Rashidi Ahmad

The Use of End-Tidal Capnography to Monitor Non-Intubated Patients Presenting with Acute Exacerbation of Asthma in the Emergency Department

STUDY OBJECTIVE To determine if the slope of Phase II and Phase III, and the alpha angle of the expiratory capnographic waveform, as measured via computer-recognizable algorithms, can reflect changes in bronchospasm in acute asthmatic non-intubated patients presenting to the emergency department (ED). METHODS In this prospective study carried out in a university hospital ED, 30 patients with acute asthma were monitored with clinical severity scoring and peak flow measurements, and then had a nasal cannula attached for sidestream sampling of expired carbon dioxide. The capnographic waveform was recorded onto a personal computer card for analysis. The patients were treated according to departmental protocols. After treatment, when they had improved enough for discharge, a second set of results was obtained for capnographic waveform recording. The pre-treatment and post-treatment results were then compared with paired-samples t-test analysis. RESULTS On the capnographic waveform pre- and post-treatment, there was a significant difference in the slope of Phase III (p < 0.001) and alpha angle (p < 0.001), but not in the Phase II slope (p = 0.35). There was significant change in peak flow meter reading, but it was poorly correlated with all the capnographic indices. CONCLUSION The study provides some preliminary data showing that capnographic waveform indices can indicate improvement in airway diameter in acute asthmatics in the ED. Capnographic waveform analysis presents several advantages in that it is effort-independent, and provides continuous monitoring of normal tidal respiration. With further refined studies, it may serve as a new method of monitoring non-intubated asthmatics in the ED.

A five-year retrospective review of snakebite patients admitted to a tertiary university hospital in Malaysia

BackgroundAlthough the majority of the snakebite cases in Malaysia are due to non-venomous snakes, venomous bites cause significant morbidity and mortality if treatment measures, especially ant-venom therapy, are delayed.MethodsTo determine the demographic characteristics, we conducted a retrospective study on all snakebite patients admitted to the Emergency Department of Hospital Universiti Sains Malaysia (HUSM) from January 2006 to December 2010.ResultsIn the majority of the 260 cases that we found (138 cases or 52.9%), the snake species was unidentified. The most common venomous snakebites among the identified species were caused by cobras (52 cases or 20%). Cobra bites are significantly more likely to result in severe envenomation compared to non-cobra bites. Post hoc analysis also showed that cobra bite patients are significantly less likely to have complete recovery than non-cobra bite patients (48 cases, 75.0% vs. 53 cases, 94.6%; p = 0.003) and more likely to result in local gangrene (11 cases, 17.2% vs. 3 cases, 5.4%; p = 0.044).ConclusionCobra bites are significantly more likely to result in severe envenomation needing anti-venom administration and more likely to result in local gangrene, and the patients are significantly less likely to have complete recovery than those with non-cobra bites.

Agent-based modelling and simulation of emergency department re-triage

Triage is a process of accessing patients on their severity based on a triage acuity scale in hospital emergency department (ED). Re-triage is a process where the severity of a patients condition is reassessed when there is a clinical need for it. Re-triage does not feature in the conventional triage, where the patients with non-urgent consideration will have to wait to be treated on a first come first serve basis. In this study, we investigate the effect of re-triage on patients waiting time and on the ED service by means of agent-based modelling and simulation. The simulation is based on historical records of patients presenting to the ED of Hospital USM in the year 2011. The result of the simulation shows that the implementation of re-triage in the conventional three-level triage system can significantly Reduce the waiting time of patients with deteriorating clinical conditions, with slight increase in the demand for ED service due to the re-triage activity.

A Conceptualisation of an Agent-Oriented Triage Decision Support System

Triage is a complex process in ED that necessitates accurate, consistent and timely decision for assessment and management of incoming patients. With triage officers having different levels of expertise and experience, the triage scales are applied inconsistently, as evident from the lack of uniformity in the existing triaging system in Malaysian hospitals. In many hospitals, the triaging largely occurs in an ad hoc basis, placing patients at risk and contributing to inefficient resource utilisation. A computer system can be used to overcome these problems. Consequently, the paper proposes the development of a knowledge-based, agent-oriented decision support system for triage assessment and management. The ability to implement goal-directed behaviour, communicative processes and schedule-oriented, but concurrently executed tasks among others, make the agent technology suitable to be applied. We intend to adopt a modelling view to knowledge engineering, and plan to use the CommonKADS methodology as a basis for knowledge engineering, modelling and knowledge base development.

Melioidosis: a rare cause of anterior chest wall abscess

Melioidosis is an unusual tropical infectious disease caused by the gram-negative bacterium Burkholderia pseudomallei, which was formerly known as Pseudomonas pseudomallei. Melioidosis is characterized by abscess formation and it may manifest in any part of the human body, however, musculoskeletel melioidosis is uncommon and chest wall melioidosis is very rare. To determine the exact organism based solely on clinical presentation poses a great challenge to the physician. Yet, delay administration of antibiotic may be harmful. We describe a diabetic patient who had anterior chest wall melioidosis that mimics Staphylococcus aureus infection. A description of his presentation and management, along with a review of literature is presented.

Ultrasonographic assessment of inferior vena cava/abdominal aorta diameter index: a new approach of assessing hypovolemic shock class 1.

