Pub Date : 2024-02-24DOI: 10.1101/2024.02.22.24303100
Chen Wenchong
[Abstract] Objective To explore the value of bedside ultrasound in monitoring peak flow velocity of abdominal aorta and its branches in assessing the volume status of patients with septic shock.Methods A total of 80 patients with septic shock admitted to the Foshan Rehabilitation Hospital(The Fifth People's Hospital of Foshan) and the Guangdong Provincial People's Hospital from June 2022 to June 2023 were selected as the research subjects. All patients were treated with mechanical ventilation,and deep venous catheters were placed in the internal jugular vein or subclavian vein to monitor central venous pressure (CVP).PiCCO catheters were placed in the femoral artery to monitor hemodynamic data.At the same time,the maximum internal diameter of the inferior vena cava (IVCmax),the respiratory variation of the inferior vena cava (△IVC),the peak flow velocity of the abdominal aorta (VpeakAA),the peak flow velocity of the celiac artery (VpeakCA),and the peak flow velocity of the superior mesenteric artery (VpeakSMA)were monitored under bedside ultrasound.The global end-diastolic volumn index(GEDI)was used as a grouping indicator,with GEDI≤680ml/m2 as the low-volume group and GEDI≥800ml/m2 as the high-volume group.Compare the differences in peak flow velocity between the abdominal aorta,celiac artery,and superior mesenteric artery between the two groups,and analyze the correlation between peak flow velocity of the abdominal aorta,celiac artery,and superior mesenteric artery and IVCmax,ΔIVC,CVP,and stroke volume variability (SVV);draw a receiver operating characteristic (ROC) curve for the subjects,calculate the area under the curve,and find the diagnostic threshold.Results There was no significant difference in general data between the two groups (P>0.05).The VpeakAA,VpeakCA,and VpeakSMA in the high-volume group were all higher than those in the low-volume group, and the differences were statistically significant (P<0.05). However,VpeakCA and VpeakSMA were significantly correlated with IVCmax,△IVC,CVP,and SVV (P<0.05).The ROC curve analysis showed that VpeakAA,VpeakCA,and VpeakSMA could effectively evaluate the volume status of patients with septic shock, and the area under the VpeakSMA curve was 0.846,with a 95% confidence interval of 0.693-0.999,and had high sensitivity and specificity.Conclusion Bedside ultrasound can dynamically monitor VpeakAA,VpeakCA,and VpeakSMA,which has great value in the evaluation of volume status in patients with septic shock.
{"title":"Evaluation value of bedside ultrasound monitoring of peak flow velocity of abdominal aorta and its branches in volume status of patients with septic shock","authors":"Chen Wenchong","doi":"10.1101/2024.02.22.24303100","DOIUrl":"https://doi.org/10.1101/2024.02.22.24303100","url":null,"abstract":"[Abstract] Objective To explore the value of bedside ultrasound in monitoring peak flow velocity of abdominal aorta and its branches in assessing the volume status of patients with septic shock.Methods A total of 80 patients with septic shock admitted to the Foshan Rehabilitation Hospital(The Fifth People's Hospital of Foshan) and the Guangdong Provincial People's Hospital from June 2022 to June 2023 were selected as the research subjects. All patients were treated with mechanical ventilation,and deep venous catheters were placed in the internal jugular vein or subclavian vein to monitor central venous pressure (CVP).PiCCO catheters were placed in the femoral artery to monitor hemodynamic data.At the same time,the maximum internal diameter of the inferior vena cava (IVCmax),the respiratory variation of the inferior vena cava (△IVC),the peak flow velocity of the abdominal aorta (VpeakAA),the peak flow velocity of the celiac artery (VpeakCA),and the peak flow velocity of the superior mesenteric artery (VpeakSMA)were monitored under bedside ultrasound.The global end-diastolic volumn index(GEDI)was used as a grouping indicator,with GEDI≤680ml/m2 as the low-volume group and GEDI≥800ml/m2 as the high-volume group.Compare the differences in peak flow velocity between the abdominal aorta,celiac artery,and superior mesenteric artery between the two groups,and analyze the correlation between peak flow velocity of the abdominal aorta,celiac artery,and superior mesenteric artery and IVCmax,ΔIVC,CVP,and stroke volume variability (SVV);draw a receiver operating characteristic (ROC) curve for the subjects,calculate the area under the curve,and find the diagnostic threshold.Results There was no significant difference in general data between the two groups (P>0.05).The VpeakAA,VpeakCA,and VpeakSMA in the high-volume group were all higher than those in the low-volume group, and the differences were statistically significant (P<0.05). However,VpeakCA and VpeakSMA were significantly correlated with IVCmax,△IVC,CVP,and SVV (P<0.05).The ROC curve analysis showed that VpeakAA,VpeakCA,and VpeakSMA could effectively evaluate the volume status of patients with septic shock, and the area under the VpeakSMA curve was 0.846,with a 95% confidence interval of 0.693-0.999,and had high sensitivity and specificity.Conclusion Bedside ultrasound can dynamically monitor VpeakAA,VpeakCA,and VpeakSMA,which has great value in the evaluation of volume status in patients with septic shock.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139953198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-23DOI: 10.1101/2024.02.21.24302399
