Investigating the Time Indicators of the Emergency Department and Design a Management Dashboard for it

سابقه و هدف: سرعت ارائه خدمات در مراكز درماني به خصوص اورژانس، در جهت كاستن از مرگ و مير و معلوليت ها از اهميت ويژه اي برخوردار است. مديريت زمان در ارائه خدمات درماني بسيار حياتي و کوتاهي از آن مي تواند جان بيماران را به خطر اندازد. يكي از مهمترين شاخص هايي كه در ارزيابي مراكز اورژانس به كار گرفته مي شود مدت زمان انتظار بيماران براي دريافت خدمات تشخيصي درماني مي باشد. اين مطالعه به منظور بررسي شاخص هاي زمان سنجي و طراحي داشبورد مديريتي در يک مرکز تخصصي قلب در شهر تهران در سال1397 انجام شد. روش بررسي: اين پژوهش از نوع، مقطعي بود که در آن شاخص هاي زماني اورژانس وزارت بهداشت مورد بررسي قرار گرفت.کليه داده هاي مربوطه در بخش اورژانس در يک بيمارستان شهر تهران سال1397گردآوري شد. سپس طراحي و ايجاد داشبورد براساس داده هاي شاخص هاي تعيين شده در بخش اورژانس با استفاده از نرم افزار Qlick View بارگذاري شده و نمايش عملکرد اين بخش ارائه گرديد. اين مطالعه در کميته اخلاق دانشگاه بررسي و مجوز اخلاق کسب کرد. يافته ها: با انجام مطالعه ي حاضر، 6 شاخص زمان سنجي اورژانس مورد بررسي قرار گرفت. سپس با توجه به اطلاعات بدست آمده داشبورد مربوطه طراحي گرديد. نتيجه گيري: كاهش طول مدت اقامت در بخش اورژانس، منجر به افزايش رضايتمندي بيماران و به طور بالقوه صرفه جويي در هزينه‌ها مي‌شود. در واقع، رسالت اصلي اورژانس، ارايه خدمات با كيفيت بالا در كوتاه‌ترين زمان ممکن است. توقف طولاني مدت در اورژانس، امکان ارايه خدمات به ساير بيماران نيازمند به فوريت‌هاي پزشکي را كاهش مي‌دهد و اين امر موجب نارضايتي بيماران و افزايش تلفات ناشي از حوادث خواهد شد. How to cite this article: Mayelafshar M, Noohi F, Riahi L, Nikravan A.Investigating the Time Indicators of the Emergency Department and Design a Management Dashboard for it. J Saf Promot Inj Prev. 2020; 8(2):86-96.Background and Objectives: The speed of service delivery in medical centers, especially emergencies, is of particular importance in reducing mortality and disability. Time management in providing vital and short-term health care services can endanger patients' lives. One of the most important indicators used in the evaluation of emergency centers is the waiting time for patients to receive diagnostic and treatment services. This study was conducted in 1397 in order to study the timing indicators and design of the management dashboard in a specialized heart center in Tehran. Materials and Methods: This type of research is a section in which the emergency time indicators of the Ministry of Health were examined. All the relevant data in the emergency department was collected in a hospital in Tehran in 1397. Then, the design and creation of the dashboard was loaded based on the data of the indicators specified in the emergency department using QuickView software and the performance of this section was presented. Results: In the present study, six emergency timing indicators were examined. Then, according to the information obtained, the relevant dashboard was designed. Conclusion: Reducing the length of stay in the emergency department leads to increased patient satisfaction and potentially cost savings. The main mission of the emergency is to providing high quality services in the shortest possible time. Prolonged emergency stops reduced the possibility of providing services to other patients in need of emergency medical care, which can lead to patient dissatisfaction and increased casualties. How to cite this article: Mayelafshar M, Noohi F, Riahi L, Nikravan A.Investigating the Time Indicators of the Emergency Department and Design a Management Dashboard for it. J Saf Promot Inj Prev. 2020; 8(2):86-96

Evaluation of left ventricular systolic and diastolic regional function after enhanced external counter pulsation therapy using strain rate imaging

