World Journal of Emergency Medicine

Does shifting to professional emergency department staffing affect the decision for chest radiography?

Marin Pavlov, Lucija Klobučar, Iva Klobučar, Kristina Žgela, Vesna Degoricija

2021, 12(2): 87-92. doi:10.5847/wjem.j.1920-8642.2021.02.001

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BACKGROUND: The study aims to determine whether shifting to professional emergency department (ED) teams leads to a higher rate of radiologic workup.

METHODS: We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1 (G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013 (all patients were examined by an internal medicine specialist); group 2 (G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019 (all patients were examined by an emergency physician).

RESULTS: The chest X-ray (CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR (38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found (47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1.

CONCLUSIONS: Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.

Effectiveness of an educational program on improving healthcare providers’ knowledge of acute stroke: A randomized block design study

Jehad A. Rababah, Mohammed M. Al-Hammouri, Esra’a AlNsour

2021, 12(2): 93-98. doi:10.5847/wjem.j.1920-8642.2021.02.002

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BACKGROUND: Stroke is a time-sensitive neurological disease and a life-threatening medical condition. Providing timely management for stroke patients is a crucial issue in healthcare settings. The primary objective of this study is to evaluate the effectiveness of an evidence-based educational program on healthcare providers’ (HCPs) overall knowledge of stroke.

METHODS: A randomized block design with post-test only was used. A total of 189 HCPs (physicians, registered nurses, and paramedics) involved with treating stroke patients in the emergency were recruited. Participants were randomly assigned to either the intervention or waiting list control group. A one-session, stroke educational program was offered to the HCPs followed by a post-test designed to assess knowledge about stroke.

RESULTS: A significant main effect on the profession type was found, with physicians having higher mean scores of stroke knowledge compared with nurses and paramedics (F [2, 183]=48.55, P<0.001). The implemented educational program had a positive effect on increasing the level of stroke knowledge among HCPs (F [1, 183]=43.31, P<0.001). The utilization of any evidence-based assessment tools for patients with suspected stroke was denied by 36% of the total sample.

CONCLUSIONS: The implemented intervention can increase HCP’s knowledge regarding stroke. Stroke education should be considered as one of the essential requirements for professional development for all HCPs in the emergency.

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department

Hady Zgheib, Aline El Zakhem, Cynthia Wakil, Mohamad Ali Cheaito, Rola Cheaito, Antoine Finianos, Ralphe Bou Chebl, Rima Kaddoura, Nader Al Souky, Imad El Majzoub

2021, 12(2): 99-104. doi:10.5847/wjem.j.1920-8642.2021.02.003

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BACKGROUND: The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients.

METHODS: This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student’s t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher’s exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥10 ⁵ cfu/mL and ≥10 ⁴ cfu/mL.

RESULTS: We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥10 ⁵ cfu/mL and ≥10 ⁴ cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥10 ⁵ cfu/mL and ≥10 ⁴ cfu/mL respectively had a normal UA.

CONCLUSIONS: In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study

Yan-yan Liu, Yu-peng Wang, Ling-yun Zu, Kang Zheng, Qing-bian Ma, Ya-an Zheng, Wei Gao

2021, 12(2): 105-110. doi:10.5847/wjem.j.1920-8642.2021.02.004

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BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients.

METHODS: In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above.

RESULTS: A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups.

CONCLUSIONS: IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

Violence toward emergency physicians: A prospective-descriptive study

Kasım Turgut, Erdal Yavuz, Mine Kayacı Yıldız, Mehmet Kaan Poyraz

2021, 12(2): 111-116. doi:10.5847/wjem.j.1920-8642.2021.02.005

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BACKGROUND: The highest rate of workplace violence occurs in the health sector, although most cases remain unreported. Emergency services face the majority of these incidents for many reasons, such as the patient profile, long waiting time, and overcrowding. We aimed to determine the characteristics and causes of violence toward emergency physicians.

METHODS: The acts of violence toward emergency physicians over a one-year period were prospectively recorded. After a violent incident took place, a third party separately interviewed the physician exposed to the violent behavior and the perpetrator who displayed this behavior. We examined the perpetrator’s reasons for violence, their demographic characteristics, and the medical complaints of patients involved in such events to determine the characteristics and causes of violence.

