World Journal of Emergency Medicine

Mobile technology: Usage and perspective of patients and caregivers presenting to a tertiary care emergency department

Zhenghong Liu, Mingwei Ng, Dinesh V. Gunasekeran, Huihua Li, Kishanti Ponampalam, R Ponampalam

2020, 11(1): 5-11. doi:10.5847/wjem.j.1920-8642.2020.01.001

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BACKGROUND: Developments in information technology (IT) have driven a push in healthcare innovation in the emergency department (ED). Many of these applications rely on mobile technology (MT) such as smartphones but not everyone is comfortable with MT usage. Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED.

METHODS: A cross-sectional survey was conducted in the emergency department of a tertiary hospital. Patients and their caregivers aged 21 and above were recruited. The survey collected demographic information, technology usage patterns, and participant reported comfort level in the usage of MT. We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT.

RESULTS: A total of 498 participants were recruited, and 299 (60%) were patients. English was the most commonly written and read language (66.9%) and 64.2% reported a comfort level of 3/5 or more in using MT. Factors that were associated with being comfortable in using MT include having a tertiary education, being able to read and write English, as well as being a frequent user of IT. Caregivers were more likely to display these characteristics.

CONCLUSION: A large proportion of ED patients are not comfortable in the usage of MT. Factors that predicted comfort level in the usage of MT were common amongst caregivers. Future interventions should take this into consideration in the design of MT interventions.

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center

Samantha Shwe, Lauren Witchey, Shadi Lahham, Ethan Kunstadt, Inna Shniter, John C. Fox

2020, 11(1): 12-17. doi:10.5847/wjem.j.1920-8642.2020.01.002

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BACKGROUND: Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients.

METHODS: This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was cross-referenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented.

RESULTS: We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.

CONCLUSION: A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function

Yi-wen Fan, Shao-wei Jiang, Jia-meng Chen, Hui-qi Wang, Dan Liu, Shu-ming Pan, Cheng-jin Gao

2020, 11(1): 18-26. doi:10.5847/wjem.j.1920-8642.2020.01.003

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BACKGROUND: Hospital mortality rates are higher among patients with sepsis-associated acute kidney injury (SA-AKI) than among patients with sepsis. However, the pathogenesis underlying SA-AKI remains unclear. We hypothesized that the source of infection affects development of SA-AKI. We aim to explore the relationship between the anatomical source of infection and outcome in patients with SA-AKI.

METHODS: Between January 2013 and January 2018, 113 patients with SA-AKI admitted to our Emergency Center were identified and divided into two groups: those with pulmonary infections and those with other sources of infection. For each patient, we collected data from admission until either discharge or death. We also recorded the clinical outcome after 90 days for the discharged patients.

RESULTS: The most common source of infection was the lung (52/113 cases, 46%), followed by gastrointestinal (GI) (25/113 cases, 22.1%) and urinary (22/113, 19.5%) sources. Our analysis showed that patients with SA-AKI had a significantly worse outcome (30/52 cases, P<0.001) and poorer kidney recovery (P=0.015) with pulmonary sources of infection than those infected by another source. Data also showed that patients not infected by a pulmonary source more likely experienced shock (28/61 cases, P=0.037).

CONCLUSION: This study demonstrated that the source of infection influenced the outcome of SA-AKI patients in an independent manner. Lung injury may influence renal function in an as-yet undetermined manner as the recovery of kidney function was poorer in SA-AKI patients with a pulmonary source of infection.

Admission delay is associated with worse surgical outcomes for elderly hip fracture patients: A retrospective observational study

Wei He, Yue-yang You, Kai Sun, Chen Xie, Yue Ming, Li-na Yu, Feng-jiang Zhang, Min Yan

2020, 11(1): 27-32. doi:10.5847/wjem.j.1920-8642.2020.01.004

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BACKGROUND: The influence of surgical delay on mortality and morbidity has been studied extensively among elderly hip fracture patients. However, most studies only focus on the timing of surgery when patients have already been hospitalized, without considering pre-admission waiting time. Therefore, the present study aims to explore the influence of admission delay on surgical outcomes.

METHODS: In this retrospective study, we recorded admission timing and interval from admission to surgery for included patient. Other covariates were also collected to control confounding. The primary outcome was 1-year mortality. The secondary outcomes were 1-month mortality, 3-month mortality, ICU admission and postoperative pneumonia. We mainly used multivariate logistic regression to determine the effect of admission timing on postoperative outcomes. An additional survival analysis was also performed to assess the impact of admission delay on survival status in the first year after operation.

RESULTS: The proportion of patients hospitalized on day 0, day 1, day 2 after injury was 25.4%, 54.7% and 66.3%, respectively. And 12.6% patients visited hospital one week later after injury. Mean time from admission to surgery was 5.2 days (standard deviation 2.8 days). Hospitalization at one week after injury was a risk factor for 1-year mortality (OR 1.762, 95% CI 1.026-3.379, P=0.041).

