Yuan-Chia Cheng

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.

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.

Management of motorcycle accident-related blunt hepatic injury-a different strategy.

BACKGROUND In motorcycle accidents, especially in an urban area with lightweight motorcycles, the belly of the motorcyclist is not protected, and this makes this type of trauma a cause of blunt hepatic injuries. This study investigated the effect and safety of using nonoperative management and selective early angioembolization to treat patients with blunt liver injuries as a result of motorcycle accident. METHODS This was a retrospective study of the hepatic injuries sustained by motorcyclists involved in traffic accidents. We collected patient demographic information, the severity of total injuries, grade of liver injury, associated concomitant injuries, management scheme, and outcome of patients from 2006 to 2007. These patients were treated nonoperatively with selective early angioembolization and close monitoring in our intensive care unit (ICU). RESULTS We reviewed the cases of 266 patients sustaining blunt abdominal injuries. Thirty-four patients (12.78%) had hepatic injuries. All survived with no obvious morbidity, and no further invasive procedures were performed after admission to ICU. There was no significant association between grade of injury and ICU length of stay (P = .073), but there was a significant association between grade and in-patient length of stay on our regular ward (P = .001). CONCLUSION Most patients with hepatic injury caused by motorcycle accidents can be treated safely by nonoperative management. Early selective angioembolization improved the success of nonoperative management of blunt liver injury without other surgical intervention. Routine follow-up with computed axial tomography scans and endoscopic retrograde cholangiopancreatography may not be necessary because complications associated with hepatic injuries were rare.

Neck hyperflexion causing isolated thyroid cartilage fracture--a case report

Isolated thyroid cartilage fracture is very rare, and most cartilage fractures are caused by direct impact to the laryngotracheal complex of the neck. Isolated thyroid cartilage fracture caused by hyperflexion of the neck has not been reported before. We present a case where an unrestrained front seat car passenger struck his forehead on the windshield during a motor vehicle accident. Direct impact of his forehead with sudden and forceful flexion of his neck caused isolated thyroid cartilage fracture without direct impact to the neck. Therefore, injury to the thyroid cartilage should be kept in the list of detailed evaluation with high index of suspicion in patients presenting with trauma mechanism possibly causing neck hyperflexion, even without signs of direct neck trauma.

Surgeon commitment to trauma care decreases missed injuries.

STUDY OBJECTIVE Missed injuries sustain an important issue concerning patient safety and quality of care. The purpose of this study is to examine the effect of surgeon commitment to trauma care on missed injuries. We hypothesised that surgeons committed to the trauma service has less missed injuries than surgeons not committed to the trauma service would have. METHODS By retrospective analysis of 976 adult patients admitted to the trauma intensive care unit (ICU) at an urban, university-based trauma centre. Missed injuries were compared between two groups; in group 1 the patients were evaluated and treated by the surgeons who were committed to the trauma service and in group 2 the patients were evaluated and treated by surgeons practicing mainly in other specialties. RESULTS Patients had significantly lower rates of missed major or life-threatening injuries when treated by group 1 surgeons. Logistic regression model revealed significant factors associated with missed major or life-threatening injuries including ISS and groups in which patients were treated by different group surgeons. CONCLUSIONS Physicians will perform better when they are trained and interested in a specific area than those not trained, or even not having any particular interest in that specific area. Surgeons committed to the trauma service had less missed injuries in severely injured patients, and it is vital to improve patient safety and quality of care for trauma patients. Staff training and education for assessing severely injured patients and creating an open culture with detection and reduction of the potential for error are important and effective strategies in decreasing missed injuries and improving patient safety.

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.

Relationship Between Blood Alcohol Concentration and Hepatic Enzymes in an Emergency Department

Abstract Objective Hepatic enzymes can be used as a predictor of hepatic injury. The present study investigated the relationship between blood alcohol concentration (BAC) and hepatic enzymes in patients intoxicated with ethanol at an emergency department (ED). Materials and Methods To determine whether BAC is an independent predictor of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, we retrospectively reviewed the medical data for patients who were intoxicated and whose BAC and hepatic enzyme levels were measured. Patients who had hepatitis caused by viruses or traumatic hepatic injury, as well as patients with a normal BAC, were excluded. Results Of the 1432 patients, 298 were female and 1134 were male. The average age of males was 41.4 ± 11.7 years and that of females was 35.6 ± 11.8 years. Mean serum AST and ALT levels were 78 ± 88 IU/L and 51 ± 67 IU/L in males, while those in females were 63 ± 110 IU/L and 40 ± 83 IU/L, respectively. Mean BACs were 199.6 ± 99.0 mg/dL for males and 175.1 ± 101.1 mg/dL for females. Log BAC had a high positive correlation with log ALT ( r = 0.208; p r = 0.086; p = 0.001) when BAC was above 50 mg/dL (0.05%). Multivariate linear regression showed that BAC was an independent predictor of AST and ALT ( r 2 = 0.057 and 0.056, respectively). Conclusion The high correlation of BAC with serum AST and ALT levels in patients intoxicated with ethanol when their BAC was above 50 mg/dL can be used to predict serum AST and ALT levels. However, a high BAC only appears to be associated with a slight elevation in hepatic enzymes. Therefore, in patients with acute alcohol intoxication at the ED, an elevation in AST and ALT levels should be considered as a result of hepatic injury rather than an effect of alcohol.

Retrosternal Hemomediastinum Caused by Internal Mammary Artery Injury: A Case Report and Review of the Literature

We describe a 35-year-old multi-trauma patient who had a high-grade liter laceration with extensive retrosternal hemomediastinum. Extra pericardial tamponade secondary to the fracture of the stern um was followed by the instantaneous surgical evacuation of the hematoma. Computed tomography (CT) angiography helped diagnose this uncommon entity of blunt trauma-induced internal mammary artery bleeding. Despite a large amount of blood accumulation in the retrosternal space after a period of rime, it may have been misdiagnosed as pericardiac hemorrhage before operation due to its rarity and the physicians lack of experience for this kind of problem. To prevent such disastrous injuries from being unnoticed and thus unattended, consideration should be given to possible injuries to the internal mammary artery and early detection using CT of the anterior mediastinal hematoma that is associated with a frature of the sternum is important. This can also avoid misdiagnosis and ensure prompt surgical or angiographic intervention.