RESULTS: Of the violent acts investigated, 85.1% were verbal, and most were directed toward male doctors by the young male relatives of the patients. More than half of the violent acts occurred within the 15 minutes of presentation to emergency service (60.5%) and at off-hours (69.4%). Concerning the health insurance, 20.4% of the cases were covered by the free green card system, and a small number of the perpetrators of violence lived in rural areas (38.2%). The most common reason for violent behavior was the patients’ or their relatives’ dissatisfaction with the examination or treatment method (38.2%).

CONCLUSIONS: Appropriate communication should be established with the patients, and they should be adequately informed about the treatments and interventions to be performed in order to prevent possible acts of violence.

Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study

Wen Gao, Yu-ping Zhang, Jing-fen Jin

2021, 12(2): 117-123. doi:10.5847/wjem.j.1920-8642.2021.02.006

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BACKGROUND: Delirium in patients in intensive care units (ICUs) is an acute disturbance and fluctuation of cognition and consciousness. Though increasing age has been found to be related to ICU delirium, there is limited evidence of the effect of age on delirium outcomes. The aim of this study is to investigate the relationship between age categories and outcomes among ICU delirium patients.

METHODS: Data were extracted from the electronic ICU (eICU) Collaborative Research Database with records from 3,931 patients with delirium. Patients were classified into non-aged (<65 years), young-old (65-74 years), middle-old (75-84 years), and very-old (≥85 years) groups. A Cox regression model was built to examine the role of age in death in ICU and in hospital after controlling covariates.

RESULTS: The sample included 1,667 (42.4%) non-aged, 891 (22.7%) young-old, 848 (21.6%) middle-old, and 525 (13.3%) very-old patients. The ICU mortality rate was 8.3% and the hospital mortality rate was 15.4%. Compared with the non-aged group, the elderly patients (≥65 yeras) had higher mortality at ICU discharge (χ ²=13.726, P=0.001) and hospital discharge (χ ²=56.347, P<0.001). The Cox regression analysis showed that age was an independent risk factor for death at ICU discharge (hazard ratio [HR]=1.502, 1.675, 1.840, 95% confidence interval [CI] 1.138-1.983, 1.250-2.244, 1.260-2.687; P=0.004, 0.001, 0.002 for the young-, middle- and very-old group, respectively) as well as death at hospital discharge (HR=1.801, 2.036, 2.642, 95% CI 1.454-2.230, 1.638-2.530, 2.047-3.409; all P<0.001).

CONCLUSIONS: The risks of death in the ICU and hospital increase with age among delirious patients.

Efficacy and safety of corticosteroids in immunocompetent patients with septic shock

Xin Lu, Wei Han, Yan-xia Gao, Shi-gong Guo, Shi-yuan Yu, Xue-zhong Yu, Hua-dong Zhu, Yi Li

2021, 12(2): 124-130. doi:10.5847/wjem.j.1920-8642.2021.02.007

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BACKGROUND: The use of corticosteroids in septic shock has been studied for many decades but yielded conflicting results. We conducted a systematic review to evaluate the efficacy and the safety of corticosteroids in immunocompetent patients with septic shock.

METHODS: Medline via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, and EMBASE were searched from inception to March 2020. Two reviewers independently identified randomized controlled trials (RCTs) comparing corticosteroids with a control group for immunocompetent patients with septic shock. Data were abstracted and reported following the Cochrane Handbook for Systematic Review of Intervention and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The efficacy outcome included mortality and shock reversal. The safety outcomes were infection, gastrointestinal bleeding, and hyperglycemia.

RESULTS: Nine RCTs with a total of 1,298 patients were included. Compared with the control group, corticosteroid group did not lower the short-term (28 or 30 days) mortality (risk ratio [RR] 0.95, 95% confidence interval (CI) 0.85 to 1.06, inconsistency [I ²]=0%, trial sequential analysis [TSA]-adjusted CI 0.83 to 1.09, moderate-certainty evidence). Corticosteroids significantly shortened the time to shock reversal compared with the control group (mean difference [MD] -21.56 hours; 95% CI -32.95 to -10.16, I ²=0%; TSA-adjusted CI -33.33 to -9.78, moderate-certainty evidence). The corticosteroid treatment was associated with an increased risk of hyperglycemia but not the infection or gastrointestinal bleeding.

