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BackgroundCommunity-acquired pneumonia (CAP) poses a significant health threat to the elderly population, leading to high morbidity and mortality rates. Serum ferritin, a critical indicator of iron metabolism, plays a pivotal role in inflammation and immune regulation. Nevertheless, its specific prognostic relevance in elderly patients with CAP remains unclear. This study aimed to evaluate the predictive capacity of serum ferritin in determining the prognosis of elderly patients with CAP and to investigate its effectiveness when combined with the sequential organ failure assessment (SOFA) or CURB-65 (confusion, uremia, respiratory rate, blood pressure, aged ≥65 years) scores.MethodsThis retrospective cohort study included 451 elderly patients (aged ≥65 years) diagnosed with CAP according to established criteria. Serum ferritin concentrations were measured upon admission and various prognostic indicators such as 28-day mortality, mechanical ventilation requirement, and vasopressor administration were analyzed in conjunction with white blood count (WBC), C-reactive protein (CRP), procalcitonin (PCT), lactate (Lac), SOFA scores, and CURB-65 scores. The independent predictive value of ferritin was assessed through receiver operating characteristic (ROC) curve analysis and multivariate logistic regression.ResultsAmong the 451 patients, 99 (22%) died within 28 days. The area under the curve (AUC) of serum ferritin for predicting 28-day mortality was 0.75 (95%CI: 0.695-0.805). Ferritin outperformed WBC, CRP, and PCT in predictive performance, and its performance was comparable to Lac. When combined with SOFA or CURB-65 scores, the AUC of ferritin for predicting 28-day mortality increased to 0.84 and 0.847, respectively (P

ABSTRACTIntroduction Poisoning is a major public health issue and a leading cause of admission to the emergency department (ED). There is a paucity of data describing the epidemiology and cost of acute poisoning. Therefore, this study investigated the epidemiology, patterns, and associated costs of acute poisoning in emergency department of the largest tertiary care healthcare centre in Qatar.Method This study was a retrospective review of the health records of patients admitted to the ED due to poisoning between January 2015 and December 2019. Incidence, clinical characteristics, and costs associated with acute poisoning were assessed. Frequency and percentages were calculated for categorical variables and mean and SD for continuous variables. The relationship between sociodemographic characteristics and poisoning profile was assessed using the chi-square test. A micro-costing approach using the cost of each resource was applied for cost calculations.Result The incidence of acute poisoning was 178 cases per 100,000 patients. Females (56%) and children below 14 years (44.3%) accounted for the largest proportion. Most of the exposures were accidental involving therapeutic agents (64.2%). The mean length of hospital stay was found to be 1.84 ± 0.81 days, and most patients (76.6%) were discharged within the first 8 h. A statistically significant difference was found between age groups and type of toxin (χ2 = 23.3, p < 0.001), cause and route of exposure (χ2 = 42.2, p < 0.001), and length of hospital stay (χ2 = 113.16, p < 0.001). Admission to intensive care units had the highest cost expenditure (USD 326,008), while general wards accounted for the least (USD 57,709).Conclusion Unintentional poisoning by pharmacological agents is common in infants and children. This study will assist in the development of educational and preventive programmes to minimise exposure to toxic agents. Further studies are required to explore the impact of medical toxicology services, and post discharge monitoring of poisoning.

Abstract Background Shortages of mechanical ventilation have become a constant problem in Emergency Departments (EDs), thereby affecting the timely deployment of medical interventions that counteract the severe health complications experienced during respiratory disease seasons. It is then necessary to count on agile and robust methodological approaches predicting the expected demand loads to EDs while supporting the timely allocation of ventilators. In this paper, we propose an integration of Artificial Intelligence (AI) and Discrete-event Simulation (DES) to design effective interventions ensuring the high availability of ventilators for patients needing these devices. Methods First, we applied Random Forest (RF) to estimate the mechanical ventilation probability of respiratory-affected patients entering the emergency wards. Second, we introduced the RF predictions into a DES model to diagnose the response of EDs in terms of mechanical ventilator availability. Lately, we pretested two different interventions suggested by decision-makers to address the scarcity of this resource. A case study in a European hospital group was used to validate the proposed methodology. Results The number of patients in the training cohort was 734, while the test group comprised 315. The sensitivity of the AI model was 93.08% (95% confidence interval, [88.46 − 96.26%]), whilst the specificity was 85.45% [77.45 − 91.45%]. On the other hand, the positive and negative predictive values were 91.62% (86.75 − 95.13%) and 87.85% (80.12 − 93.36%). Also, the Receiver Operator Characteristic (ROC) curve plot was 95.00% (89.25 − 100%). Finally, the median waiting time for mechanical ventilation was decreased by 17.48% after implementing a new resource capacity strategy. Conclusions Combining AI and DES helps healthcare decision-makers to elucidate interventions shortening the waiting times for mechanical ventilators in EDs during respiratory disease epidemics and pandemics.