Joseph A Bauer, Adrianne R Blocklin, Annette M Sysel, Thomas J Sheperak
Introduction: Wound healing presents a critical challenge in military operational medicine and combat casualty care, especially for soldiers in high-risk environments such as combat zones and training exercises. In these scenarios, wounds often result from bullets, shrapnel, burns, and blasts, affecting soft tissue, bone, and internal organs, and are frequently contaminated with hazardous substances like debris and bacteria. Limited resources in these environments make rapid and effective treatment difficult, often leading to delayed medical care and poorer healing outcomes. Emerging technologies like nonthermal plasma (NTP), also known as cold plasma, may provide superior wound healing treatment efficacy in these environments, owing to the ability to effectively kill pathogens, stimulate tissue regeneration, and minimize collateral damage compared to traditional methods. The Plasma Directed Electron Beam™ (PDEB™), an innovative advancement in nonthermal plasma research, shows promise in addressing these challenges. Materials and Methods: The antibiofilm efficacy of the PDEB™ was investigated on Acinetobacter baumannii and Streptococcus mutans. Cytotoxicity was assessed using primary human epithelial cells and TR146 cells, immortalized epithelial cells. Cell proliferation assays, immunoblotting, and lactate dehydrogenase (LDH) release were evaluated. Results: Our study demonstrates the effectiveness of the PDEB™ handheld in inhibiting the growth of bacterial pathogens implicated in biofilms. Acinetobacter baumannii and Streptococcus mutans showed zones of inhibition starting at lower power levels, achieving complete inhibition at 14 watts (W) and 7W respectively for 90-120 seconds. The safety of the PDEB™ was assessed through cell proliferation assays using human epithelial cells and semi-confluent TR146 cells, which were exposed to similar conditions as the bacterial assays. TR146 cells showed negligible differences in cleaved caspase 3 levels compared to controls. Cytotoxicity and apoptosis assays further confirmed the safety of PDEB™, as lactate dehydrogenase (LDH) release in epithelial cells and activated caspase 3 levels in cell extracts were comparable to untreated and helium-treated cells, indicating minimal cellular damage. Conclusion: The PDEB™ handheld, a first-generation device, has demonstrated significant efficacy in inhibiting the growth of bacteria. Concurrently, its application on human epithelial cells has shown encouraging safety profiles. These findings align with the effectiveness of traditional nonthermal plasma devices, positioning the PDEB™ as a viable and promising option for wound healing applications in Combat Casualty Care and Military Operational Medicine.
{"title":"Safety and efficacy of the Plasma Directed Electron Beam (PDEB ™) - implications for enhanced wound healing treatment in military operational medicine and beyond","authors":"Joseph A Bauer, Adrianne R Blocklin, Annette M Sysel, Thomas J Sheperak","doi":"10.1101/2024.02.21.24302399","DOIUrl":"https://doi.org/10.1101/2024.02.21.24302399","url":null,"abstract":"Introduction: Wound healing presents a critical challenge in military operational medicine and combat casualty care, especially for soldiers in high-risk environments such as combat zones and training exercises. In these scenarios, wounds often result from bullets, shrapnel, burns, and blasts, affecting soft tissue, bone, and internal organs, and are frequently contaminated with hazardous substances like debris and bacteria. Limited resources in these environments make rapid and effective treatment difficult, often leading to delayed medical care and poorer healing outcomes. Emerging technologies like nonthermal plasma (NTP), also known as cold plasma, may provide superior wound healing treatment efficacy in these environments, owing to the ability to effectively kill pathogens, stimulate tissue regeneration, and minimize collateral damage compared to traditional methods. The Plasma Directed Electron Beam™ (PDEB™), an innovative advancement in nonthermal plasma research, shows promise in addressing these challenges. Materials and Methods: The antibiofilm efficacy of the PDEB™ was investigated on Acinetobacter baumannii and Streptococcus mutans. Cytotoxicity was assessed using primary human epithelial cells and TR146 cells, immortalized epithelial cells. Cell proliferation assays, immunoblotting, and lactate dehydrogenase (LDH) release were evaluated. Results: Our study demonstrates the effectiveness of the PDEB™ handheld in inhibiting the growth of bacterial pathogens implicated in biofilms. Acinetobacter baumannii and Streptococcus mutans showed zones of inhibition starting at lower power levels, achieving complete inhibition at 14 watts (W) and 7W respectively for 90-120 seconds. The safety of the PDEB™ was assessed through cell proliferation assays using human epithelial cells and semi-confluent TR146 cells, which were exposed to similar conditions as the bacterial assays. TR146 cells showed negligible differences in cleaved caspase 3 levels compared to controls. Cytotoxicity and apoptosis assays further confirmed the safety of PDEB™, as lactate dehydrogenase (LDH) release in epithelial cells and activated caspase 3 levels in cell extracts were comparable to untreated and helium-treated cells, indicating minimal cellular damage. Conclusion: The PDEB™ handheld, a first-generation device, has demonstrated significant efficacy in inhibiting the growth of bacteria. Concurrently, its application on human epithelial cells has shown encouraging safety profiles. These findings align with the effectiveness of traditional nonthermal plasma devices, positioning the PDEB™ as a viable and promising option for wound healing applications in Combat Casualty Care and Military Operational Medicine.