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

Early post-resuscitation outcomes in patients receiving norepinephrine versus epinephrine for post-resuscitation shock in a non-trauma emergency department: A parallel-group, open-label, feasibility randomized controlled trial

Background: Post-resuscitation shock is the main cause of early death in post-cardiac arrest patients. To date, no randomized trial compares the efficacy between norepinephrine and epinephrine in post-resuscitation shock patients. Objectives: This study aimed to assess the feasibility of the study protocol, and explore potential differences in efficacy and adverse events between norepinephrine and epinephrine in post-resuscitation shock patients. Methods: This single-center, parallel-group, open-label, feasibility randomized controlled trial included adult non-traumatic cardiac arrest patients who had post-resuscitation shock within one hour after successful resuscitation. Patients were randomized to receive norepinephrine or epinephrine in a 1:1 ratio. Feasibility outcomes were reported descriptively and narratively. Exploratory analyses were performed to compare the efficacy and adverse events. Results: A total of 40 patients were equally allocated. Most feasibility goals were achieved. All patients received the allocated intervention with no withdrawals. Ten (50%) patients in the norepinephrine group and 15 (75%) patients in the epinephrine group achieved the target blood pressure by the protocol with a median time of 42 and 39 min, respectively. However, the protocol deviated in 10 (25%) patients and the recruitment rate did not reach the acceptable threshold. The vasopressor dose to achieve the target blood pressure was significantly lower in the norepinephrine group. No significant differences in mortality rates and adverse outcomes were observed in the exploratory analyses. Conclusion: It is feasible to conduct the definitive trial comparing early post-resuscitation outcomes in patients receiving NE versus EPI for post-resuscitation shock. Some protocol modifications are necessary

Predictors of Mortality in Elderly and Very Elderly Emergency Patients with Sepsis: A Retrospective Study

Introduction: Elderly patients are at increased risk of developing sepsis and its adverse outcomes. Diagnosing and prognosing sepsis is particularly challenging in older patients, especially early at emergency department (ED) arrival. We aimed to study and compare the characteristics of elderly and very elderly ED patients with sepsis and determine baseline factors associated with in-hospital mortality. We also compared prognostic accuracy of the criteria for systemic inflammatory response syndrome, quick sequential organ failure assessment (qSOFA), and the National Early Warning Score in predicting mortality.Methods: We conducted a retrospective study at the ED of Siriraj Hospital Mahidol University in Bangkok, Thailand. Patients over 18 years old who were diagnosed and treated for sepsis in the ED between August 2018–July 2019 were included. We categorized patients into non-elderly (aged <65 years), elderly (aged 65-79 years), and the very elderly (aged >80 years) groups. The primary outcome was in-hospital mortality. Baseline demographics, comorbidities, source and etiology of sepsis, including physiologic variables, were compared and analyzed to identify predictors of mortality. We calculated and compared the area under the receiver operator characteristics curves (AUROC) of early warning scores.Results: Of 1616 ED patients with sepsis, 668 (41.3%) were very elderly, 512 (31.7%) were elderly, and 436 (27.0%) were non-elderly. The mortality rate was highest in the very elderly, followed by the elderly and the non-elderly groups (32.3%, 25.8%, and 24.8%, respectively). Factors associated with mortality in the very elderly included the following: age; do-not-resuscitate (DNR) status; history of recent admission <3 months; respiratory tract infection; systolic blood pressure <100 millimeters mercury (SBP<100); oxygen saturation; and Glasgow Coma Scale (GCS) score. Factors associated with mortality in the elderly were DNR status, body temperature, and GCS score. qSOFA had the highest AUROC in predicting in-hospital mortality in both very elderly and elderly patients (AUROC 0.60 [95% confidence interval {CI}, 0.55-0.65] and 0.55 [95% CI, 0.49-0.61, respectively]).Conclusion: The mortality rate in the very elderly was higher than in the younger populations. Age, DNR status, recent admission, respiratory tract infection, SBP<100, oxygen saturation. and GCS score independently predicted hospital mortality in very elderly patients. The qSOFA score had better but only moderate accuracy in predicting mortality in elderly and very elderly sepsis patients

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

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 &lt; 0.001). Moreover, EMSuse 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 &lt; 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

Assessment of Prehospital Management of Patients Transported to a Thai University Hospital