The Emergency Department (ED) plays an important role in the healthcare field, due to the nature of the services it provides, especially for patients with urgent cases. Therefore, good management of ED is very important in improving the quality of services. Good management depends on the effective use of material and human resources. One of the most common problems that the ED suffers from is the long waiting period and the length of the patient’s stay. Many researchers have proposed many solutions to reduce waiting time and length of stay (LOS). One of the best solutions for resource optimization is modeling and simulation based on inputs such as patient length of stay and door-to-doctor time (DTDT). In this study, the ED was modeled using a Coloured Petri Net, and to determine the number of resources needed, genetic algorithms were used. This study was conducted in the ED of Hassani Abdelkader Hospital in Sidi Bel Abbes, and several simulation models were evaluated, which reduced the waiting time and the length of stay for the patient.

Introduction: A full-scale simulation exercise is a comprehensive drill designed to replicate a real-world emergency scenario, thereby identifying the strengths and weaknesses in current practices. The overarching goal is to enhance healthcare system resilience through improved protocols, as highlighted in this systematic review tailored for researchers. The study aims specifically to assess the impact of full-scale simulations on enhancing hospital disaster plans. Methodology: Following PRISMA guidelines, this systematic review investigates the impact of full-scale simulation exercises on hospital disaster preparedness. The focus was on hospital staff involved in disaster and emergency preparedness training. The primary intervention was the execution of full-scale simulation exercises, and our research included various study designs, including randomised controlled trials and observational study designs. A comprehensive electronic database search was conducted, spanning PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials, from inception until October 9, 2023. The risk of bias was assessed using NIH tools. Results: The literature search yielded 2398 results, with 28 publications finally included in the systematic review. Summarising a broad range of disaster preparedness simulation exercises with a specific focus on full-scale simulation (FSS), the studies consistently demonstrated a positive impact on participants' skills, as well as identifying safety issues in hospital settings. Moreover, they revealed that simulations effectively addressed crucial areas for improvement in disaster response, including communication breakdowns, equipment deficiencies, and flaws in emergency plans. The studies utilised a multidimensional approach to evaluation metrics, encompassing non-technical skills, communication, teamwork, decision-making, and operational readiness. The exercises varied in duration from 30 minutes to multi-day simulations, covering a diverse range of disaster scenarios, such as mass casualties, viral epidemics, large aviation accidents, and terrorist attacks. Conclusion: Full-scale simulation exercises are a preparatory learning tool to test facility and staff readiness for complex emergencies. This systematic review focused on the different exercise scenarios used to address critical aspects of disaster response such as communication breakdowns, equipment deficiencies, and flaws in emergency plans. The scenarios and their duration were varied, and involved a multidimensional approach to evaluation. Such exercises enhance critical thinking and problem-solving skills, increase familiarity with potential emergencies, and build confidence in making judgments in real-world situations. In our opinion, there is a need for further programs that align simulation exercises with community resources for better preparedness in the face of public health disasters.

Abstract Background People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. Methods This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. Results Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were

Purpose – Patient length of stay (LOS) is an important indicator of emergency department (ED) performance. Investigating factors that influence LOS could thus improve healthcare delivery and patient safety. Previous studies have focused on patient-level factors to explain LOS variation, with little research into service-related factors. This study examined the association between LOS and multi-level factors including patient-, service- and organization-level factors. Design/methodology/approach – This study uses a retrospective observational design to identify a cohort of patients from arrival to discharge from ED. A year-long data regarding patients flow trhoguh ED were analyzed using analytics techniques and multi-regression models. The response variable was patient LOS, and the independent variables were patient characteristics, service-related factors and organizational variables. Findings – The findings of this study showed that older patients, middle triage and hospitalization were all associated with longer LOS. Service-related factors such as complexity of care provided, initial ward designation and ward transfer had a significant impact as well. Finally, prolonged LOS was associated with a higher ratio of patients per medical doctor and per nurse. In contrast, a higher number of residents in the ED were associated with longer patient LOS. Originality/value – Previous studies on patient LOS have focused on patient-level factors, with little research on service-related factors. This study has addressed that gap by examining the association between LOS and multi-level factors including patient-, service- and organization-level factors. Patient-level factors included demographics, acuity, arrival shift, arrival mode and discharge type. Service-level factors consisted of first ward, ward transfer and complexity of care provided. Organizational factors consisted of three ratios: patients per MD, patients per nurse and patients per resident. The results add to the current understanding of factors that increase patient LOS in EDs and contribute to the body of knowledge on ED performance, operation management and quality of care. The study also provides practical and managerial insights that could be used to improve patient flow in EDs and reduce LOS.

