injuries, treatment, and medical outcome among casualties of the Beirut Port Blast, immediately after the blast and up to 1 week from the blast to the emergency department of the American University of Beirut Medical Center (AUBMC). RESULTS: A total of 359 patients were included. Most (n = 343, 95.6%) were adults (> 19 years), and males (56%) with a mean age of 42 ± 20 years. The most frequent mechanism of injury was a penetrating injury (45.7%), followed by other blast-related injuries (30.4%), and blunt injuries (23.4%). The most affected anatomical location were the limbs. Most (n = 217, 60.4%) patients required imaging. The most frequently administered medication was analgesics (38%), followed by anesthetics (35%), antibiotics (31%), tetanus vaccine (31%), and fluids (28%). Blood and blood products were administered in 3.8% of cases. Emergent procedures included endotracheal intubation (n = 18, 5%), surgical airway (n = 3, 0.8%), chest tube insertion (n = 4, 1.1%), thoracotomy (n = 1, 0.3%), and CPR (n = 5, 1.4%). A quarter of patients required surgical operations in the operating room (n = 85, 23.6%) and 18% required noncritical care admissions, 5.3% required critical care admissions, and 2.8% were dead on arrival. CONCLUSION: Casualties from this event had significant injuries requiring lifesaving interventions, surgical procedures, and admission to critical care units. High utilization of imaging modalities and of medications from existing stockpiles was also observed.

Association between Mode of Transportation and Survival in Adult Trauma Patients with Penetrating Injuries: Matched Cohort Study between Police and Ground Ambulance Transport.

INTRODUCTION: Police transport (PT) of penetrating trauma patients has the potential to improve survival rates. There are no well-established guidelines for PT of penetrating trauma patients. STUDY OBJECTIVE: This study examines the association between survival rate to hospital discharge of adult penetrating trauma patients and mode of transport (PT versus ground ambulance [GA]). METHODS: A retrospective, matched cohort study was conducted using the United States (US) National Trauma Data Bank (NTDB). All adult penetrating injury patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by GA for analysis. Descriptive analysis was carried out. The patients' demographic and clinical characteristics were tabulated and stratified by the transport mode. RESULTS: Out of the 733 patients with penetrating injuries, ground Emergency Medical Services (EMS) transported 513 patients and police transported 220 patients. Most patients were 16-64 years of age with a male (95.6%) and Black/African American race (79.0%) predominance. Firearm-related injuries (68.8%) were the most common mechanism of injury with the majority of injuries involving the body extremities (62.9%). Open wounds were the most common nature of injury (75.7%). The overall survival rate to hospital discharge was similar for patients transported by GA and by police (94.5% versus 92.7%; P = .343). CONCLUSION: In this study, patients with penetrating trauma transported by police had similar outcomes to those transported by GA. As such, PT in penetrating trauma appears to be effective. Detailed protocols should be developed to further improve resource utilization and outcomes.

Paediatric injury in Beirut: a multicentre retrospective chart review study.

OBJECTIVE: This study aims to assess the epidemiology of paediatric injury in Beirut, giving insights into their characteristics, contributing risk factors and outcomes. DESIGN AND SETTING: A retrospective study was conducted to review medical charts for children aged 0-15 years presented to five hospital emergency departments (ED) located in Beirut over a 1-year period (June 2017-May 2018). PARTICIPANTS: A total of 1142 trauma-related visits for children under 15 years of age were included. A descriptive analysis and a bivariate analysis were performed to investigate admitted and treated/discharged patients. PRIMARY OUTCOME: A logistic regression was conducted to identify factors associated with hospital admission among injured children. RESULTS: A total of 1142 cases of paediatric injury ED cases were sampled, mean age was 7.7±4.35 years. Children aged 0-5 years accounted for more than one-third of the total cases, 40.0% (206/516) of the fall injuries and 60.1% (220/366) of home injuries. The leading cause of paediatric injury was fall (45.2%), nearly 4.1% of the cases were admitted to hospitals. Factors associated with admission included injury to abdomen (OR=8.25 (CI 1.11 to 61.24)), to upper extremity (OR=5.79 (CI 2.04 to 16.49)), to lower extremity (OR=5.55 (95% CI 2.02 to 15.20) and other insurance type (OR=8.33 (CI 2.19 to 31.67)). The three types of injuries mostly associated with hospital admission were fracture (OR=13.55 (CI 4.77 to 38.44)), concussion (OR=13.60 (CI 2.83 to 65.41)) and organ system injury (OR=31.63 (CI 3.45 to 290.11)). CONCLUSIONS: Injury remains a major health problem among the paediatric population in Lebanon. Parental child safety educational programmes and age-targeted injury prevention strategies should be initiated and implemented to mitigate the burden of child injuries and improve child safety and well-being.