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"81 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139956989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-22DOI: 10.1101/2024.02.20.24303094
Pablo Ferri, Carlos Sáez, Antonio Félix-De Castro, Purificación Sánchez-Cuesta, Juan M García-Gómez
When developing Machine Learning models to support emergency medical triage, it is important to consider how changes over time in the data distribution can negatively affect the models' performance. The objective of this study was to assess the effectiveness of various Continual Learning pipelines in keeping model performance stable when input features are subject to change over time, including the emergence of new features and the disappearance of existing ones. The model is designed to identify life-threatening situations, calculate its admissible response delay, and determine its institution jurisdiction. We analyzed a total of 1 414 575 events spanning from 2009 to 2019. Our findings demonstrate important performance improvements, up to 7.8% in life-threatening and 14.8% in response delay, in terms of F1-score, when employing deep continual approaches. We noticed that combining fine-tuning and dynamic feature domain updating strategies offers a practical and effective solution for addressing these distributional drifts in medical emergency data.
{"title":"Deep continual multitask severity assessment from changing clinical features","authors":"Pablo Ferri, Carlos Sáez, Antonio Félix-De Castro, Purificación Sánchez-Cuesta, Juan M García-Gómez","doi":"10.1101/2024.02.20.24303094","DOIUrl":"https://doi.org/10.1101/2024.02.20.24303094","url":null,"abstract":"When developing Machine Learning models to support emergency medical triage, it is important to consider how changes over time in the data distribution can negatively affect the models' performance. The objective of this study was to assess the effectiveness of various Continual Learning pipelines in keeping model performance stable when input features are subject to change over time, including the emergence of new features and the disappearance of existing ones. The model is designed to identify life-threatening situations, calculate its admissible response delay, and determine its institution jurisdiction. We analyzed a total of 1 414 575 events spanning from 2009 to 2019. Our findings demonstrate important performance improvements, up to 7.8% in life-threatening and 14.8% in response delay, in terms of F1-score, when employing deep continual approaches. We noticed that combining fine-tuning and dynamic feature domain updating strategies offers a practical and effective solution for addressing these distributional drifts in medical emergency data.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"124 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139953163","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-13DOI: 10.1101/2024.02.11.24302630
Temesgen T Tsige, Rida Nasir, Daisy Puca, Kevin Charles, Sandhya Scarlet LoGalbo, Lisa Iyeke, Lindsay Jordan, Melva Morales Sierra, David Silver, Mark Richman
Abstract Introduction: The Emergency Severity Index (ESI) stratifies Emergency Department (ED) patients for triage, from 'most-acute' (level 1) to 'least-acute' (level 5). Many EDs have a split-flow model where less-acute (ESI 4 and 5) are seen in a Fast Track, while more-acute (ESI 1, 2, and 3) are seen in the acute care area. As a core principle of Emergency Medicine is to attend to more-acute patients first, deliberately designating an area for less-acute patients to be seen quickly might result in their being seen before more-acute patients. This study aims to determine the percentage of less-acute patients seen by a provider sooner after triage than more-acute patients who arrived within 10 minutes of one another. Additionally, this study compares the Fast Track and acute care areas to see if location affects triage-to-provider time. Methods A random convenience sample of 252 ED patients aged 18 or greater was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended by the author. We collected data on ESI level, timestamps for triage and first provider sign-up, and location to which patient was triaged (Fast Track vs. acute care). Paired patients ESI levels, locations, and triage and first provider sign-up times were compared. Results One hundred twenty-six pairs of patients were included. More-acute patients were seen significantly-faster after triage (~20 