Aims Enhanced external counter pulsation (EECP) is a non-invasive and non-pharmacological therapy for patients with symptomatic coronary artery disease (CAD). There are, however, insufficient data to support the effectiveness of EECP in improving the myocardial mechanical properties of patients with refractory stable angina. We aimed to assess the effects of EECP on myocardial mechanical properties and cardiac functions in CAD patients not eligible for surgical or percutaneous revascularization procedures. Methods and results Twenty patients in New York Heart Association (NYHA) functional Class III and IV angina were evaluated. The mean age of the patients was 63+9 years, and 65% were male. A comprehensive echocardiographic study including an evaluation of the tissue Doppler-based parameters of systolic and diastolic functions was performed before and after the termination of the protocol. EECP was carried out 1 h per day, 5 days per week, for 7 weeks. EECP resulted in a significant increase in peak late diastolic transmitral inflow velocity (0.75+0.14 vs. 0.83+0.20 m/s, P , 0.05), propagation velocity (42.35+6.25 vs. 46.00+5.68 cm/s, P , 0.05), peak early diastolic velocity of mitral annulus (5.35+1.79 vs. 5.95+1.10 cm/s, P , 0.05), peak systolic velocity (2.51+0.28 vs. 2.67+ 0.26, P , 0.05), and early diastolic velocity (3.24+0.18 vs. 3.52+0.26 cm/s, P , 0.01) of all middle segments, peak late diastolic velocity of all basal (4.48+0.58 vs. 4.75+0.70 cm/s, P , 0.05) and middle segments (2.82+0.66 vs. 3.25+0.46 cm/s, P , 0.01), peak systolic strain rate of all basal (0.76+0.07 vs. 0.99+0.08 1/s, P ¼ 0.001) and middle segments (0.75+0.09 vs. 0.94+0.09 1/s, P , 0.001), peak systolic strain of basal (11.64+1.51 vs. 13.97+1.52%, P , 0.01) and middle segments (11.81+1.15 vs.13.73+1.57%, P , 0.001), and left ventricular (LV) ejection fraction (40.25+ 12.72 vs. 46.25+12.97%, P , 0.001).There was also a significant decrease in the ratios of transmitral E/A (0.92+ 0.41 vs. 1.08+ 0.46, P , 0.05) and E/Ea (12.61+4.22 vs. 15.44+6.96, P , 0.05) after EECP therapy. A significant reduction in NYHA angina class ( 1 angina class) was seen in the patients, who completed treatment. Conclusion EECP therapy seemed to improve both regional and global LV systolic and diastolic functions in patients with chronic angina pectoris

Echocardiographic evaluation of mitral geometry in functional mitral regurgitation

<p>Abstract</p> <p>Objectives</p> <p>We sought to evaluate the geometric changes of the mitral leaflets, local and global LV remodeling in patients with left ventricular dysfunction and varying degrees of Functional mitral regurgitation (FMR).</p> <p>Background</p> <p>Functional mitral regurgitation (FMR) occurs as a consequence of systolic left ventricular (LV) dysfunction caused by ischemic or nonischemic cardiomyopathy. Mitral valve repair in ischemic MR is one of the most controversial topic in surgery and proper repairing requires an understanding of its mechanisms, as the exact mechanism of FMR are not well defined.</p> <p>Methods</p> <p>136 consecutive patients mean age of 55 with systolic LV dysfunction and FMR underwent complete echocardiography and after assessing MR severity, LV volumes, Ejection Fraction, LV sphericity index, C-Septal distance, Mitral valve annulus, Interpapillary distance, Tenting distance and Tenting area were obtained.</p> <p>Results</p> <p>There was significant association between MR severity and echocardiogarphic indices (all p values < 0.001). Severe MR occurred more frequently in dilated cardiomyopathy (DCM) patients compared to ischemic patients, (p < 0.001). Based on the model, only Mitral valve tenting distance (TnD) (OR = 22.11, CI 95%: 14.18 – 36.86, p < 0.001) and Interpapillary muscle distance (IPMD), (OR = 6.53, CI 95%: 2.10 – 10.23, p = 0.001) had significant associations with MR severity.</p> <p>Mitral annular dimensions and area, C-septal distance and sphericity index, although greater in patients with severe regurgitation, did not significantly contribute to FMR severity.</p> <p>Conclusion</p> <p>Degree of LV enlargement and dysfunction were not primary determinants of FMR severity, therefore local LV remodeling and mitral valve apparatus deformation are the strongest predictors of functional MR severity.</p