International multi-center real world implementation trial to increase out-of-hospital cardiac arrest survival with a dispatcher-assisted cardio-pulmonary resuscitation package (Pan-Asian resuscitation outcomes study phase 2).

BACKGROUND: Dispatcher-assisted CPR (DA-CPR) has the potential to deliver early bystander CPR (BCPR) and improve out-of-hospital cardiac arrest (OHCA) survival. This study in the Asia-Pacific evaluated the impact of a DA-CPR program on BCPR rates and survival. METHODS: This was a three-arm, prospective, multi-national, population-based, community-level, implementation trial. Cases between January 2009 and June 2018 from the Pan-Asian Resuscitation Outcomes Study were included. Sites either implemented a comprehensive (with quality improvement tool) or a basic DA-CPR package, or served as controls. Primary outcome was survival-to-discharge/30th day post-arrest. Secondary outcomes were BCPR and favorable neurological outcome. A before-after comparison was made within each country; this before-after change was then compared across the three groups using logistic regression. RESULTS: 170,687 cases were analyzed. Before-after comparison showed that survival to discharge was higher in the 'implementation' period in all three groups: comprehensive odds ratio (OR) 1.09, 95% confidence interval (CI; [1.0-1.19]); basic OR 1.14, 95% CI (1.08-1.2); and control OR 1.25, 95% CI (1.02-1.53). Comparing between groups, the comprehensive group had significantly higher change in BCPR (comprehensive vs control ratio of OR 1.86, 95% CI [1.66-2.09]; basic vs control ratio of OR 0.94, 95% CI [0.85-1.05]; and comprehensive vs basic ratio of OR 1.97, 95% CI [1.87-2.08]) and survival with favorable neurological outcome (comprehensive vs basic ratio of OR 1.2, 95% CI [1.04-1.39]). CONCLUSION: We evaluated the impact of a DA-CPR program across heterogeneous EMS systems and demonstrated that a comprehensive DA-CPR program had the most impact on BCPR and favorable neurological outcome.

The Risk Factors for Mortality among Septic Trauma Patients: A Retrospective Cohort Study Using the National Trauma Data Bank.

Introduction: In trauma patients, the development of sepsis as a hospital complication is significantly associated with morbidity and mortality. We aimed to assess the risk factors associated with in-hospital mortality among trauma patients who developed sepsis during their hospital stay. Material and methods. Using the 2017 National Trauma Data Bank, a retrospective cohort study was conducted to identify adult trauma patients who developed sepsis during their hospital stay. The primary outcome of interest was in-hospital mortality. Multivariate analysis was used to determine the risk factors associated with in-hospital mortality. Results: 1782 trauma patients developed sepsis. 567 patients (31.8%) died during their hospital stay. The following patient factors were associated with higher odds of in-hospital mortality: age (OR = 1.045 95% CI = 1.036-1.054), chronic renal failure (OR = 2.564 95% CI = 1.528-4.301), and liver cirrhosis (OR = 3.699 95% CI = 2.267-6.033). Patients who developed cardiac arrest (OR = 4.994 95% CI = 3.381-7.378), acute kidney injury (OR = 3.808 95% CI = 2.837-5.110), acute respiratory distress syndrome (OR = 1.688 95% CI = 1.197-2.379), and stroke (OR = 1.998 95% CI = 1.075-3.714) during their hospital stay had higher odds of mortality. Higher Glasgow Coma Scale (13-15) at presentation was associated with lower odds of mortality (OR = 0.467 95% CI = 0.328-0.667). Conclusion: Among trauma patients who developed sepsis, age, chronic renal failure, cirrhosis, the development of cardiac arrest, acute kidney injury, acute respiratory distress syndrome, and stroke in the hospital were associated with in-hospital mortality. These factors can be used to identify patients who are at higher risk of adverse outcomes and implement standardized or protocol-driven methods to improve patient care.