minutes) than less-acute patients in two groups: ESI level 2 vs. 3 and overall high- vs. low-acuity. However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less-acute patient was seen before the more-acute patient. Additionally, patients in the acute care area had significantly-shorter median triage-to-provider times (~ 40 minutes) compared to those in the Fast Track area for ESI 2 (acute care) vs ESI 3 (Fast Track) and overall high-acuity (acute care) vs low-acuity (Fast-track). Nonetheless, approximately one-third of ESI 3 patients triaged to Fast Track were seen before ESI 2 patients triaged to the acute care area. Conclusion The split-flow model reduces overall ED length of stay (LOS), improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of Emergency Medicine and potentially subverts the intended triage process. Although most more-acute patients are seen by a provider sooner after triage than less-acute patients, a substantial number are seen later, which could delay urgent medical needs and impact patients' outcome negatively. Furthermore, acute care area patients are seen sooner post-triage than identical-ESI-level Fast Track patients, suggesting Fast Track might not function as intended. Further examination of patient outcomes is necessary to determine the impact of the ESI triage
摘要 简介：急诊严重程度指数（ESI）对急诊科（ED）病人进行分层，从 "最急性"（1 级）到 "最不急性"（5 级）进行分流。许多急诊室都采用了分流模式，即急性程度较低（ESI 4 级和 5 级）的患者在快速通道就诊，而急性程度较高（ESI 1 级、2 级和 3 级）的患者则在急诊护理区就诊。由于急诊医学的核心原则是先诊治病情较轻的病人，因此特意为病情较轻的病人指定一个快速诊治区可能会导致他们在病情较重的病人之前得到诊治。本研究旨在确定在分诊后 10 分钟内到达的急性病患者中，较急性病患者更快得到医护人员诊治的比例。此外，本研究还对快速通道和急症护理区进行了比较，以了解地点是否会影响分诊到医护人员的时间。方法随机抽取 252 名年龄在 18 岁或以上的急诊室患者作为样本。如果患者的电子病历（ESI）可在登记时提供给医疗服务提供者，则患者被纳入样本。如果患者被直接送往急诊室精神科或由笔者接诊，则排除在外。我们收集的数据包括 ESI 水平、分诊和首次医护人员签到的时间戳，以及患者被分诊的地点（快速通道与急症护理）。我们比较了配对患者的 ESI 水平、地点、分诊和第一医护人员签到时间。结果 共纳入了 126 对患者。在两组患者中，急症患者在分诊后的就诊时间（约 20 分钟）明显快于急症患者：ESI 2 级与 3 级，以及总体高敏锐度与低敏锐度。然而，在 34.8% 的 ESI 2 级与 3 级配对患者中，ESI 3 级患者比 ESI 2 级配对患者先就诊；在 39.4% 的高危与低危配对患者中，低危患者比高危患者先就诊。此外，就 ESI 2（急症护理）与 ESI 3（快速通道）以及总体高危急值（急症护理）与低危急值（快速通道）而言，急症护理区患者从分诊到医护人员的中位时间（约 40 分钟）明显短于快速通道区患者。尽管如此，约有三分之一被分流到快速通道的 ESI 3 患者在被分流到急症护理区的 ESI 2 患者之前就诊。结论分流模式缩短了整个急诊室的住院时间（LOS），提高了流量、收入和患者满意度。然而，这种模式以牺牲急诊医学的基本精神为代价，并有可能颠覆预期的分流流程。虽然大多数急性病人在分诊后比非急性病人更早得到医疗服务提供者的诊治，但仍有相当一部分病人的就诊时间较晚，这可能会延误紧急医疗需求，并对病人的治疗效果产生负面影响。此外，急症护理区患者在分诊后的就诊时间早于相同ESI级别的快速通道患者，这表明快速通道可能没有发挥预期的作用。有必要对患者的治疗效果进行进一步检查，以确定ESI分诊流程和分流模式的影响。类别急诊医学, 质量改进 Keywords：分流模式 急诊严重程度指数（ESI） 急诊医学
{"title":"Does practice match protocol? A comparison of \"triage-to-provider\" time among more- vs. less-acute ED patients.","authors":"Temesgen T Tsige, Rida Nasir, Daisy Puca, Kevin Charles, Sandhya Scarlet LoGalbo, Lisa Iyeke, Lindsay Jordan, Melva Morales Sierra, David Silver, Mark Richman","doi":"10.1101/2024.02.11.24302630","DOIUrl":"https://doi.org/10.1101/2024.02.11.24302630","url":null,"abstract":"Abstract Introduction: The Emergency Severity Index (ESI) stratifies Emergency Department (ED) patients for triage, from 'most-acute' (level 1) to 'least-acute' (level 5). Many EDs have a split-flow model where less-acute (ESI 4 and 5) are seen in a Fast Track, while more-acute (ESI 1, 2, and 3) are seen in the acute care area. As a core principle of Emergency Medicine is to attend to more-acute patients first, deliberately designating an area for less-acute patients to be seen quickly might result in their being seen before more-acute patients. This study aims to determine the percentage of less-acute patients seen by a provider sooner after triage than more-acute patients who arrived within 10 minutes of one another. Additionally, this study compares the Fast Track and acute care areas to see if location affects triage-to-provider time. Methods\u0000A random convenience sample of 252 ED patients aged 18 or greater was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended by the author. We collected data on ESI level, timestamps for triage and first provider sign-up, and location to which patient was triaged (Fast Track vs. acute care). Paired patients ESI levels, locations, and triage and first provider sign-up times were compared. Results One hundred twenty-six pairs of patients were included. More-acute patients were seen significantly-faster after triage (~20 minutes) than less-acute patients in two groups: ESI level 2 vs. 3 and overall high- vs. low-acuity. However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less-acute patient was seen before the more-acute patient. Additionally, patients in the acute care area had significantly-shorter median triage-to-provider times (~ 40 minutes) compared to those in the Fast Track area for ESI 2 (acute care) vs ESI 3 (Fast Track) and overall high-acuity (acute care) vs low-acuity (Fast-track). Nonetheless, approximately one-third of ESI 3 patients triaged to Fast Track were seen before ESI 2 patients triaged to the acute care area. Conclusion\u0000The split-flow model reduces overall ED length of stay (LOS), improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of Emergency Medicine and potentially subverts the intended triage process. Although most more-acute patients are seen by a provider sooner after triage than less-acute patients, a substantial number are seen later, which could delay urgent medical needs and impact patients' outcome negatively. Furthermore, acute