Tsung-Ying Lin

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study

BackgroundTo evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting.MethodsA pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression.ResultsStructured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis.ConclusionsSignificant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.

Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration

BACKGROUND It is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans. METHODS In this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex. RESULTS In patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P < .001), and alanine aminotransferase (ALT) (P < .001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm(3), we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims. CONCLUSION In patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

Neck collar used in treatment of victims of urban motorcycle accidents: over- or underprotection?

BACKGROUND Cervical collar brace protection of the cervical spine at the scene of the incident is the first priority for emergency medical technicians treating patients who have sustained trauma. However, there is still controversy between over- or underprotection. The objective of this study was to survey the cervical spine injury of lightweight motorcycle accident victims and further evaluate the neck collar protection policy. MATERIALS AND METHODS We retrospectively reviewed patients who sustained lightweight motorcycle injuries, assumed to have been at a low velocity, with incidence of cervical spine damage, from a single medical centers trauma registration from 2008 to 2009. Patients were divided into 2 groups: those who were immobilized by cervical collar brace and those who were not. RESULTS Of the 8633 motorcycle crash victims, 63 patients had cervical spine injury. The average of the injury severity score in these patients was 14.31 ± 8.25. There was no significant correlation of cervical spine injury between the patients who had had the neck collar applied and those who had not (χ(2), P = .896). The length of stay in intensive care unit was longer in the patients who had the neck collar applied, but the total hospital length of stay was not statistically different to the patients who did not have the neck collar applied. CONCLUSION The incidence of cervical spinal injuries in the urban area lightweight motorcyclists is very low. Prehospital protocol for application of a cervical collar brace to people who have sustained a lightweight motorcycle accident in the urban area should be revised to avoid unnecessary restraint and possible complications.

How early should VATS be performed for retained haemothorax in blunt chest trauma

BACKGROUND Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood. MATERIALS AND METHODS In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2-3 days (Group 1), 4-6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups. RESULTS The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference. DISCUSSION This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.

ASSOCIATION OF HEAD, THORACIC AND ABDOMINAL TRAUMA WITH DELAYED DIAGNOSIS OF CO-EXISTING INJURIES IN CRITICAL TRAUMA PATIENTS

BACKGROUND Management of critically injured patients is usually complicated and challenging. A structured team approach with comprehensive survey is warranted. However, delayed diagnosis of co-existing injuries that are less severe or occult might still occur, despite a standard thorough approach coupled with advances in image intervention. Clinicians are easily distracted or occupied by the more obvious or threatening conditions. We hypothesised that the major area of injured body regions might contribute to this unwanted condition. METHODS A retrospective study of all trauma patients admitted to our surgical intensive care units (ICU) was performed to survey the incidence of delayed diagnosis of injury (DDI) and the association between main body region injured and possibility of DDI. Demographic data and main body regions injured were compared and statistically analysed between patients with and without DDI. RESULTS During the two-year study period, a total 976 trauma patients admitted to our surgical ICU were included in this study. The incidence of DDI was 12.1% (118/976). Patients with DDI had higher percentages of thoracic, abdominal, and pelvic injuries (30.5%, 16.1%, and 7.6% respectively) than the non-DDI group (14.7%, 7.5%, and 3.0% respectively) (p<0.001, 0.003, and 0.024 respectively). A logistic regression model demonstrated that head (odds ratio=1.99; 95%CI=1.20-3.31), thoracic (odds ratio=2.44; 95%CI=1.55-3.86), and abdominal injuries (odds ratio=2.38; 95%CI=1.28-4.42) were independently associated with increasing DDI in patients admitted to the surgical ICU. DISCUSSION In conclusion, critical trauma patients admitted to the surgical ICU with these categories of injuries were more likely to have DDI. Clinicians should pay more attention to patients admitted due to injuries in these regions. More detailed and dedicated secondary and tertiary surveys should be given, with more frequent and careful re-evaluation.