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) in an Old Adult

The anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac malformation. It presents predominantly in infancy and its main presenting feature is myocardial ischemia or heart failure. Survival to adulthood is quite uncommon. If untreated, mortality from ALCAPA approaches 90% in infancy; early recognition and surgical correction are, therefore, essential. With early surgical correction, the prognosis is good. There are two types of ALCAPA syndrome: the infant type and the adult type, each of which has different manifestations and outcomes. Infants experience myocardial infarction and congestive heart failure, and approximately 90% die within the first year of life. A literature review regarding this anomaly in teenagers and adults show that only 25 cases have been diagnosed during life and 18 additional cases of ALCAPA in these age groups have been diagnosed post mortem. We present a rare case of a 60-year-old man, who referred to our center due to dyspnea on exertion from the previous year without any history of chest pain and diagnosed as ALCAPA. Given the absence of ischemia and the patient’s age, only medical therapy was recommended

Evaluation of the Ventricular Mechanical Dyssynchrony in Patients with Atrial Septal Defect

Background: There is some evidence indicating improvement in myocardial performance after atrial septal defect closure, either device closure or surgical, but ventricular dyssynchrony has not been evaluated before and after surgical closure. The aim of this study was to evaluate ventricular mechanical dyssynchrony in patients with atrial septal defect before and after surgical closure.Methods: Twenty patients (mean age: 23±11years) with isolated secundum or sinus venosus type atrial septal defect, unsuitable for device closure, were evaluated before and after successful surgical closure. Interventricular and intraventricular dyssynchrony (using 6 basal and 6 mid-segmental models) were determined.Results: A significant reduction in the right atrial and right ventricular dimensions and the tricuspid regurgitation peak gradient was noted after atrial septal defect closure (3.6±0.54 cm versus 4.2±0.7, P=0.009; 3.5±0.29 cm versus 4.3±0.41, P=0.02; and 20.4±10.5 mmHg versus 35.3±6.5, P<0.002; respectively).There was no significant difference in the maximum difference in time-to-peak systolic velocity and the standard deviation of time-to-peak systolic velocity of the l2 left ventricular myocardial segments in the patients with atrial septal defect before and after surgical closure in comparison with the normal subjects (normal: 26±10.64 ms versus before closure: 21.0±33.9 versus after closure: 27±29.5, both P=0.68) and the left ventricular asynchrony index after atrial septal defect closure (normal: 14.9±8.7 versus before closure: 11.46±8.5 versus after closure: 18.12±13.6, both P=0.2). There was a significant positive relation between the tricuspid regurgitation peak gradient and the left ventricular asynchrony index (r=0.67, P=0.03) and an insignificant negative relation between the left ventricular ejection fraction and the asynchrony index before atrial septal defect closure (r=−0.53, P=0.11). No significant relation was found between the total asynchrony index and the atrial septal defect size, the degree of left-to-right shunt, and the tricuspid regurgitation peak gradient.Conclusion: There was no significant ventricular dyssynchrony in the patients with atrial septal defect before and after surgical closure

Assessment of Subclinical Left Ventricular Dysfunction in Patients with Chronic Mitral Regurgitation Using Torsional Parameters Described by Tissue Doppler Imaging