care area patients are seen sooner post-triage than identical-ESI-level Fast Track patients, suggesting Fast Track might not function as intended. Further examination of patient outcomes is necessary to determine the impact of the ESI triage","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"26 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139753498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Shock is a common emergency condition which can lead to organ failure and death if not diagnosed and managed timely. Despite its huge global impact, data is scarce in resource-limited settings, such as Ethiopia, which hinders the provision of quality care for improved patient outcomes. Hence, the aim of the study was to determine the incidence of death and predictors among adult patients with shock managed at the Emergency Department of St. Paul's Hospital Millennium Medical College in Ethiopia. Methods: A retrospective chart review study was conducted between July to September 2022 among 178 eligible adult patients who were managed at hospital between October 2021 and May 2022. The characteristics of the participants were summarized using frequency and median with interquartile range. The incidence of mortality was estimated using incidence density using person hour (PH) of observation. To identify predictors of mortality, a generalized linear model using poisson regression model with robust standard errors was run at 5% level of significance, where adjusted relative risk (ARR) with its 95% CI was used to interpret significant results Result: The incidence of death was 6.87 deaths per 1000 PH (95% CI= 5.44 to 8.69). Significant predictors of death were being triaged orange (ARR=0.46, 95% CI=0.24-0.88, p=0.020), having a high shock index (ARR=1.59, 95% CI=1.07-2.36, p=0.021), being diagnosed with septic shock (ARR=3.66, 95% CI=1.20-11.17, p=0.023), taking vasopressors (ARR=3.18, 95% CI=1.09, 9.27, p=0.034), and developing organ failure (ARR=1.79, 95% CI=1.04-3.07, p=0.035). Conclusion: The incidence of mortality among shock patients was found to be considerable but relatively lower than previous studies. To optimize patient care and improve outcomes, it is important to remain vigilant in the proper triage and early diagnosis of shock using more sensitive tools for prompt identification of high-risk cases, as well as to provide timely, prioritized and effective interventions.
{"title":"Incidence of Mortality and Predictors Among Patients with Shock Managed in the Emergency Room of a Large Tertiary Referral Hospital in Ethiopia","authors":"Kalsidagn Girma Asfaw (MD), Abel Getachew Adugna (MD, Nahom Mesfin Mekonen (MD), Tigist Workneh Leulseged (MD, MPH), Merahi Kefyalew Merahi (MD, MPH), Segni Kejela (MD), Fekadesilassie Henok Moges (MD)","doi":"10.1101/2024.02.10.24302628","DOIUrl":"https://doi.org/10.1101/2024.02.10.24302628","url":null,"abstract":"Background: Shock is a common emergency condition which can lead to organ failure and death if not diagnosed and managed timely. Despite its huge global impact, data is scarce in resource-limited settings, such as Ethiopia, which hinders the provision of quality care for improved patient outcomes. Hence, the aim of the study was to determine the incidence of death and predictors among adult patients with shock managed at the Emergency Department of St. Paul's Hospital Millennium Medical College in Ethiopia.\u0000Methods: A retrospective chart review study was conducted between July to September 2022 among 178 eligible adult patients who were managed at hospital between October 2021 and May 2022. The characteristics of the participants were summarized using frequency and median with interquartile range. The incidence of mortality was estimated using incidence density using person hour (PH) of observation. To identify predictors of mortality, a generalized linear model using poisson regression model with robust standard errors was run at 5% level of significance, where adjusted relative risk (ARR) with its 95% CI was used to interpret significant results\u0000Result: The incidence of death was 6.87 deaths per 1000 PH (95% CI= 5.44 to 8.69). Significant predictors of death were being triaged orange (ARR=0.46, 95% CI=0.24-0.88, p=0.020), having a high shock index (ARR=1.59, 95% CI=1.07-2.36, p=0.021), being diagnosed with septic shock (ARR=3.66, 95% CI=1.20-11.17, p=0.023), taking vasopressors (ARR=3.18, 95% CI=1.09, 9.27, p=0.034), and developing organ failure (ARR=1.79, 95% CI=1.04-3.07, p=0.035).\u0000Conclusion: The incidence of mortality among shock patients was found to be considerable but relatively lower than previous studies. To optimize patient care and improve outcomes, it is important to remain vigilant in the proper triage and early diagnosis of shock using more sensitive tools for prompt identification of high-risk cases, as well as to provide timely, prioritized and effective interventions.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139753563","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-11DOI: 10.1101/2024.02.09.24302601
J Mark Ansermino, Yashodani Pillay, Abner Tagoola, Cherri Zhang, Dustin Dunsmuir, Stephen Kamau, Joyce Kigo, Collins Agaba, Ivan Aine Aye, Bella Hwang, Stefanie K Novakowski, Charly Huxford, Matthew O. Wiens, David Kimutai, Mary Ouma, Ismail Ahmed, Paul Mwaniki, Florence Oyella, Emmanuel Tenywa, Harriet Nambuya, Bernard Opar Toliva, Nathan Kenya-Mugisha, Niranjan Kissoon, Samuel Akech
