Methods: This study was conducted in HUSM's ED over two study periods. In the first three months, 300 patients were triaged under the three-tier triaging system, and, in the subsequent three months, 280 patients were triaged under the ESI. The patients were triaged by junior paramedics and the triage records were retained and later re-triaged by senior paramedics. The inter-rater reliability was evaluated using Cohen's Kappa statistics. The acuity ratings of the junior paramedics were compared with those of the expert panel to determine the sensitivity and specificity of each acuity level for both the ESI and the three-tier triaging system. The over-triage rate, under-triage rate, amount of resources used, admission rate and discharge rate were also determined.
Results: The inter-rater agreement for the three-tier triaging system was 0.81 while that of the ESI was 0.75. The ESI had a higher average sensitivity of 74.3% and a specificity of 94.4% while the three-tier system's average sensitivity was 68.5% and its specificity 87.0%. The average under-triage and over-triage rates for the ESI were 10.7% and 6.2%, respectively, which were lower than the three-tier system's average under-triage rate of 13.1% and over-triage rate of 17.1%. The urgency levels of both the ESI and the three-tier system were associated with increased admission rates and resources used in the ED.
Conclusion: The ESI's inter-rater reliability was comparable to the three-tier triaging system and it demonstrated better validity than the existing three-tier system.
Methods: A completed clinical audit cycle was conducted in 2018 in the busy emergency department of a public hospital in Malaysia. Pre- and post-intervention antibiotic prescription data were collected, and changes were implemented through a multifaceted intervention similar to Thailand's Antibiotics Smart Use programme.
Results: Data from a total of 1,334 pre-intervention and 1,196 post-intervention patients were collected from the hospital's electronic medical records. The mean (SD) age of participants was 19.88 (17.994) years. The pre-intervention antibiotic prescription rate was 11.2% for acute diarrhoea and 29.1% for acute URI, both of which are above the average national rates. These antibiotic prescription rates significantly reduced post-intervention to 6.2% and 13.7%, respectively, falling below national averages. Antibiotic prescription rate was highest for young children. There were no significant changes in rates of re-attendance or hospital admission following the intervention.
Conclusion: The multifaceted intervention, which included continuing medical education, physician reminders and patient awareness, was effective in improving the antibiotic prescription rates for these two conditions.
Methods: This cross-sectional study involved patients over age 3 years old who presented with URTI to the green zone of the ED of a tertiary hospital on the east coast of Malaysia in 2018-2019. Convenient sampling was done. The patients were categorised into two groups according to their McIsaac scores: positive (≥ 2) or negative (< 2). Antibiotics given to the negative McIsaac group were considered inappropriate.
Results: A total of 261 cases were included - 127 with positive and 134 with negative McIsaac scores. The most common symptoms were fever and cough. About 29% had inappropriate antibiotic prescribing with a high rate for amoxycillin. Duration of symptoms of one day or less (OR 18.5; 95% CI: 1.65, 207.10; P = 0.018), presence of chills (OR 4.36; 95% CI: 1.13, 16.88; P = 0.033) and diagnosis of acute tonsillitis (OR 5.26; 95% CI: 1.76, 15.72; P = 0.003) were significantly associated with inappropriate antibiotic prescription.
Conclusion: Factors influencing inappropriate antibiotic prescribing should be pointed out to emergency doctors to reduce its incidence.
Methods: A total of 110 severe TBI patients, aged 18-60, who underwent emergency brain surgery were randomised into Group T (TCI) (n = 55) and Group S (sevoflurane) (n = 55). Anaesthesia was maintained in Group T with propofol target plasma concentration of 3-6 μg/mL and in Group S with minimum alveolar concentration (MAC) of sevoflurane 1.0-1.5. Both groups received TCI remifentanil 2-8 ng/mL for analgesia. After the surgery, patients were managed in the intensive care unit and were followed up until discharge for the outcome parameters.
Results: Demographic characteristics were comparable in both groups. Differences in Glasgow Outcome Scale (GOS) score at discharge were not significant between Group T and Group S (P = 0.25): the percentages of mortality (GOS 1) [27.3% versus 16.4%], vegetative and severe disability (GOS 2-3) [29.1% versus 41.8%] and good outcome (GOS 4-5) [43.6% versus 41.8%] were comparable in both groups. There were no significant differences in other outcome parameters.
