N. K. Cheung

High risk trauma in older adults in Hong Kong: A multicentre study

BACKGROUND Trauma is the eighth leading cause of death in Hong Kong. In 2002, 18.5% of the population of Hong Kong was aged 55 years or above, which increased to 22.1% in 2006. The increasing older population in Hong Kong presents a challenge to the health care system yet there is little local data on older trauma patients. The objectives of this study are firstly to describe the epidemiology of high risk trauma in older patients in Hong Kong, and secondly to identify predictors of trauma mortality. METHOD Retrospective analysis of prospectively collected data from a centralised trauma database; data collected from 2002 to 2004 from four trauma centres in Hong Kong. RESULTS Between 2002 and 2004, the four trauma centres had a total of 2,124,175 emergency department attendances of which 376,021 (17.7%) were trauma patients, and 80,827 (3.8%) were aged 55 years or older. 810 injured older patients met the inclusion criteria for this study. 380 (46.9%) patients had co-morbidity at the time of injury. Common causes of injury were falls (50.0%, 405/810) and motor vehicle crashes (33.6%, 272/810) of which (77.2%, 210/272) were pedestrians. Mortality was 24.4% (198/810) and increased with advancing age (p<0.0001). 53.5% (433/810) of patients had major trauma (ISS>15). Head injury contributed to 80.3% (159/198) of deaths. 38.4% (311/810) of patients required operations. Most patients were discharged home (40.5%, 328/810) and one-third (270/810) required rehabilitation. Significant predictors of mortality included co-morbidity, injury severity score, age and decreasing Glasgow Coma Score. CONCLUSION Pedestrians struck by motor vehicles and falls are the principal causes of trauma in older patients in Hong Kong. Mortality increased with advancing age. The independent indicators of trauma mortality in older patients are co-morbidity, age, ISS and GCS.

Comprehensive care programme for patients with chronic obstructive pulmonary disease: a randomised controlled trial

Background There have been no randomised controlled trials that specifically evaluate the effect of a comprehensive programme with multidisciplinary input on patients who have just been discharged from hospital after treatment of acute exacerbation of COPD (AECOPD). The aim of this study was to assess whether a comprehensive care programme would decrease hospital readmissions and length of hospital stay (LOS) for patients with COPD. Methods Patients discharged from hospital after an episode of AECOPD were randomised to an intervention group (IG) or usual care group (UG). The IG received a comprehensive, individualised care plan which included education from a respiratory nurse, physiotherapist support for pulmonary rehabilitation, 3-monthly telephone calls by a respiratory nurse over 1 year, and follow-up at a respiratory clinic with a respiratory specialist once every 3 months for 1 year. The UG were managed according to standard practice. The primary outcome was hospital readmission rate at 12 months. Results 180 patients were recruited (IG, N=90; UG, N=90; mean±SD age 74.7±8.2 years, 172 (95.6%) men; mean±SD FEV1 45.4±16.6% predicted). At 12 months, the adjusted relative risk of readmission was 0.668 (95% CI 0.449 to 0.995, p=0.047) for the IG compared with the UG. At 12 months, the IG had a shorter LOS (4.59±7.16 vs 8.86±10.24 days, p≤0.001), greater improvement in mean Modified Medical Research Council Dyspnoea Scale (−0.1±0.6 vs 0.2±0.6, p=0.003) and St Georges Respiratory Questionnaire score (−6.9±15.3 vs −0.1±13.8, p=0.003) compared with the UG. Conclusions A comprehensive COPD programme can reduce hospital readmissions for COPD and LOS, in addition to improving symptoms and quality of life of the patients. Trial registration number NCT 01108835, Results.

Role of the trauma nurse coordinator in Hong Kong

Background:  Trauma is one of the leading causes of death for all ages in Hong Kong. In 2003, the Hospital Authority designated five hospitals as trauma centres. Five Trauma Nurse Coordinators (TNCs) were employed to facilitate multidisciplinary care and to coordinate all aspects of quality improvement for injured patients. The present paper investigates the characteristics and roles of TNCs in Hong Kong.