PLOS DH (298/300 word limit) Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study. Smart Triage was implemented (with control sites) in Kenya (February 2021-December 2022) and Uganda (April 2020-April 2022). Children presenting to the outpatient departments with an acute illness were enrolled. A controlled interrupted time series was used to assess the effect on time from arrival at the facility to intravenous antimicrobial administration. Secondary analyses included antimicrobial use, admission rates and mortality (NCT04304235). During the baseline period, the time to antimicrobials decreased significantly in Kenya (132 and 58 minutes) at control and intervention sites, but less in Uganda (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to IVA at the intervention site decreased by 98 min (57%, 95% CI 81-114) but increased by 49 min (21%, 95% CI: 23-76) at the control site. In Uganda, the time to IVA initially decreased but was not sustained, and there was no significant difference between intervention and control sites. At the intervention sites, there was a significant reduction in IVA utilization of 47% (Kenya) and 33% (Uganda), a reduction in admission rates of 47% (Kenya) and 33% (Uganda) and a 25% (Kenya) and 75% (Uganda) reduction in mortality rates compared to the baseline period. We showed significant improvements in time to intravenous antibiotics in Kenya but not Uganda, likely due to COVID-19, a short study period and resource constraints. The reduced antimicrobial use and admission and mortality rates are remarkable and welcome benefits but should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in resource-poor health systems.
{"title":"Implementation of Smart Triage combined with a quality improvement program for children presenting to facilities in Kenya and Uganda: An interrupted time series analysis.","authors":"J Mark Ansermino, Yashodani Pillay, Abner Tagoola, Cherri Zhang, Dustin Dunsmuir, Stephen Kamau, Joyce Kigo, Collins Agaba, Ivan Aine Aye, Bella Hwang, Stefanie K Novakowski, Charly Huxford, Matthew O. Wiens, David Kimutai, Mary Ouma, Ismail Ahmed, Paul Mwaniki, Florence Oyella, Emmanuel Tenywa, Harriet Nambuya, Bernard Opar Toliva, Nathan Kenya-Mugisha, Niranjan Kissoon, Samuel Akech","doi":"10.1101/2024.02.09.24302601","DOIUrl":"https://doi.org/10.1101/2024.02.09.24302601","url":null,"abstract":"PLOS DH (298/300 word limit)\u0000Sepsis occurs predominantly in low-middle-income countries. Sub-optimal triage contributes to poor early case recognition and outcomes from sepsis. We evaluated the impact of Smart Triage using improved time to intravenous antimicrobial administration in a multisite interventional study.\u0000Smart Triage was implemented (with control sites) in Kenya (February 2021-December 2022) and Uganda (April 2020-April 2022). Children presenting to the outpatient departments with an acute illness were enrolled. A controlled interrupted time series was used to assess the effect on time from arrival at the facility to intravenous antimicrobial administration. Secondary analyses included antimicrobial use, admission rates and mortality (NCT04304235).\u0000During the baseline period, the time to antimicrobials decreased significantly in Kenya (132 and 58 minutes) at control and intervention sites, but less in Uganda (3 minutes) at the intervention site. Then, during the implementation period in Kenya, the time to IVA at the intervention site decreased by 98 min (57%, 95% CI 81-114) but increased by 49 min (21%, 95% CI: 23-76) at the control site. In Uganda, the time to IVA initially decreased but was not sustained, and there was no significant difference between intervention and control sites. At the intervention sites, there was a significant reduction in IVA utilization of 47% (Kenya) and 33% (Uganda), a reduction in admission rates of 47% (Kenya) and 33% (Uganda) and a 25% (Kenya) and 75% (Uganda) reduction in mortality rates compared to the baseline period.\u0000We showed significant improvements in time to intravenous antibiotics in Kenya but not Uganda, likely due to COVID-19, a short study period and resource constraints. The reduced antimicrobial use and admission and mortality rates are remarkable and welcome benefits but should be interpreted cautiously as these were secondary outcomes. This study underlines the difficulty of implementing technologies and sustaining quality improvement in resource-poor health systems.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139753416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-06DOI: 10.1101/2024.01.31.24301668
Haley C. Meltzer, Jane L. Goodwin, Lauren A. Fowler, Thomas W. Britt, Ronald G. Pirrallo, Jennifer T. Grier
Background On 19 January 2020, the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was identified in the US, with the first cases in South Carolina (SC) confirmed on 06 March 2020. Due to initial limited testing capabilities and potential for asymptomatic transmission, it is possible that the virus was present earlier than previously thought while preexisting immunity in at-risk populations was unknown.