Objective: To assess the quality of prehospital care given to patients transported to a Thai university hospital.    Methods: This prospective observational study collected data from EMS providers who transported patients to Siriraj Hospital during August 2017 to November 2017. Collected data was evaluated by at least 2 EMS medical directors for appropriateness of EMS dispatch and prehospital care. The primary outcome was to determine the quality of prehospital management among patients transported by EMS. Inter-rater variability in the evaluation of patient care between EMS medical directors and medical providers in the emergency department (ED) was performed using Cohen’s kappa coefficient, with a value lower than 0.7 indicating significant variability. Results: Data was collected from 246 EMS providers that transported patients to our center. Evaluation by EMS medical directors found EMS dispatch to be appropriate in 216 cases (87.8%), and patient management to be appropriate in 198 cases (80.5%). Inappropriate prehospital management was found most often in patients who presented with out-of-hospital cardiac arrest (OHCA) (87.5%), and with chest pain (63.6%). Medical providers in the ED rated prehospital management to be appropriate in 93.1% of cases. Cohen’s kappa coefficient between EMS medical directors and ED providers was 0.2, which indicates significant variability between the two groups of assessors. Conclusion: Quality assessment of the Thai EMS system revealed opportunities for improvement in prehospital management of patients dispatched by Thai EMS. Moreover, this study found variability in the evaluation of prehospital care between medical providers at the ED and EMS medical directors. Information from this study will help to influence and guide improvement in prehospital patient care in Thailand

Agreement between Emergency Physicians and a Cardiologist on Cardiac Function Evaluation after Short Training

Objective: Delayed diagnosis and treatment of shock patients may lead to multiorgan dysfunction syndrome and death. Volume status assessment in shock patients is crucial for guiding early management. Focused echocardiography has become an important tool for assessing volume status because it is non-invasive and easy to perform. We aimed to ascertain the degree of agreement between emergency medicine (EM) residents and a cardiologist on cardiac function evaluations using echocardiography. We also assessed the extent of agreement on pericardial effusion diagnoses. Methods: A cross sectional study was conducted at the Emergency Department, Siriraj Hospital. The EM residents who had limited experience in ultrasound examination underwent a 3-hour echocardiography training course consisting of a lecture and a workshop before starting the study. Patients with shock or suspected hypervolemia were included. Echocardiography was performed by EM residents to evaluate ventricular function of each patients. With visual estimation, they classified the left ventricular function (LVF) into 3 categories: good, moderate and poor. The video files were recorded and re-evaluated by a cardiologist offline. The correlation of left ventricular function estimation and the diagnosis of pericardial effusion between the two operators were determined. Results: Ninety-two patients were enrolled between October and December 2014. The overall agreement of ventricular function assessment between the EM residents and the cardiologist was 79.4% (weighted kappa = 0.73). The degree of agreements of LVF classified as poor, moderate and good LVF were 87.5%, 37.5% and 95% respectively. Moreover, the residents diagnosed the pericardial effusion with 100% accuracy, compared to the cardiologist. Conclusion: Following a short educational training, the EM residents efficiently assessed the left ventricular function with a high level of agreement with a cardiologist

Ward Characteristics Associated with Delayed Defibrillator and Doctor Presence in Cardiopulmonary Resuscitation Simulated Survey

Objective: To survey the times to critical actions (defibrillator and doctor presence, initiation of chest compression) of inhospital simulated cardiopulmonary resuscitation (CPR). Methods: A 1-year retrospective simulated audit 2009 in a 2,400-bed university hospital in Thailand. Results: A total of 57 adult wards (around a third of all wards in the hospital), including intensive care units, critical wards, procedural units, general wards and out-patient units were audited. Overall, the median time of initiation of chest compression and defibrillator presence among CPR teams were 1.27 (0.35-7.19) and 1.16 (0.00-26.00) minutes, respectively. The median time of the first doctor presence was 3.45 (0.00-15.15) minutes. However, there were significant differences in time to defibrillator and doctor presence among wards. The longer time of these critical managements were recorded in non-monitored areas (general wards and out-patient units) (p = 0.004 and 0.007, respectively). Conclusion: In our CPR simulated survey, delayed initiation of critical managements commonly occurred in non-monitored areas. Better management should be concerned for favorable outcomes

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 &lt;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 &lt;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