Conclusion: TCI propofol and sevoflurane anaesthesia were comparable in the outcomes of TBI patients after emergency surgery.
CASE SERIES: We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients.
METHODS: Non-inferiority randomized, clinical trial involving patients presenting with acute respiratory failure conducted in the ED of a local hospital. Participants were randomly allocated to receive either hCPAP or fCPAP as per the trial protocol. The primary endpoint was respiratory rate reduction. Secondary endpoints included discomfort, improvement in Dyspnea and Likert scales, heart rate reduction, arterial blood oxygenation, partial pressure of carbon dioxide (PaCO2), dryness of mucosa and intubation rate.
RESULTS: 224 patients were included and randomized (113 patients to hCPAP, 111 to fCPAP). Both techniques reduced respiratory rate (hCPAP: from 33.56 ± 3.07 to 25.43 ± 3.11 bpm and fCPAP: from 33.46 ± 3.35 to 27.01 ± 3.19 bpm), heart rate (hCPAP: from 114.76 ± 15.5 to 96.17 ± 16.50 bpm and fCPAP: from 115.07 ± 14.13 to 101.19 ± 16.92 bpm), and improved dyspnea measured by both the Visual Analogue Scale (hCPAP: from 16.36 ± 12.13 to 83.72 ± 12.91 and fCPAP: from 16.01 ± 11.76 to 76.62 ± 13.91) and the Likert scale. Both CPAP techniques improved arterial oxygenation (PaO2 from 67.72 ± 8.06 mmHg to 166.38 ± 30.17 mmHg in hCPAP and 68.99 ± 7.68 mmHg to 184.49 ± 36.38 mmHg in fCPAP) and the PaO2:FiO2 (Partial pressure of arterial oxygen: Fraction of inspired oxygen) ratio from 113.6 ± 13.4 to 273.4 ± 49.5 in hCPAP and 115.0 ± 12.9 to 307.7 ± 60.9 in fCPAP. The intubation rate was lower with hCPAP (4.4% for hCPAP versus 18% for fCPAP, absolute difference -13.6%, p = 0.003). Discomfort and dryness of mucosa were also lower with hCPAP.
CONCLUSION: In patients presenting to the ED with acute cardiogenic pulmonary edema or decompensated COPD, hCPAP was non-inferior to fCPAP and resulted in greater comfort levels and lower intubation rate.
METHODS: This retrospective study was conducted in emergency departments of two tertiary hospitals from June 1 to August 31, 2021. Consecutive patients aged >18 years admitted for COVID-19-related HRF (World Health Organization criteria: confirmed COVID-19 pneumonia with respiratory rate > 30 breaths/min, severe respiratory distress, or peripheral oxygen saturation < 90% on room air) requiring NRB + NC or HFNC were screened for enrollment. Primary outcome was improvement of partial pressure arterial oxygen (PaO2) at two hours. Secondary outcomes were intubation rate, ventilator-free days, hospital length of stay, and 28-day mortality. Data were analyzed using linear regression with inverse probability of treatment weighting (IPTW) based on propensity score.
RESULTS: Among the 110 patients recruited, 52 (47.3%) were treated with NRB + NC, and 58 (52.7%) with HFNC. There were significant improvements in patients' PaO2, PaO2/FIO2 ratio, and respiratory rate two hours after the initiation of NRB + NC and HFNC. Comparing the two groups, after IPTW adjustment, there were no statistically significant differences in PaO2 improvement (adjusted mean ratio [MR] 2.81; 95% CI -5.82 to 11.43; p = .524), intubation rate (adjusted OR 1.76; 95% CI 0.44 to 6.92; p = .423), ventilator-free days (adjusted MR 0.00; 95% CI -8.84 to 8.85; p = .999), hospital length of stay (adjusted MR 3.04; 95% CI -2.62 to 8.69; p = .293), and 28-day mortality (adjusted OR 0.68; 95% CI 0.15 to 2.98; p = .608).
CONCLUSION: HFNC may be beneficial in COVID-19 HRF. NRB + NC is a viable alternative, especially in resource-limited settings, given similar improvement in oxygenation at two hours, and no significant differences in long-term outcomes. The effectiveness of NRB + NC needs to be investigated by a powered randomized controlled trial.
METHODS: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays.
RESULTS AND DISCUSSION: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic.
CONCLUSION: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.