The Effect of Alcohol Intoxication on Mortality of Blunt Head Injury

Alcohol is found to have neuroprotection in recent studies in head injuries. We investigated the association of blood alcohol concentration (BAC) with mortality of patients with blunt head injury after traffic accident. All patients sustaining blunt head injury caused by traffic accident brought to our emergency department who had obtained a brain computed tomography scans and BAC were analyzed. Patients with unknown mechanisms, transfers from outside hospitals, and incomplete data were excluded. Logistic regression was used to identify independent predictors of mortality. During the study period, 3,628 patients with brain computed tomography (CT) were included. Of these, BAC was measured in 556 patients. Patients with the lowest BAC (less than 8 mg/dl) had lower mortality; intoxicated patients with BAC between 8 and less than 100 mg/dl were associated with significantly higher mortality than those patients in other intoxicated groups. Adjusted logistic regression demonstrated higher BAC group and Glasgow coma scale (GCS) scores, and lower ISS and age were identified as independent predictors of reduced mortality. In our study, we found that patients who had moderate alcohol intoxication had higher risk of mortality. However, higher GCS scores, lower ISS, and younger age were identified as independent predictors of reduced mortality in the study patients.

More Becomes Less: Management Strategy Has Definitely Changed over the Past Decade of Splenic Injury—A Nationwide Population-Based Study

Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X 2, P = 0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, P < 0.001, CI 1.017–1.049), with or without CT obtained (OR 0.347, P = 0.026, CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346, P = 0.043, CI 1.010–1.842). Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality.

Incidence, National Trend, and Outcome of Nontraumatic Subarachnoid Haemorrhage in Taiwan: Initial Lower Mortality, Poor Long-Term Outcome

To investigate the longitudinal trend of nontraumatic subarachnoid haemorrhage (SAH), we analyzed the annual population-based incidence and mortality rate of nontraumatic subarachnoid hemorrhage in Taiwan. Logistic regression was used to identify independent predictors of mortality. The average incidence rate (IR) of nontraumatic SAH was 6.25 ± 0.88 per 100,000 per year. The prevalence of female patients was higher than in the male population (54.5% versus 45.5%). The average age of these patients was 55.78 ± 17.09 and females were older than males (58.50 ± 15.9 versus 52.45 ± 18.50, P < 0.001). Of these patients, 97.6% (611/626) were treated with surgical intervention with clipping procedure and 2.9% (18/626) with coiling. Total mortality of these patients was 13.4% (84/626). In adjusted analysis, age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.98-0.98; P < 0.001) and Charlson comorbidity index (OR, 0.709; 95% CI, 0.57–0.88; P = 0.002) remained independent predictors of the mortality. Patients with nontraumatic SAH had a much higher prevalence in older age groups and in females than in the general population. Patients with old age and more comorbidity have higher mortality. Aggressive management of patients might reduce the initial mortality; however, patient outcome still remains poor.

