Wen-Huei Lee

Determining delayed admission to the intensive care unit for mechanically ventilated patients in the emergency department

IntroductionThe adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission vary across studies. This study proposed a model to define `delayed admission’, and explored the effect of ICU waiting time on patients’ outcome.MethodsThis retrospective cohort study included nontraumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cutoff point between `delayed’ and `non-delayed’ subsets from the overall data were made based on ICU waiting time and the hazard ratio of ICU waiting hour in each subset was iteratively calculated. The cutoff time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay.ResultsThe final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU waiting time in the ED of >4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21-ventilator-day mortality and prolonged hospital stay, with an odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively.ConclusionsFor patients on mechanical ventilation in the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

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.

Delayed diagnosis of active pulmonary tuberculosis in emergency department

BACKGROUND AND PURPOSE Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED. METHODS We used a retrospective chart review. PATIENTS A total of 103 patients were enrolled between December 2003 and March 2006. RESULTS Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis. CONCLUSION Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Adverse event and error of unexpected life-threatening events within 24 hours of ED admission

Objectives: Errors and adverse events associated with unexpected life‐threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life‐threatening events as a trigger to capture errors and adverse events for ED patient safety. Methods: This prospective observational study enrolled adult non‐trauma patients with unexpected life‐threatening events within 24 h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated. Results: Of 33,224 adult non‐trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%). Conclusions: Unexpected life‐threatening events within 24 h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED.

Analysis of closed malpractice medical claims against Taiwanese EDs: 2003 to 2012.

OBJECTIVES The objective of the study is to examine the epidemiologic data of closed malpractice medical claims against emergency departments (EDs) in Taiwanese civil courts and to identify high-risk diseases. METHODS We conducted a retrospective study and reviewed the verdicts from the national database of the Taiwan judicial system that pertained to EDs. Between 2003 and 2012, a total of 63 closed medical claims were included. RESULTS Seven cases (11.1%) resulted in an indemnity payment, 55.6% of the cases were closed in the district court, but appeals were made to the supreme court in 12 cases (19.1%). The mean incident-to-litigation closure time was 57.7 ± 26.8 months. Of the cases with indemnity paid, 5 cases (71.4%) were deceased, and 2 cases (28.6%) were gravely injured. All cases with indemnity paid were determined to be negligent by a medical appraisal. The gravely injured patients had more indemnity paid than deceased patients (

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician

299800 ± 37000 vs

Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department

68700 ± 29300). The most common medical conditions involved were infectious diseases (27.0%), central nervous system bleeding (15.9%), and trauma cases (12.7%). It was also found that 71.4% of the allegations forming the basis of the lawsuit were diagnosis related. CONCLUSIONS Emergency physicians (EPs) in Taiwan have similar medico-legal risk as American EPs, with an annual risk of being sued of 0.63%. Almost 90% of EPs win their cases but spend 58 months in litigation, and the mean indemnity payment was

72-Hour Revisit, Hospitalization, and Operations Performed among Patients Originally Discharged from the Emergency Department

134738. Cases with indemnity paid were mostly categorized as having diagnosis errors, with the leading cause of error as failure to order an appropriate diagnostic test.