Beirut Ammonium Nitrate Explosion: A Man-Made Disaster in Times of the COVID-19 Pandemic.

The largest non-nuclear blast in modern history took place on August 4, 2020, at 6:07 PM in Beirut, Lebanon, after an estimated 2750 tons of unsafely stored ammonium nitrate exploded. The physical and social impacts of this catastrophic event coinciding with the coronavirus disease (COVID-19) pandemic were massive. This article describes the national and international emergency responses to this event and highlights the impact of the explosion on the health care sector in Lebanon. Challenges noted during this response with recommendations for improving response to future disasters are also described.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States.

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Liver function tests as predictors of common bile duct stones in acute cholecystitis patients with a chronic history: A retrospective cohort study on the ACS-NSQIP database.

ABSTRACT: Liver function tests (LFTs) use for common bile duct stone (CBDS) prediction in acute cholecystitis (AC) patients is challenging, especially in patients with chronic cholecystitis (CC) history.This study aims to describe characteristics of AC patients with CC history and assess LFTs' utility for CBDS prediction in these patients.A retrospective cohort study was conducted on adults with a diagnosis of AC and CC history included in the National Surgical Quality Improvement Program database from 2008 to 2016. Patients were categorized into CBDS- (without CBDS) and CBDS+ (with CBDS). Multivariate logistic regression was used to determine CBDS predictors.This study included 7458 patients, of which 40.2% were CBDS+. CBDS+ patients were more commonly females (64.4% vs 54.7%, P < .001). Mean levels of bilirubin (1.70 vs 0.90, P < .001), SGOT (105.9 vs 49.0, P < .001) and ALP (164.6 vs 103.8, P < .001) were significantly higher among CBDS+ patients.Significant positive predictors of CBDS were female gender, increased BMI, and abnormal bilirubin, ALP and SGOT. AC patients with CC history are more likely to have CBDS. Abnormal LFTs are significantly associated with CBDS in this patient population. Familiarity with these findings can help raise clinical suspicion of providers for earlier evaluation and management of CBDS.

The prevalence of bacteremia in out of hospital cardiac arrest patients presenting to the emergency department of a tertiary care hospital.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains one of the most common causes of death. There is a scarcity of evidence concerning the prevalence of bacteraemia in cardiac arrest patients presenting to the Emergency Department (ED). We aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the ED, as well as study the association between bacteraemia and in-hospital mortality in OHCA patients. In addition, the association between antibiotic use during resuscitation and in-hospital mortality was examined. METHODS AND RESULTS: This was a study of 200 adult OHCA patients who presented to the ED between 2015 and 2019. Bacteraemia was confirmed if at least one of the blood culture bottles grew a non-skin flora pathogen or if two blood culture bottles grew a skin flora pathogen from two different sites. The prevalence of bacteraemia was 46.5%. Gram positive bacteria, specifically Staphylococcus species, were the most common pathogens isolated from the bacteremic group. 42 patients survived to hospital admission. The multivariate analysis revealed that there was no association between bacteraemia and hospital mortality in OHCA patients (OR = 1.3, 95% CI= 0.2-9.2) with a p-value of .8. There was no association between antibiotic administration during resuscitation and hospital mortality (OR = 0.6, 95% CI= 0.1 - 3.8) with a p-value of .6. CONCLUSION: In our study, the prevalence of bacteraemia among OHCA patients presenting to the ED was found to be 46.5%. Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group. In OHCA patients who survived their ED stay there was no association between hospital mortality and bacteraemia or antibiotic administration during resuscitation. There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.KEY MESSAGESWe aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the Emergency Department. In our study, we found that 46.5% of patients presenting to our ED with OHCA were bacteremic.Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group.We found no association between bacteraemia and hospital mortality. There was no association between antibiotic administration during resuscitation and hospital mortality.There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.

Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers.

BACKGROUND: Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers. METHODS: This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with "no signs of life". Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses. RESULTS: The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16-64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9-30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16-24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay). CONCLUSION: Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests. LEVEL OF EVIDENCE: Level III.