The epidemiology of patients with dizziness in an emergency department

Objectives The aims of this prospective study were (1) to describe the patterns of presentation, causes and disposition of patients with dizziness in an emergency department (ED) and (2) to identify the factors that predict central vestibular disorder. Methods All adult patients (≥18 years) attending our ED with a chief complaint of dizziness were included. Demographic characteristics, presenting complaint, symptoms, past medical illnesses, physical findings, provisional diagnosis and disposition were recorded in a data collection sheet by the medical officers. Results A total of 104 consecutive dizzy patients were recruited from 12th to 19th December 2003. The incidence of adult patients with dizziness was 4.0% (104/2594). There were 34 (32.7%) male and 70 (67.3%) female patients; 64 (61.5%) patients were below 65 and 40 (38.5%) were above 65. Lightheadedness (61.5%), vertigo (31.7%) and disequilibrium (4.8%) were the most frequent complaints. Nausea and/or vomiting (32.7%) and raised blood pressure on arrival (23.1%) were the most common associated symptoms and physical finding respectively. Hypertension (38.5%) was the most common pre-existing medical illness. Of all patients, 63.5% had non-vestibular disorder, 31.7% had peripheral vestibular disorder and 4.8% had central vestibular disorder. A clinical diagnosis could be made in 52.9% of our dizzy patients and about 20 different diagnoses were made. The majority (82.7%) of the patients were discharged from the ED. A presenting complaint of lightheadedness, altered mental state, focal neurological signs, raised blood pressure and history of stroke were predictors of central vestibular disorder (p<0.05). Conclusions Lightheadedness and vertigo were the two commonest presentations of dizzy patients. Most dizzy patients had benign causes and could be discharged from the ED. Lightheadedness, focal neurological symptoms and signs, altered mental state, hypertension and previous stroke were factors that would help to diagnose central vestibular disorder.

Differences in Injury Pattern and Mortality between Hong Kong Elderly and Younger Patients

Background The rapidly aging population in Hong Kong is causing an impact on our health care system. In Hong Kong, 16.5% of emergency department trauma patients are aged ≥65 years. Objective We aim to compare factors associated with trauma and differences in trauma mortality between elderly (≥65 years) and younger adult patients (15 to 64 years) in Hong Kong. Methods A retrospective observational study was performed using trauma registry data from the Prince of Wales Hospital, a 1200–bed acute hospital which is a regional trauma centre. Results A total of 2172 patients (331 [15.2%] elderly and 1841 [84.8%] younger) were included. Male patients predominated in the younger adult group but not in the elderly group. Compared with younger patients, elderly patients had more low falls and pedestrian-vehicle crashes and sustained injuries to the head, neck and extremities more frequently. The odds ratio (OR) for death following trauma was 5.5 in the elderly group (95% confidence interval [CI] 3.4–8.9, p>0.0001). Mortality rates increased progressively with age (p>0.0001) and were higher in the elderly at all levels of Injury Severity Score (ISS). Age ≥65 years independently predicted mortality (OR=5.7, 95% CI 3.5–9.3, p>0.0001). The elderly had a higher co-morbidity rate (58.6% vs. 14.1%; p>0.01). There was a lower proportion of trauma call activations for the elderly group (38.6% vs. 53.3%; p>0.01). Conclusion Elderly trauma patients differ from younger adult trauma patients in injury patterns, modes of presentation of significant injuries and mortality rates. In particular, the high mortality of elderly trauma requires renewed prevention efforts and aggressive trauma care to maximise the chance of survival.

Trauma team activation criteria and outcomes of geriatric trauma: 10 year single centre cohort study

Background With the aging population, the number of older patients with multiple injuries is increasing. The aim of this study was to understand the patterns and outcomes of older patients admitted to a major trauma centre in Hong Kong from 2006 to 2015, and investigate the performance of the trauma team activation (TTA) criteria for these elderly patients. Methods This was a retrospective cohort study from a university hospital major trauma centre in Hong Kong from 2006 to 2015. Patients aged 55 or above who entered the trauma registry were included. Patients were divided into those aged 55–70, and above 70. To test the performance of the TTA criteria, we defined injured patients with severe outcomes as those having any of the following: death within 30 days; the need for surgery; or the need for intensive care unit (ICU) care. Results 2218 patients were included over the 10 year period. The 30‐day mortality was 7.5% for aged 55–70 and 17.7% for those aged above 70. The sensitivity of TTA criteria for identifying severe outcomes for those aged 55 or above was 35.6%, with 91.6% specificity. The under‐triage rate was 59% for age 55–70, and 69.1% for those aged above 70. Conclusion There is a need to consider alternative TTA criteria for our geriatric trauma population, and to more clearly define the process and standards of care in Hong Kong.