CONCLUSION: Admission delay of more than one week is significantly associated with higher 1-year mortality. As a supplement to the current guidelines which emphasizes early surgery after admission, we also advocate early admission once patients get injured.

The first two cases of transcatheter mitral valve repair with ARTO system in Asia

Kai-da Ren, Zhao-xia Pu, Lei Yu, Feng Gao, Li-han Wang, Stella Ng, Ju-bo Jiang, Hua-jun Li, Yong Xu, Wei He, Min Yan, Xian-bao Liu, Jian-an Wang

2020, 11(1): 33-36. doi:10.5847/wjem.j.1920-8642.2020.01.005

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BACKGROUND: MAVERIC (Mitral Valve Repair Clinical Trial) validates the safety and efficacy of the ARTO system. We here report the first two successful cases of utilizing the ARTO system in patients with symptomatic heart failure (HF) with functional mitral regurgitation (FMR) in Asia.

METHODS: Two patients, aged 70 and 63, had severe HF with FMR. Transesophageal echocardiography confirmed that the left ventricular ejection fractions were less than 50% with severe mitral regurgitation (MR) in both patients. Optimizing drug treatment could not mitigate their symptoms. Therefore, we used the ARTO system to repair the mitral valve for these patients on March 5 and 6, 2019, respectively.

RESULTS: Mitral valve repairs using the ARTO system were successfully performed under general anaesthesia for these two patients. MR was decreased immediately after the procedures in both patients. The 30-day and 3-month transthoracic echocardiography (TTE) revealed a moderate to severe MR in both patients, and the New York Heart Association (NYHA) scales were also partially improved.

CONCLUSION: The first two cases in Asia indicate that the ARTO system is feasible for patients with heart failure with FMR, and the patient selection appears to be crucial.

Role of penehyclidine in acute organophosphorus pesticide poisoning

Shi-yuan Yu, Yan-xia Gao, Joseph Walline, Xin Lu, Li-na Zhao, Yuan-xu Huang, Jiang Tao, An-yong Yu, Na Ta, Ren-ju Xiao, Yi Li

2020, 11(1): 37-47. doi:10.5847/wjem.j.1920-8642.2020.01.006

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BACKGROUND: Penehyclidine is a newly developed anticholinergic agent. We aimed to investigate the role of penehyclidine in acute organophosphorus pesticide poisoning (OP) patients.

METHODS: We searched the Pubmed, Cochrane library, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical literature (CBM) and Wanfang databases. Randomized controlled trials (RCTs) recruiting acute OP patients were identified for meta-analysis. Main outcomes included cure rate, mortality rate, time to atropinization, time to 60% normal acetylcholinesterase (AchE) level, rate of intermediate syndrome (IMS) and rate of adverse drug reactions (ADR).

RESULTS: Sixteen RCTs involving 1,334 patients were identified. Compared with the atropine- or penehyclidine-alone groups, atropine combined with penehyclidine significantly increased the cure rate (penehyclidine+atropine vs. atropine, 0.97 vs. 0.86, RR 1.13, 95% CI [1.07-1.19]; penehyclidine+atropine vs. penehyclidine, 0.93 vs. 0.80, RR 1.08, 95% CI [1.01-1.15]) and reduced the mortality rate (penehyclidine+atropine vs. atropine, 0.015 vs. 0.11, RR 0.17, 95% CI [0.06-0.49]; penehyclidine+atropine vs. penehyclidine, 0.13 vs. 0.08, RR 0.23, 95% CI [0.04-1.28]). Atropine combined with penehyclidine in OP patients also helped reduce the time to atropinization and AchE recovery, the rate of IMS and the rate of ADR. Compared with a single dose of atropine, a single dose of penehyclidine also significantly elevated the cure rate, reduced times to atropinization, AchE recovery, and rate of IMS.

CONCLUSION: Atropine combined with penehyclidine benefits OP patients by enhancing the cure rate, mortality rate, time to atropinization, AchE recovery, IMS rate, total ADR and duration of hospitalization. Penehyclidine combined with atropine is likely a better initial therapy for OP patients than atropine alone.

Epidemiological characteristics and disease spectrum of emergency patients in two cities in China: Hong Kong and Shenzhen

Shao-xi Chen, Karren Fan, Ling-pong Leung

2020, 11(1): 48-53. doi:10.5847/wjem.j.1920-8642.2020.01.007

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Investigations for the assessment of adult patients presenting to the emergency department with supraventricular tachycardia

Harith Fernando, Nicholas Adams, Biswadev Mitra

2020, 11(1): 54-59. doi:10.5847/wjem.j.1920-8642.2020.01.008

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