BackgroundWe designed this study to expand the usage of ultrasound to detect early occurrence of hypovolemia. We explore the potential use of inferior vena cava (IVC) and abdominal aorta (AA) diameter index (IVC:AA) measured ultrasonographically to detect class 1 hypovolemic shock with blood loss less than 15%.ᅟMethodsThe aim of this study was to determine the changes in the diameter of inferior vena cava and abdominal aorta in blood donors by using ultrasound, pre and post blood donation. The result of the study would be further explorated to determine the inferior vena cava (IVC) abdominal aorta (Aorta) diameter index (IVC:Aorta). This was a prospective study done in the blood bank of a university hospital. Researcher was trained by a senior radiologist to assess inferior vena cava and abdominal aorta diameter. Fifty-two healthy blood donors were included in the study. Inclusion criteria were same with the blood bank criteria to donate blood. Demographic data and vital signs were taken before the ultrasound measurement done for inferior vena cava and abdominal aorta diameter. Once the volunteers donated their blood of approximately 450 mls; the measurements were repeated using the same methods.ResultsThere were differences in IVC, abdominal aorta and inferior vena cava:aorta diameters index pre and post donation. With mathematical analysis, we suggested the number of IVC:Aorta index as 1.14±2SD with SD 0.18 as a cut off value for class 1 hypovolemic shock.ConclusionThe IVC:Aorta diameter index can be used as a parameter for detecting early phase (Class 1) of hypovolemic shock.

Task-Based Modelling of the Triage Domain Knowledge

Triage is a decision-making process that classifies incoming patients for presentational urgency in Emergency Departments (EDs). There are issues with triage reliability in EDs, which we can be resolved through uniform application of a robust triage scale. However, the complex robust triaging knowledge is not easy to understand or recalled for timely decision-making. Therefore, we suggest the development of a knowledge-based triage decision support system to help triage officers to make correct and consistent triage decisions. Consequently, we pursued knowledge engineering to construct the models of the knowledge in order to make explicit the conceptualisation of the assumptions and constraints in triage decision-making. We regard task as a rationale basis for modelling the purposive domain knowledge. Consequently, the paper discusses the modelling of the domain knowledge to support the triage decision-making task. The triage decision-making task model is presented in a complementary paper. Together, the knowledge models can be viewed as meta models that provide the conceptual guiding principles for the consequent design of the triage decision support system.

Using modified early warning score to predict need of lifesaving intervention in adult non-trauma patients in a tertiary state hospital:

Background: Modified early warning score has been validated in many uses in the emergency department. We propose that the modified early warning score performs well in predicting the need of lifesaving interventions in the emergency department, as a predictor of patients who are critically ill. Objective: The study aims to evaluate the use of modified early warning score in sorting out critically ill patients in the emergency department. Methods: The patients’ demographic data and first vital signs (blood pressure, heart rate, temperature, respiratory rate, and level of consciousness) were collected prospectively. Individual modified early warning score was calculated. The outcome was a patient received one or more lifesaving interventions toward the end of stay in emergency department. Multivariate logistic regression analysis was utilized to assess the association between modified early warning score and other potential predictors with outcome. Results: There are a total of 259 patients enrolled into the study. The optimal modified early warning score in predicting lifesaving intervention was ≥4 with a sensitivity of 95% and specificity of 81%. Modified early warning score ≥4 (odds ratio = 96.97, 95% confidence interval = 11.82–795.23, p < 0.001) was found to significantly increase the risk of receiving lifesaving intervention in the emergency department. Conclusion: Modified early warning score is found to be a good predictor for patients in need of lifesaving intervention in the emergency department.

A Conceptualisation of a Strategy to Shiftwork Scheduling Optimisation in an Emergency Department

Shiftwork schedule is required to provide uninterrupted service for the hospital emergency department. There are many limitations with the manual shiftwork scheduling applied at the University of Malaya Medical Centre Emergency Department (UMMC-ED). We propose an alternative shiftwork scheduling strategy to solve these limitations which consists of three modes; Initialization, Sufficient and Insufficient mode. These modes detect the imbalance between workforce and workload which enable the appropriate distribution according to the demands of individual staff. We developed a tool, Trauma Hospital Online Roster (THOR) that implements the above strategy.

Domain Expert Maintainable Inference Knowledge of Assessment Task

Inference and domain knowledge are the foundation of a Knowledge-based System (KBS). Inference knowledge describes the steps or rules used to perform a task inference; making reference to the domain knowledge that is used. The inference knowledge is typically acquired from the domain experts and communicated to the system developers to be implemented in a KBS. The explicit representation of inference knowledge eases the maintenance of the evolving knowledge. However, the involvements of the knowledge engineers and software developers during the maintenance phase give cause to several problems during the systems life-cycle. In this paper, we provide a possible way of using rule templates to abstract away the inference knowledge to higher conceptual categories that are amenable to domain experts. Backed by a rule editing user-interface that is designed to instantiate the rule templates, the responsibility to maintain the inference knowledge can be assigned to the domain experts, i.e., the originators of the knowledge. The paper demonstrates the feasibility of the idea by making a case of inference knowledge applied to assessment task such as triage decision making. Five rule templates to represent the inference knowledge of assessment tasks are proposed. We validated the rule templates through case studies in several domains and task, as well as through usability testing.