{"title":"Severe Acute Respiratory Syndrome Coronavirus 2 – Reactive Salivary Antibody Detection in South Carolina Emergency Healthcare Workers: September 2019–March 2020","authors":"Haley C. Meltzer, Jane L. Goodwin, Lauren A. Fowler, Thomas W. Britt, Ronald G. Pirrallo, Jennifer T. Grier","doi":"10.1101/2024.01.31.24301668","DOIUrl":"https://doi.org/10.1101/2024.01.31.24301668","url":null,"abstract":"<strong>Background</strong> On 19 January 2020, the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was identified in the US, with the first cases in South Carolina (SC) confirmed on 06 March 2020. Due to initial limited testing capabilities and potential for asymptomatic transmission, it is possible that the virus was present earlier than previously thought while preexisting immunity in at-risk populations was unknown.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"13 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-02-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139753396","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-31DOI: 10.1101/2024.01.30.24301996
Arjen-Kars Boer, Ruben Deneer, Maaike Maas, Heidi Ammerlaan, Roland H.H. van Balkom, Mathie PG Leers, Remy J.H. Martens, Madelon M. Buijs, Jos J. Kerremans, Muriël Messchaert, Jeroen D.E. van Suijlen, Natal A.W. van Riel, Volkher Scharnhorst
Background<br />Rapid identification of emergency department (ED) patients with a possible COVID-19 infection is needed. PCR-testing all ED patients is neither feasible nor effective in most centers, therefore a rapid, objective, low-cost screening tool to triage ED patients is necessary.<br />Methods<br />Results from all routine lab tests from ED patients at the Catharina Hospital were collected from July 2019 to July 2020 and used in a statistical model to obtain the CoLab-score. The score was validated temporally and externally in three independent centers.<br />Results<br />The CoLab-score consists of 10 routine lab results and can be used to safely rule-out a COVID-19 infection in more than one third of ED presentations with a negative predictive value of 0.997 (95% CI: 0.994 – 0.999) .<br />Conclusions<br />The CoLab-score is a valuable tool to rule out COVID-19, guide PCR testing and is available to any center with access to routine laboratory tests.