CONCLUSIONS: The corticosteroid treatment is not associated with lower short- or long- term mortality compared with placebo in immunocompetent patients with septic shock. However, corticosteroids significantly shorten the time to shock reversal without increasing the risk of infection. The patient’s immune status should also be considered during clinical treatment and clinical trials in future.

Blood eosinophils and mortality in patients with acute respiratory distress syndrome: A propensity score matching analysis

Hao-tian Chen, Jian-feng Xu, Xiao-xia Huang, Ni-ya Zhou, Yong-kui Wang, Yue Mao

2021, 12(2): 131-136. doi:10.5847/wjem.j.1920-8642.2021.02.008

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BACKGROUND: The effect of blood eosinophils (EOSs) on mortality in acute respiratory distress syndrome (ARDS) patients and whether corticosteroids affect this effect are unclear.

METHODS: The Medical Information Mart for Intensive Care III database (version 1.4) was used to extract data. Patients with ARDS were selected for inclusion. Cox regression models using the backward stepwise method and propensity score matching (PSM) were used to assess the relationship between blood EOS counts and 28-day mortality.

RESULTS: A total of 2,567 patients with ARDS were included, and the 28-day mortality rate was 24.19%. The crude 28-day mortality was significantly lower in patients with EOS counts ≥2% (18.60% [85/457] vs. 25.40% [536/2,110], P=0.002) than in those with EOS counts <2%. In the Cox regression model, the EOS counts ≥2% showed a significant association with the decreased 28-day mortality (hazard ratio [HR] 0.731; 95% confidence interval [95% CI] 0.581-0.921, P=0.008). In the corticosteroid non-use subgroup, EOS counts ≥2% was significantly related to decreased 28-day mortality (HR 0.697, 95% CI 0.535-0.909, P=0.008), but the result was not significant in the corticosteroid non-use subgroup model (P=0.860). A total of 457 well-matched pairs were obtained by a 1:1 matching algorithm after PSM. The 28-day mortality remained significantly lower in the EOS counts ≥2% group (18.60% [85/457] vs. 26.70% [122/457], P=0.003).

CONCLUSIONS: Higher EOS counts are related to lower 28-day mortality in ARDS patients, and this relationship can be counteracted by using corticosteroids.

Prevalence of post-traumatic stress disorder after earthquakes among the elderly in China: A meta-analysis

Yong Liang, Hong Zeng, Yu-geng Liu, Ai-min Xu, Wen-hong Liu

2021, 12(2): 137-142. doi:10.5847/wjem.j.1920-8642.2021.02.009

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BACKGROUND: The study aims to investigate the occurrence of post-traumatic stress disorder (PTSD) after earthquakes among the elderly.

METHODS: Data from cross-sectional studies focusing on the prevalence of PTSD after earthquakes among the elderly were collected from PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure in December 2019. The search terms included post-traumatic stress disorder, earthquake, and elderly. This study used Review Manager 5.0 to evaluate the impact of the results. In addition, forest plots, sensitivity analysis, and bias analysis were carried out on the included articles. The combined estimate of the risk ratio and the standard deviation of the 95% confidence interval (95% CI) were measurements of the size of the effect.

RESULTS: There were 4,834 patients included from 10 eligible studies. The sample sizes of PTSD group and non-PTSD group were 1,277 and 3,557, respectively. The meta-analysis showed that the overall occurrence of PTSD after earthquakes among the elderly was 0.25; the occurrence in females was higher than that in males, and the occurrence in the same province indicated little difference (Wenchuan city 0.25 and Ya’an city 0.24).

CONCLUSIONS: After earthquakes, the occurrence of PTSD is higher among the elderly than among other age groups, and higher among the females than among the males, while there is little difference among different areas within the same province. This indicated that prioritized specific psychological interventions should be provided to the aged and the females.

Traditional Chinese medicine poisoning in the emergency departments in Hong Kong: Trend, clinical presentation and predictors for poor outcome

Rex Pui Kin Lam, Eric Ho Yin Lau, Wai Lam Yip, Joe Kai Shing Leung, Matthew Sik Hon Tsui

2021, 12(2): 143-150. doi:10.5847/wjem.j.1920-8642.2021.02.010

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Overlapping public health crises during the coronavirus disease pandemic

Nilanga Aki Bandara, Ricky Jhauj, Jayson Fernando, Vahid Mehrnoush, Namal Wijesinghe

2021, 12(2): 151-153. doi:10.5847/wjem.j.1920-8642.2021.02.011

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