BMC Emergency Medicine最新文献

Background & objectives: The increasing proportion of elderly populations has led to a rise in chronic diseases and frequent transfers between long-term care hospitals (LTCHs) and emergency departments (EDs). This study investigates the patterns of risk factors of initial-transfers and subsequent re-transfers among patients aged 65 or older. Specifically, we focus on those re-transferred from LTCHs to EDs within 48 h of discharge, often without adequate treatment.

Method: This nationwide cross-sectional study used data from South Korea's National Emergency Department Information System (NEDIS) from January 1, 2017, to December 31, 2019. Patients aged 65 or older who were initially transferred from LTCHs to EDs and re-transferred within 48 h, were identified. Logistic regression was employed to analyze risk factors associated with re-transfers.

Results: 140,282 elderly patients were identified as having been transferred from LTCHs to EDs. Of these, 38,180 patients received emergency care in the EDs and were discharged back to LTCHs. Among them, 679 patients were returned to LTCHs after receiving acute treatment but revisited the EDs within 48 h. Hospital ward admission rates were higher for re-transferred patients (71.3%) compared to initial transfers (42.1%, p < 0.0001). Risk factors for re-transfer included male, nighttime admissions, and longer ED stays (> 6 h). Tertiary hospitals showed higher re-transfer rates to other facilities (13.1%) than general hospitals (2.9%).

Conclusion: This study reveals that many health outcomes worsen upon re-transfer compared to the initial-transfer. These findings underscore the need for a coordinated healthcare system that ensures elderly patients from long-term care facilities are initially sent to appropriate hospitals during the initial transfer, which could mitigate repeated ED visits and ensure timely care.

Background: The reduction of processing times in the treatment of acute ischemic stroke is of outstanding importance. Our objective is to analyze the acute stroke care chain from onset to treatment in a city in Germany comprising three stroke units. Additionally, we discuss solutions for detected treatment delays.

Methods: We conducted an in-depth analysis of acute stroke care processing times across three local stroke centers in Düsseldorf among all emergency services transportations for suspected stroke. Isochrone mapping was performed to identify areas with prolonged transportation times.

Results: Among the 1,714 transportations, 943 patients had confirmed strokes. Prehospital care constituted 58% of total emergency care time until imaging. Patients with confirmed stroke had reduced in-hospital times while patients receiving treatment experienced faster in-hospital times. Isochrone mapping revealed disparities in transportation times within the city.

Conclusions: In conclusion, we identified confirmation of stroke symptoms as pre- and in-hospital and treatment eligibility as in-hospital process accelerators in stroke care. We propose the introduction of an in-ambulance video consulting model to accelerate contact to stroke-experts and accelerate processing times for patients eligible for treatment. Furthermore, we discuss the combination of in-ambulance video consulting with imaging and starting treatment outside traditional stroke centers, followed by transportation to a stroke center during thrombolysis, which might further accelerate treatment in specific cases.

Background: Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of "negative but measurable" hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels.

Methods: This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3-50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality.

Results: Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p < 0.001), and 30-day mortality (0.3% vs. 0.01%, p < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L.

Conclusions: Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

Background: In healthcare facilities, an efficient triage system is critical to optimize patient care. The main objective of this study was to explore the triage processes and practices in three different tiers of healthcare facilities in the Kathmandu Valley, Nepal.

Methods: A mixed-methods approach in this study comprised observations and interviews in ten healthcare settings across primary care centers (PHC; n = 6), secondary care centers (SHC; n = 3), and tertiary care hospital (n = 1). Data were collected from June to November 2023. Semi-structured interviews were conducted among patients (n = 30) including survey questionnaires among 144 healthcare workers (HCWs) focused on triage. The qualitative data were analyzed using Interpretative Phenomenological Analysis and quantitative data were analyzed to explore the median score on the consistent practice of triage based on the Likert scale.