Factors affecting outcomes in traumatic liver injury: a retrospective study

To achieve better outcomes, nonoperative management (NOM) and damage control surgery (DCS) are now recommended for traumatic liver injury. The aim of the present study was to review the outcomes of patients suffering from liver trauma and to determine the factors affecting the outcomes, with emphasis on NOM and DCS.

Intergrated care programme for patients with chronic obstructive pulmonary disease (COPD) – a randomized controlled trial [Abstract]

ID – 21 AN EPIDEMIOLOGICAL STUDY OF BRONCHIAL ASTHMA IN GREENHOUSE FARMERS IN NORTHEAST OF CHINA FROM 2006 TO 2009Introduction: COPD has significant morbidity and incurs heavy utilization ofhealthcare resources.Objectives: To assess whether a comprehensive care programme candecrease hospital admissions and length of hospital stay (LOS) for COPDpatients.Methods: In a randomized control trial of patients discharged from hospitalafter an episode of acute exacerbation of COPD, patients were randomized toan Intervention Group (IG) or Usual Care Group (UG). The IG received acomprehensive, individualized care plan which included respiratory nurse edu-cation, physiotherapist support for pulmonary rehabilitation, 3-monthly tele-phone calls by a respiratory nurse for a period of 1 year, and followed up inrespiratory clinic by a respiratory specialist once every 3 months for 1 year. TheUG were managed according to standard practice. All patients had assess-ments (spirometry, 6 minute walk test, dyspnoea score [Modified MedicalResearch Council Dyspnoea Scale {MMRC}], and quality of life [QOL] [St.Georges Respiratory Questionnaire {SGRQ}]) at baseline and at 12 months.The primary outcome was 12-month hospital readmission.Results: 180 patients were recruited (IG N = 90,UG N = 90; mean age74.7 ± 8.2yrs, 172(95.6%) males; mean FEV1 45.4 ± 16.6% predicted). At 12months, the IG had fewer readmissions (1.56 ± 2.13 vs 2.38 ± 2.14times,p = 0.0008) and shorter LOS (7.41 ± 11.29 vs 12.21 ± 12.87days, p = 0.0003)for COPD than UG. IG at 12 months had improved mean MMRC (-0.1 ± 0.7 vs0.2 ± 0.6, p = 0.033) and SGRQ score (-8.5 ± 16.6 vs −0.1 ± 15.7, p = 0.002)compared with UG.Conclusion: Comprehensive COPD programme can reduce hospital read-missions for COPD and LOS, and improve symptoms and QOL of the patients.

Focused echocardiogram by emergency physicians (EP) in resuscitation room of Accident and Emergency (A&E) Department

Results Patient A, elderly lady with lung cancer presented with progressive dyspnoea, desaturation, and low blood pressure. Bedside echo showed dilated right ventricle and McConnell sign. Diagnosis of pulmonary embolism was confirmed by CTPA. She was given thrombolytic in A&E with hemodynamic improvement. Patient B, 55 year old man presented with vomiting, diarrhoea, hypotension and tachycardia. Bedside echo showed severely depressed myocardial contractility. Provisional diagnosis of myocarditis was made, which proved to be the eventual diagnosis. Patient C, 49 year-old lady presented with epigastric discomfort and desaturation. Bedside echo showed right atrial (RA) mass. CT in A&E showed large anterior mediastinal mass with invasion into RA. The diagnosis was later confirmed to be spindle cell carcinoma with RA invasion. Patient D, 63 year-old man presented with dizziness and breathlessness. Clinically he was in profound shock, with pale appearance and cold extremities. BP was not recordable and blood gas showed severe lactic acidosis with pH 6.9. Bedside echo showed a large circumferential pericardial effusion with collapsed right chambers and plethoric IVC. Emergency pericardiocentesis was done with dramatic improvement in hemodynamic status. CT thorax showed a right lung tumour abutting the pericardium.

Use of point-of-care ultrasound (POCUS) by emergency physicians for general surgical patients in resuscitation room

Patients and methods Patients having general surgical presentation (i.e. excluding patients with neurosurgical, urological or cardiothoracic chief complaints) who attended Emergency Department of Prince of Wales Hospital, and triaged as category I or II (emergency or urgent) were included. The inclusion period was from Sep 2012 to Mar 2013. Patients’ clinical records were retrieved. Documented POCUS and scope of use by EP, yield to diagnosis, and eventual diagnoses after admission were studied.