{"title":"The CoLab-score rapidly and efficiently excludes COVID-19 at the emergency department without need for SARS-CoV-2 testing: a multicenter case-control study","authors":"Arjen-Kars Boer, Ruben Deneer, Maaike Maas, Heidi Ammerlaan, Roland H.H. van Balkom, Mathie PG Leers, Remy J.H. Martens, Madelon M. Buijs, Jos J. Kerremans, Muriël Messchaert, Jeroen D.E. van Suijlen, Natal A.W. van Riel, Volkher Scharnhorst","doi":"10.1101/2024.01.30.24301996","DOIUrl":"https://doi.org/10.1101/2024.01.30.24301996","url":null,"abstract":"Background<br />Rapid identification of emergency department (ED) patients with a possible COVID-19 infection is needed. PCR-testing all ED patients is neither feasible nor effective in most centers, therefore a rapid, objective, low-cost screening tool to triage ED patients is necessary.<br />Methods<br />Results from all routine lab tests from ED patients at the Catharina Hospital were collected from July 2019 to July 2020 and used in a statistical model to obtain the CoLab-score. The score was validated temporally and externally in three independent centers.<br />Results<br />The CoLab-score consists of 10 routine lab results and can be used to safely rule-out a COVID-19 infection in more than one third of ED presentations with a negative predictive value of 0.997 (95% CI: 0.994 – 0.999) .<br />Conclusions<br />The CoLab-score is a valuable tool to rule out COVID-19, guide PCR testing and is available to any center with access to routine laboratory tests.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"61 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139657902","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-30DOI: 10.1101/2024.01.29.24301925
Hoa Thi Truong, Sam Hoanh Guyen, Cuong Van Le, Shinichi Tokuno, Aya Kuchiba, Shinji Nakahara
Background: Delayed hospital arrival lowers the proportion of patients with stroke receiving recanalization therapy and results in poor outcomes. This study investigated the factors associated with pre-hospital delays in hospital arrival after stroke onset in the Thanh Hoa Province, Vietnam. Methods: Clinical data were collected from stroke patients within 7 days of symptom onset who were prospectively registered in this study. Patients and/or their relatives were interviewed using a structured questionnaire about patient social demographics, address, post-stroke support actions, and stroke awareness. Pre-hospital delay in hospital arrival was dichotomized into <4.5 hours and > 4.5 hours, and multivariable logistic regression analysis was used to investigate factors associated with the delay. Result: Of the 328 participants analyzed, 181 (55.4%) arrived at the hospital 4.5 hours after the symptom onset. The patients' and relatives' awareness of stroke was poor. Pre-hospital delays were longer for patients living > 10 km away from a healthcare facility and those with secondary or lower education levels, with odds ratios of 2.07 and 1.98, respectively. Seeking care at a district or private hospital as the first point of healthcare or non-use of emergency medical services did not show significant associations. Discussion: The study revealed that most patients with stroke did not arrive at the hospital in time for recanalization therapy. Moreover, the low stroke awareness among patients and their relatives is concerning. Further research is needed to investigate the reasons for pre-hospital delays and develop targeted interventions to improve stroke awareness and reduce these delays.
{"title":"Factors Associated with Delayed Hospital Arrival after Stroke Onset: An Observational Study in Thanh Hoa Province, Vietnam","authors":"Hoa Thi Truong, Sam Hoanh Guyen, Cuong Van Le, Shinichi Tokuno, Aya Kuchiba, Shinji Nakahara","doi":"10.1101/2024.01.29.24301925","DOIUrl":"https://doi.org/10.1101/2024.01.29.24301925","url":null,"abstract":"Background: Delayed hospital arrival lowers the proportion of patients with stroke receiving recanalization therapy and results in poor outcomes. This study investigated the factors associated with pre-hospital delays in hospital arrival after stroke onset in the Thanh Hoa Province, Vietnam.\u0000Methods: Clinical data were collected from stroke patients within 7 days of symptom onset who were prospectively registered in this study. Patients and/or their relatives were interviewed using a structured questionnaire about patient social demographics, address, post-stroke support actions, and stroke awareness. Pre-hospital delay in hospital arrival was dichotomized into <4.5 hours and > 4.5 hours, and multivariable logistic regression analysis was used to investigate factors associated with the delay.\u0000Result: Of the 328 participants analyzed, 181 (55.4%) arrived at the hospital 4.5 hours after the symptom onset. The patients' and relatives' awareness of stroke was poor. Pre-hospital delays were longer for patients living > 10 km away from a healthcare facility and those with secondary or lower education levels, with odds ratios of 2.07 and 1.98, respectively. Seeking care at a district or private hospital as the first point of healthcare or non-use of emergency medical services did not show significant associations.\u0000Discussion: The study revealed that most patients with stroke did not arrive at the hospital in time for recanalization therapy. Moreover, the low stroke awareness among patients and their relatives is concerning. Further research is needed to investigate the reasons for pre-hospital delays and develop targeted interventions to improve stroke awareness and reduce these delays.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"67 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139579520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective Indonesia’s emergency care system remains suboptimal despite rising demand due to socio-economic changes and increased life expectancy. This study aims to examine patient and family perceptions of the current emergency care system, identify potential needs, and provide a foundation for its development and improvement.
{"title":"Survey on emergency care utilization in tertiary care hospitals in Indonesia","authors":"Mineto Fujisawa, Kiyomitsu Fukaguchi, Akio Tokita, Yuta Iwamoto, Takanori Takeda, Lukito Condro, Monalisa Tobing, Bobi Prabowo, Rarasanti Rania Qodri, S.Tr. Battra, Tadahiro Goto","doi":"10.1101/2024.01.18.24301470","DOIUrl":"https://doi.org/10.1101/2024.01.18.24301470","url":null,"abstract":"<strong>Objective</strong> Indonesia’s emergency care system remains suboptimal despite rising demand due to socio-economic changes and increased life expectancy. This study aims to examine patient and family perceptions of the current emergency care system, identify potential needs, and provide a foundation for its development and improvement.","PeriodicalId":501290,"journal":{"name":"medRxiv - Emergency Medicine","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139516742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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