Results: PHCs had designated space for triage with less equipped emergency services and outpatient departments (OPDs) and received severely ill patients rarely. Although prioritizing critical patients and prompt care was part of the services, there was a lack of triage protocols with more than half of the HCWs (56.3%; 36/64) from the tertiary hospital reporting the availability of triage guidelines compared to SHCs (28.1%; 9/32) and PHCs (6.3%; 3/48). The majority of HCWs from the tertiary level recognized triage's effectiveness in reducing time lag, and prioritizing patients. Tertiary level had the consistent use of triage (94%; 60/64) compared to only around two-thirds in SHCs (66%; 19/29) and PHCs (62%; 28/45). Patients often attended PHC services for routine check-ups and were motivated by health insurance, affordability, free medicines, referral cards, and proximity. In the SHC, there was a well-equipped emergency department (ED) with specific guidelines, but its use was infrequent. Patients were unaware of the triage process and its utility. In all settings, while most HCWs had a basic knowledge of triage, some were not confident due to limited exposure to the triage process and training. Many HCWs reported the need for triage-related training and its' consistent implementation.

Conclusions: Consistent utilization of triage protocols, coupled with improved infrastructure, resource allocation, and training for healthcare workers is critical for the optimization of triage processes in healthcare settings in the Kathmandu Valley, Nepal.

Background: The high incidence of airway management failure in the emergency department (ED) necessitates a comparative analysis of laryngoscopy methods. This study aims to compare the success and complications associated with video-assisted laryngoscopy (VL) and direct laryngoscopy (DL) in emergency tracheal intubation in ED.

Methods: This retrospective cohort study was conducted at the ED of Thammasat University Hospital. It involved adult patients undergoing emergency tracheal intubation using either VL (GlideScope^®) or DL (Macintosh^®). The outcomes assessed were success rates of intubation and occurrence of peri-intubation adverse events. Propensity score matching and multivariable risk regression analysis were employed for statistical evaluation.

Results: The study included 3,424 patients, with 342 in the VL group and 3,082 in the DL group. The initial analysis revealed no significant differences in the intubation success rates between the two methods. However, the VL group experienced fewer peri-intubation adverse events (33% compared to 40%). After propensity score matching, a higher first-attempt success rate was observed in the DL group (88.9% vs. 81.3%, risk difference: 7.6, 95% CI: 1.9 to 13.2, p=0.009), but there was no statistically significant difference in peri-intubation adverse events. VL had a lower first-attempt success rate among low-experience intubators. Subgroup analyses of intubators with moderate and high experience, as well as patients who received both induction agents and neuromuscular blocking agents, show results consistent with the analysis of the entire cohort.

Conclusion: Both VL and DL have comparable first-attempt success rates and peri-intubation adverse events. VL is particularly beneficial when used by moderately or highly experienced intubator. The choice of intubation method, combined with clinical experience and technique plays a critical role in the success and safety of emergency intubations.

Emergency medical services often serve as the initial point of contact for septic patients, offering crucial pre-hospital intervention opportunities. However, the efficacy of pre-hospital interventions remains uncertain. From this perspective, we'll talk about the available evidence of pre-hospital sepsis and septic shock treatment and the barriers to its implementation.

Background: In Emergency Departments (EDs), triage is crucial for determining patient severity and prioritizing care, typically using the Manchester Triage Scale (MTS). Traditional triage systems, reliant on human judgment, are prone to under-triage and over-triage, resulting in variability, bias, and incorrect patient classification. Studies suggest that Machine Learning (ML) and Natural Language Processing (NLP) could enhance triage accuracy and consistency. This review analyzes studies on ML and/or NLP algorithms for ED patient triage.

Methods: Following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, we conducted a systematic review across five databases: Web of Science, PubMed, Scopus, IEEE Xplore, and ACM Digital Library, from their inception of each database to October 2023. The risk of bias was assessed using the Prediction model Risk of Bias Assessment Tool (PROBAST). Only articles employing at least one ML and/or NLP method for patient triage classification were included.

Results: Sixty studies covering 57 ML algorithms were included. Logistic Regression (LR) was the most used model, while eXtreme Gradient Boosting (XGBoost), decision tree-based algorithms with Gradient Boosting (GB), and Deep Neural Networks (DNNs) showed superior performance. Frequent predictive variables included demographics and vital signs, with oxygen saturation, chief complaints, systolic blood pressure, age, and mode of arrival being the most retained. The ML algorithms showed significant bias risk due to critical bias assessment in classification models.

