Yuan-Jhen Syue

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy.

AbstractThe ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ⩽5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ⩽10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

Seniority of Emergency Physician, Patient Disposition and Outcome Following Disposition

Objectives: The relationship between the seniority of emergency physicians (EPs) and disposition decision‐making is not well defined. As most responsibility by EPs involves developing an appropriate disposition plan, this study aimed to examine the influence of EP seniority on decisions regarding patient dispositions in the emergency department (ED). Materials and Methods: This retrospective, 1‐year, cohort study was conducted in 3 EDs including all day‐shift nontraumatic adult patients. The outcome involves patient dispositions at the end of the shift, patient final dispositions and patient 72‐hour ED return. The EPs were categorized into the following 3 groups according to seniority: junior group (≤5 years of work experience), intermediate group (6‐10 years) and senior group (>10 years). Results: The dispositions of 68,333 ED patients as determined by the 59 full‐time EPs were studied. Compared to junior and intermediate EPs, senior EPs kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they had the lowest patient mortality rate especially in first triage patients (3.4% fewer than junior EP, 1.3% fewer than intermediate EP); they took more time for patient discharge (0.2 more hours than junior EP, 0.1 more hours than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP). Conclusions: Senior EPs had the best quality of care (lowest mortality, fewest 72‐hour returns). This best quality of care is accompanied with a slightly longer length of stay.

The Prognosis of Cardiac Origin and Noncardiac Origin in-Hospital Cardiac Arrest Occurring during Night Shifts

Background. The survival rates of in-hospital cardiac arrests (IHCAs) are reportedly low at night, but the difference between the survival rates of cardiac origin and noncardiac origin IHCAs occurring at night remains unclear. Methods. Outcomes of IHCAs during different shifts (night, day, and evening) were compared and stratified according to the etiology (cardiac and noncardiac origin). Result. The rate of return of spontaneous circulation (ROSC) was 24.7% lower for cardiac origin IHCA and 19.4% lower for noncardiac origin IHCA in the night shift than in the other shifts. The survival rate was 8.4% lower for cardiac origin IHCA occurring during the night shift, but there was no difference for noncardiac origin IHCA. After adjusting the potential confounders, chances of ROSC (aOR: 0.3, CI: 0.15–0.63) and survival to discharge (aOR: 0.1; CI: 0.01–0.90) related to cardiac origin IHCA were lower during night shifts. Regarding noncardiac origin IHCA, chances of ROSC (aOR: 0.5, CI: 0.30–0.78) were lower in the night shift, but chances of survival to discharge (aOR: 1.3, CI: 0.43–3.69) were similar in these two groups. Conclusion. IHCA occurring at night increases mortality, and this is more apparent for cardiac origin IHCAs than for noncardiac origin IHCA.

Impact of Different Serum Potassium Levels on Postresuscitation Heart Function and Hemodynamics in Patients with Nontraumatic Out-of-Hospital Cardiac Arrest

Background Sustained return of spontaneous circulation (ROSC) can be initially established in patients with out-of-hospital cardiac arrest (OHCA); however, the early postresuscitation hemodynamics can still be impaired by high levels of serum potassium (hyperkalemia). The impact of different potassium levels on early postresuscitation heart function has remained unclear. We aim to analyze the relationship between different levels of serum potassium and postresuscitation heart function during the early postresuscitation period (the first hour after achieving sustained ROSC). Methods Information on 479 nontraumatic OHCA patients with sustained ROSC was retrospectively obtained. Measures of early postresuscitation heart function (rate, blood pressure, and rhythm), hemodynamics (urine output and blood pH), and the duration of survival were analyzed in the case of different serum potassium levels (low: <3.5; normal: 3.5–5; high: >5 mmol/L). Results Most patients (59.9%, n = 287) had previously presented with high levels of potassium. Bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis (pH < 7.35) were more common in patients with high levels of potassium (all p < 0.05). Compared with hyperkalemia, a normal potassium level was more likely to be associated with a normal heart rate (OR: 2.97, 95% CI: 1.74–5.08) and sinus rhythm (OR: 2.28, 95% CI: 1.45–3.58). A low level of potassium was more likely to be associated with tachycardia (OR: 3.54, 95% CI: 1.32–9.51), urine output >1 ml/kg/hr (OR: 5.35, 95% CI: 2.58–11.10), and nonacidosis (blood pH >7.35, OR: 7.74, 95% CI: 3.78–15.58). The duration of survival was shorter in patients with hyperkalemia than that in patients whose potassium levels were low or normal (p < 0.05). Conclusion Early postresuscitation heart function and hemodynamics were associated with the serum potassium level. A high potassium level was more likely to be associated with bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis. More importantly, a high potassium level decreased the duration of survival.

Comparison of Clinical Practice in the Emergency Department: Female versus Male Emergency Physicians

Background: There are fewer female emergency physicians (EPs) than male ones. This study attempted to analyze the differences in clinical practice between female and male EPs in the emergency department (ED). Materials and Methods: A retrospective, 1‐year cohort study was conducted across 4 EDs in the largest healthcare system in Taiwan. A total of 199,757 adult patients without trauma treated by 76 EPs (9 females and 67 males) were included in the study. The clinical practice of female and male EPs was compared. The door‐to‐order and door‐to‐disposition times were used to evaluate EP efficiency. Indicators of diagnostic tool use included laboratory examinations and computed tomography scans. Patient dispositions included discharge, ED observation, general ward and intensive care unit admissions and ED mortality rate. Disposition accuracy was evaluated by determining the 72‐hour ED revisit rate. Results: The clinical practice of female and male EPs was similar. After adjusting for the potential confounding factors through a regression model, female EPs showed slight increase in laboratory examination use (adjusted odds ratio = 1.05; 95% CI: 1.01‐1.09) compared with male EPs, but no difference in computed tomography use was observed between sexes. Additionally, no differences among patient dispositions and 72‐hour ED revisit rates (adjusted odds ratio = 1.0; 95% CI: 0.93‐1.06) were observed between female and male EPs. Conclusions: Female and male EPs had similar clinical efficiency on patient evaluation, and they had no difference in diagnostic tool use. Furthermore, they showed similar patient disposition with the same accuracy.

Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

Background Emergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. Materials and methods A retrospective, 1‐year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non‐trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non‐urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. Result Patients discharged from ED had 0.4 h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83–0.96) compared with the merged model. Conclusion The separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest.

AbstractThe postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003–2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15–30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.

Acute Ischemia Hepatitis as a Major Clinical Presentation of the Primary Cardiac Lymphoma

Primary cardiac lymphoma is extremely rare and antemortem diagnosis is difficult. Although this malignancy is not uncommonly reported, most patients in the literature typically presented with cardiac signs and symptoms. We described a 21-year-old man who presented initially with ischemic hepatitis but was finally diagnosed as having the tumor. Literature search from 1997 to 2009 revealed 27 cases of the tumor of which the clinical presentations were reviewed.