Low-dose ketamine for analgesia in the ED: a retrospective case series

Laeben et al reported a study about low-dose ketamine for analgesia in the emergency department (ED) [1]. However, there was concern about the patient group in this study which may interfere with their conclusionwhen applied to the general population. Twenty-eight (80%) of the 35 studied cases had the record of chronic pain medication use or illicit drug abuse. As far as our ED is concerned, patients with these records represent a very different issue of analgesia from that of ordinary people. Tolerance or dependence of opioids or opioidlike agents was frequently seen in these patients, which make them become a “drug seeker” in the ED, and thus, analgesia or so-called improvement of pain for them is more complicated. When doing our study, we tried to analyze the characteristics and behaviors of patients with such records. The strategy for painmanagement for them is also different. As a matter of fact, the magnitude of pain or whether it is improved after medication is totally subjective. Being a drug seeker or not, they might really experience vigorous pain when appearing at the ED, although they were seeking opioids or opioid-like agents most of the time. Usually, a nonsteroidal antiinflammatory drug, such as ketoprofen for most cases, will be given at first. If no improvement or worsening of the pain was complained of, then suspicion of drug seeking would be raised. Patients might sometimes even ask for opioids or name the drug penthidine (Demerol), which is uncommon in a nonEnglish country, thereby identifying themselves as drug seekers. For patients with drug-seeking records, use of opioids or opioid-like agents may be restricted or even prohibited by the drug administrative committee of our hospital after official discussion. Therefore, they might ask for other alternatives for temporary relief. We have one case that used to dislocate his hip joint just to receive heavy sedation during close reduction after he was on the list. Besides the high incidence of chronic pain medication use or illicit drug abuse, opioids were used in all the cases, which makes the result more unreliable. Opioids were administered before or with ketamine in 32 (91%) of 35 cases, and the remaining 3 patients were on long-acting opioids or had used heroin near their visit. Under such conditions, it is very difficult to tell whether the improvement of pain could be attributed to the low-dose ketamine, or if those reporting no improvement were asking for more medication. The authors did not describe the detail of the “additional pain medication” given to patients with insufficient pain improvement in the text, but it showed they are morphine and Dilaudid, a morphine derivative, in 6 cases according to Table 1. The unusually high-dose and multiple injections of morphine in case 23 with abscess indicated that its usage is very probably nothing to do with pain, especially when no level of pain before or after ketamine was recorded. Although pain is often overlooked or undertreated in the ED, as mentioned by the authors, the reason for pain control in this study is also confusing. Apart from the 3 cases of fracture, abscess composed 46% of the single chief complaint, which seldom needs pain control nomatter whether incision and drainage were done, and its coexistence with heroin use makes the indication of opioids and ketamine for analgesia more unclear. Other cases with cellulitis, a condition seldom needing pain control other than oral nonsteroidal antiinflammatory drugs, make their complaints of pain even more unreliable. Opioids, together with low-dose ketamine in this study truly for analgesia or just for drug addiction relief, deserve further discussion. Although the authors declared that this was the first description of low-dose ketamine for analgesia in the ED and carefully limited their conclusion to patients with high narcotic tolerance, either the patients characteristics or the unexceptional appearance of opioid use makes the true effect of analgesia and the role of ketamine in this study questionable.

Early predictors of narcotics-dependent patients in the emergency department.

It is not unusual that narcotics‐dependent patients fulfill their medical requirements in the emergency department (ED). The behavior of these patients varies, and their manifestations and predictors are still not fully studied. We performed this retrospective study by prospectively collecting data on patients with suspected drug dependence who were undiagnosed at first and then treated for some kind of reported pain at the ED. Patients who were confirmed to have narcotics dependence were compared with control patients in a ratio of 1:3 matching for age, gender, disease, and clinical diagnoses. From January 2006 to October 2009, 26 of 223 patients treated for pain were found to be drug dependent (12 males and 14 females). The average dose of narcotics used was higher than the control group [3.23 ± 1.14 vs. 1.12 ± 0.36, p < 0.001, confidence interval (CI): 1.648–2.583]. Numbers of patients making unscheduled returns to the ED within 24 hours were significant [24/26 vs. 8/78, p ≤ 0.001, odds ratio (OR) 105.00, 95% CI 20.834–529.175]. In addition, patients showing aggressive attitudes were significant (17/26 vs. 2/78, p < 0.001, OR 71.78, 95% CI 14.206–362.663). In the case group, six of them told the physician that they were allergic to medicines other than the particular one they wanted, and three of the six presented injuries that were reported to be in the same (or repeated) place for unscheduled returns, which were not found in the control group. In this study, some behaviors were commonly observed in the at‐risk group. These patients were prone to manifest some types of symptoms and behaviors, such as uncontrolled pain with three doses of analgesics, aggressive attitude, returning to the ED within 24 hours with the complaint of the same severe pain, repeating the same injury, claiming allergy to other analgesics, and asking for certain analgesics. All these behaviors should alert the physician to suspect a drug‐seeking problem.