Conclusion: NLP methods improved ML algorithms' classification capability using triage nursing and medical notes and structured clinical data compared to algorithms using only structured data. Feature engineering (FE) and class imbalance correction methods enhanced ML workflows' performance, but FE and eXplainable Artificial Intelligence (XAI) were underexplored in this field. Registration and funding. This systematic review has been registered (registration number: CRD42024604529) in the International Prospective Register of Systematic Reviews (PROSPERO) and can be accessed online at the following URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=604529 . Funding for this work was provided by the National Council for Scientific and Technological Development (CNPq), Brazil.

Background: Persons who become life-threateningly ill or injured (due to for example trauma or cardiac arrest) are cared for in hospitals' designated emergency rooms at the emergency department (ED). In these rooms, the life-threatening condition and biomedical focus may reinforce a culture that value the medical-technical care. Meeting patients fundamental care needs (integrating physical, psychosocial and relational care needs) in a person-centred way might hence be challenging in emergency rooms. Little is known about how person-centred fundamental care is experienced and valued by vulnerable and exposed patients in emergency rooms. This study aims to describe fundamental care needs experienced by patients with a life-threating condition in the emergency room.

Methods: A descriptive deductive qualitative study with individual interviews were carried out with 15 patients who had been life-threateningly ill or injured and admitted in an emergency room, in Sweden. Data collection was conducted during 2022. Transcribed interviews were analyzed with deductive content analysis, based on the Fundamentals of Care framework.

Results: Despite being life-threateningly ill or injured, patients were still able to describe their unique needs-which were not only related to biomedical care. A relationship was established between healthcare professionals and the patient in the initial stage, but not maintained during their stay at the emergency room. Patients felt their physical needs were met to a greater extent than psychosocial and relational needs, despite their prioritizing the latter. Patients preferred personalized care but described care as task oriented. The physical environment limited patients from having their fundamental care needs met, and they adopted to a "patient role" to avoid adding to staff stress. The emergency room situation evoked existential thoughts.

Conclusions: This paper provides unique insights into patients' experiences of being cared for in an emergency room. From the patient perspective, physical care was not enough. Relationship, timely and personalized information, and existential needs were identified as essential fundamental care needs, which were not, or only partly met. The finding highlights the need to embed and prioritize fundamental care in practice also for patients who are life-threateningly ill or injured, which in turn calls for focus on organizational prerequisites to enable person-centred fundamental care.

Background: Trauma represents a significant global health challenge.The development of an effective scoring tool capable of predicting mortality risk in trauma cases is essential. This study aimed to investigate the combined effects of quick sequential organ failure assessment (qSOFA) and hypothermia (H) along with prothrombin time (PT) in predicting the prognosis of patients with severe trauma.

Methods: A retrospective cohort study was conducted to analyze data from severe trauma patients in the Trauma Database of the Trauma Center at the Second Affiliated Hospital of Soochow University between January 2017 and December 2021. Patients were categorized into survival and non-survival groups based on clinical outcomes. Baseline and clinical data were compared between the groups, and prognostic factors were explored using logistic regression analysis. Receiver operating characteristic (ROC) curves generated by 10-fold cross-validation using the caret in R programming language were used to assess the predictive efficacy of Injury Severity Score (ISS) and qSOFA + H + PT score for trauma patient mortality.

Results: A total of 509 severe trauma patients (377 males and 132 females) were included, with a median age of 53 years (range: 42-65 years). The mortality rate was found to be 23.4%. Logistic regression analysis revealed that age, ISS, and qSOFA + H + PT were significant predictors of death in severe trauma patients, with odds ratios of 1.035 (95%CI:1.014-1.057), 1.052 (95%CI:1.017-1.090), and 6.124 (95%CI:3.107-12.072), respectively (P < 0.05). The predictive efficacy of ISS and qSOFA + H + PT for mortality prediction was 0.742 and 0.816, respectively.The predictive efficacy of qSOFA + H + PT for emergency blood transfusion and operation was 0.743 and 0.702.

Conclusion: qSOFA + H + PT are identified as significant predictors to the death of severe trauma patients. They could be utilized as early intervention indicators in emergency departments, facilitating clinical management strategies such as emergency blood transfusion, emergency operation, and prognosis prediction.