Chao-Jui Li

Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest

AIM OF THE STUDY Although sustained return of spontaneous circulation (ROSC) can be initially established after resuscitation from non-traumatic out-of-hospital cardiac arrest (OHCA) in some children, many of the children lose spontaneous circulation during hospital stay and do not survive to discharge. The aim of this study was to determine the clinical features during the first hour after ROSC that may predict survival to hospital discharge. METHODS We retrospectively evaluated the medical records of 228 children who presented to the emergency department without spontaneous circulation following non-traumatic OHCA during the period January 1996 to December 2008. Among these children, 80 achieved sustained ROSC for at least 20 min. The post-resuscitative clinical features during the first hour after achieving sustained ROSC that correlated with survival, median duration of survival, and death were analyzed. RESULTS Among the 80 children who achieved sustained ROSC for at least 20 min, 28 survived to hospital discharge and 6 had good neurologic outcomes (PCPC scale=1 or 2). Post-resuscitative clinical features associated with survival included sinus cardiac rhythm (p=0.012), normal heart rate (p=0.008), normal blood pressure (p<0.001), urine output>1 ml/kg/h (p=0.002), normal skin color (p=0.016), lack of cardiopulmonary resuscitation (CPR)-induced rib fracture (p=0.044), initial Glasgow Coma Scale score>7 (p<0.001), and duration of in-hospital CPR<or=10 min (p<0.001). Furthermore, these variables were also significantly associated with the duration of survival (all p<0.05). CONCLUSIONS The most important predictors of survival to hospital discharge in children with OHCA who achieve sustained ROSC are a normal heart rate, normal blood pressure, and an initial urine output>1 ml/kg/h.

The influence of physician seniority on disparities of admit/discharge decision making for ED patients ☆

OBJECTIVES Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients. METHODS In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively. RESULTS Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found. CONCLUSIONS EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

The Post-Resuscitative Urinalysis Associate the Survival of Patients with Non-Traumatic Out-of-Hospital Cardiac Arrest

Objective To analyze whether urine output and urinalysis results are predictive of survival and neurologic outcomes in patients with non-traumatic out-of-hospital cardiac arrest (OHCA). Methods Information was obtained from 1,340 patients with non-traumatic OHCA who had achieved a sustained return of spontaneous circulation (ROSC). Factors that were associated with survival in the post-resuscitative period were evaluated. The association between urine output and fluid challenge in the early resuscitative period was analyzed and compared between the survivors and the non-survivors. The results of the initial urinalysis, including the presence of proteinuria and other findings, were used to evaluate the severity of vascular protein leakage and survival. The association between proteinuria and the neurologic outcomes of the survivors was also analyzed. The clinical features of capillary leakage were examined during the post-resuscitative period. Results Of the 1,340 patients, 312 survived. A greater urine output was associated with a higher chance of survival. The initial urine output increased in proportion to the amount of fluid that was administered during early resuscitation in the emergency department for the survivors but not for the non-survivors (p<0.05). In the initial urinalysis, proteinuria was strongly associated with survival, and severe proteinuria indicated significantly poorer neurologic outcomes (p<0.05 for both comparisons). Proteinuria was associated with a risk of developing signs of capillary leakage, including body mass index gain and pitting edema (both p<0.001). Conclusion The severity of proteinuria during the early post-resuscitative period was predictive of survival.

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy.

AbstractThe ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ⩽5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ⩽10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

The impact of prolonged waiting time for coronary care unit admission on patients with non ST-elevation acute coronary syndrome

Background The boarding of patients in the emergency department consumes nursing and physician resources, and may delay the evaluation of new patients. It may also contribute to poor cardiovascular outcomes in patients with acute coronary syndrome (ACS). This study analyzed the relationship between the delay in coronary care unit (CCU) admission and the clinical outcomes of patients with ACS with non‐ST‐segment elevation (NSTE‐ACS). Methods Patients were divided into 2 groups according to the CCU waiting time (< 12 h and > 12 h). Outcome variables including in‐hospital mortality, gastrointestinal bleeding and stroke during hospitalization, and duration of hospital stay were compared between the 2 study groups. We used the GRACE risk scores to classify disease severity of the study patients for stratifying analysis. Result A difference was found in the outcome of gastrointestinal bleeding. Among those with GRACE risk scores of < 3 (low mortality risk) and 3 (high mortality risk), 5% and 3.1% of patients developed gastrointestinal bleeding, respectively, with CCU waiting time of > 12 h compared to CCU waiting time of < 12 h. However, there was no significant statistical difference (P = 0.065 and 0.547). In addition, there were no significant differences in the in‐hospital mortality rate, incidence of stoke, and duration of hospital stay between the 2 groups. Conclusion There was no significant difference in the clinical outcomes of NSTE‐ACS patients without profound shock between those with CCU waiting times of < 12 and > 12 h. If necessary, CCU admission should be prioritized for patients whose hemodynamic instability or respiratory failure.

Comparison of Clinical Practice in the Emergency Department: Female versus Male Emergency Physicians

Background: There are fewer female emergency physicians (EPs) than male ones. This study attempted to analyze the differences in clinical practice between female and male EPs in the emergency department (ED). Materials and Methods: A retrospective, 1‐year cohort study was conducted across 4 EDs in the largest healthcare system in Taiwan. A total of 199,757 adult patients without trauma treated by 76 EPs (9 females and 67 males) were included in the study. The clinical practice of female and male EPs was compared. The door‐to‐order and door‐to‐disposition times were used to evaluate EP efficiency. Indicators of diagnostic tool use included laboratory examinations and computed tomography scans. Patient dispositions included discharge, ED observation, general ward and intensive care unit admissions and ED mortality rate. Disposition accuracy was evaluated by determining the 72‐hour ED revisit rate. Results: The clinical practice of female and male EPs was similar. After adjusting for the potential confounding factors through a regression model, female EPs showed slight increase in laboratory examination use (adjusted odds ratio = 1.05; 95% CI: 1.01‐1.09) compared with male EPs, but no difference in computed tomography use was observed between sexes. Additionally, no differences among patient dispositions and 72‐hour ED revisit rates (adjusted odds ratio = 1.0; 95% CI: 0.93‐1.06) were observed between female and male EPs. Conclusions: Female and male EPs had similar clinical efficiency on patient evaluation, and they had no difference in diagnostic tool use. Furthermore, they showed similar patient disposition with the same accuracy.

Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

Background Emergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. Materials and methods A retrospective, 1‐year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non‐trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non‐urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. Result Patients discharged from ED had 0.4 h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83–0.96) compared with the merged model. Conclusion The separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest.

AbstractThe postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003–2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15–30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.

Acute Ischemia Hepatitis as a Major Clinical Presentation of the Primary Cardiac Lymphoma

Primary cardiac lymphoma is extremely rare and antemortem diagnosis is difficult. Although this malignancy is not uncommonly reported, most patients in the literature typically presented with cardiac signs and symptoms. We described a 21-year-old man who presented initially with ischemic hepatitis but was finally diagnosed as having the tumor. Literature search from 1997 to 2009 revealed 27 cases of the tumor of which the clinical presentations were reviewed.