Background: Left ventricular (LV) twist is due to oppositely directed apical and basal rotation and has been proposed as a sensitive marker of LV function. We sought to assess the impact of chronic pure mitral regurgitation (MR) on the torsional mechanics of the left human ventricle using tissue Doppler imaging. Methods: Nineteen severe MR patients with a normal LV ejection fraction and 16 non-MR controls underwent conventional echocardiography and apical and basal short-axis color Doppler myocardial imaging (CDMI). LV rotation at the apical and basal short-axis levels was calculated from the averaged tangential velocities of the septal and lateral regions, corrected for the LV radius over time. LV twist was defined as the difference in LV rotation between the two levels, and the LV twist and twisting/untwisting rate profiles were analyzed throughout the cardiac cycle. Results: LV twist and LV torsion were significantly lower in the MR group than in the non-MR group (10.38˚ ± 4.04˚ vs.13.95˚ ± 4.27˚; p value = 0.020; and 1.29 ± 0.54 ˚/cm vs. 1.76 ± 0.56 ˚/cm; p value = 0.021, respectively), both suggesting incipient LV dysfunction in the MR group. Similarly, the untwisting rate was lower in the MR group (-79.74 ± 35.97 ˚/s vs.-110.96 ± 34.65 ˚/s; p value = 0.020), but there was statistically no significant difference in the LV twist rate. Conclusion: The evaluation of LV torsional parameters in MR patients with a normal LV ejection fraction suggests the potential role of these sensitive variables in assessing the early signs of ventricular dysfunction in asymptomatic patient

Multimodality imaging in the diagnostic approach to a patient with carcinoid heart disease involving four heart valves

Abstract Carcinoid heart disease is a rare condition that occurs in less than half of patients with carcinoid syndrome. The disease mainly affects right‐sided heart valves; however, in 5%–10%, it can also involve left‐sided valves. This case illustrates the most complicated form of the disease involving four heart valves

Echocardiographic Assessment of Left Ventricle Torsion by Tissue Doppler and Velocity Vector Imaging

Introduction Left ventricular (LV) twist is believed to store potential energy and plays an important role in generating diastolic suction. Recent advances in echocardiography techniques have allowed quantification of LV twist. The aim of the present study was to compare LV twist and torsion in healthy human subjects determined by velocity vector imaging (VVI) and tissue Doppler imaging (TDI) at rest. Materials and Methods All volunteers (72 healthy subjects) underwent complete echocardiographic study and LV torsional parameters were assessed using VVI or TDI methods. LV rotation at apical and basal short-axis levels was calculated throughout cardiac cycle and LV twist was defined as net difference between rotation angles of the two levels. The LV torsion was calculated as the LV twist divided by the LV end-diastolic length. Results Twist degree was significantly lower in the VVI group than the TDI group (11.4±2.4º vs.14.1±3.0º,

The first Iranian recommendations on prevention, evaluation and management of high blood pressure

This paper presents the complete report of the first Iranian Recommendations on Prevention, Evaluation and Management of High Blood Pressure. The purpose is to provide an evidence-based approach to the prevention, management and control of hypertension (HTN) by adapting the most internationally known and used guidelines to the local health care status with consideration of the currently available data and based on the locally conducted researches on HTN as well as social and health care requirements. A working group of national and international experts participated in discussions and collaborated in decision-making, writing and reviewing the whole report. Multiple subcommittees worked together to review the recent national and international literature on HTN in different areas. We used the evaluation tool that is called &ldquo;AGREE&rdquo; and considered a score of &gt; 60% as a high score. We adapted the Canadian Hypertension Education Program (CHEP), the United Kingdom&rsquo;s National Institute for Health and Clinical Excellence (NICE) and the US-based joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7). The key topics that are highlighted in this report include: The importance of ambulatory and self-measurement of blood pressure, evaluation of cardiovascular risk in HTN patients, the role of lifestyle modification in the prevention of HTN and its control with more emphasis on salt intake reduction and weight control, introducing pharmacotherapy suitable for uncomplicated HTN or specific situations and the available drugs in Iran, highlighting the importance of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers and calcium channel blockers as the first line therapy in many situations, the non-use of beta blockers as the first time treatment except in specific conditions, treating HTN in women, children, obese and elderly patients, the patient compliance to improve HTN control, practical guidelines to improve the patient&rsquo;s information on knowing their risk and self-care as well as a quick reference guide that can serve as simplified guidelines for physicians. The working team decided to update these recommendations every two years. &nbsp; &nbsp;&nbsp; Keywords: High Blood Pressure, Prevention, Treatment, Control, Iran</p