Background: Hypoxia is a common presentation in the Emergency Department (ED) worldwide. It affects 9-12% of hospitalized adults in Sub-Saharan Africa. Timely diagnosis of the multiple causes such as pneumonia, heart failure among others is challenging. Chest X-Ray (CXR), one of the most utilized imaging modalities has many limitations, and the gold standard (Computed Tomography scan) is inaccessible. Point of care ultrasound (PoCUS) is more available and increasingly being used, however little is known of its performance in resource limited EDs. The study aimed to assess the diagnostic performance of PoCUS compared with CXR in identifying the causes of hypoxia in the medical ED. Methods: 49 adults presenting with hypoxia (SP02 ≤ 88%) in the medical ED were evaluated. Ultrasound of the lungs and heart (PoCUS) was done, then CXR obtained. Lung ultrasound (LUS) was compared with CXR (first reference standard). Chest X-Ray and PoCUS were each compared to the physician diagnosis (second reference standard) to determine agreement using an acceptable disagreement cut-off of 15%. Results: 31% more abnormalities were identified by LUS than CXR. Lung ultrasound findings agreed with CXR in 86% of the participants with moderate reliability (ĸ=0.75). There was no significant difference between the actual findings of the two tests (X2= 2, p 0.1). Using the second reference, 82% of the CXRs were similar with weak reliability (ĸ=0.5) compared to 98% of PoCUS findings with strong reliability (ĸ=0.9). Compared to PoCUS, CXRs significantly differed from the physician diagnosis (X2= 0.85, p 0.38 vs X2= 8.5, p 0.004 respectively). Conclusion: Overall, PoCUS was not inferior to CXR when compared to final physician diagnosis in identifying causes of hypoxia, and LUS and CXR had comparable performance. Significantly more abnormalities were identified on PoCUS and it demonstrated better agreement and strong reliability with the physician diagnosis than CXR. We recommend PoCUS use in patients with hypoxia attending resource limited in- and pre-hospital settings.

Abstract Background Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children’s healthcare needs. Methods This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children’s hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child’s health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above. Results Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child. Conclusions This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

Background: Drug abuse is a public health problem in any country and road safety in particular as it poses serious consequences while driving, affecting the safety of all road users. This study aimed to investigate the drug prevalence and alcohol abuse among motor vehicle crash (MVC) survivors. Methods: This descriptive study was based on a review of the retrospective chart involving patients that were admitted to the Emergency Department (ED) of a level-I trauma center in Riyadh following an MVC. Injured patients in 2018 were identified from the electronic medical record system, and substance investigation was documented. After the hospital discharge, the research team contacted patients via phone to obtain further details about the nature of the crash and illegal substance use. Results: During the study, 209 patients were admitted to the ED following MVCs. The population was primarily males (84.7%) with an average age of 30 years. Forty subjects (19.14%) were screened for illegal substances by blood, urine, or both, 35 of which had confirmed intoxication. Alcohol was used in almost two-thirds of the 35 lab-confirmed intoxicated subjects (n = 23, 65.71%) either alone or in combination with other types of drugs. Conclusion: The widespread use of alcohol and other drug abuse among those involved in MVC is alarming and endangers road safety. There is a need to implement well-defined guidelines to screen, detect, and impose a penalty on driving under the influence to reduce MVC and improve population health. [SJEMed 2022; 3(2.000): 145-150]

BackgroundPatients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples’ experiences of self-harm and suicidality are believed or not. We use an empirical method –conversation analysis – to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person’s story to contest and recharacterize their accounts.AimsTo investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples’ experiences of suicidal ideation and self-harm.MethodsUsing conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants’ medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated.ResultsWhen peoples’ experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person’s account; asked questions that implied inconsistency or implausibility (“Didn’t you tell your GP that you were coping okay?”); juxtaposed contrasting information to undermine the person’s account (“You said you were coping okay before, and now you’re saying you feel suicidal”); asked questions asserting that, e.g., asking for help implied they were not intending to end their life (“So when you called 111 what were you expecting them to do”); and resistinged or directly questioned the person’s account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person’s decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn’t take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person’s control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples’ experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients’ accounts.ConclusionThese findings advance our understanding of how peoples’ experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples’ experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy.

Objectives: Frailty is characterized by an increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, and disability. The aim of this study was to determine the relationship between frailty syndrome and polypharmacy in the elderly referred to the emergency department of Ardabil teaching hospitals. Methods & Materials: In this cross-sectional descriptive study, 505 elderly people referred to the hospital emergency department were selected by convenience sampling method. Frailty syndrome was measured using the five-item criteria of fried which include: 1) slow walking, 2) muscular weakness, 3) exhaustion, 4) low physical activity and 5) unintentional weight loss. Polypharmacy considered the use of 5 or more drugs. Data were analyzed using descriptive statistics including mean and standard deviation and inferential analysis including analysis of variance, independent t-test, correlation, and multiple regression using spss v. 22 statistical software. Results: The mean age of participants was 70.91‌±‌7.49 and 255 (50.5%) were male, 318 (63%) were married and 271 (53.7%) were illiterate. the results of the study showed that 204 (40.4%) of the elderly who referred to the emergency department had frailty and 177 (35%) had pre frailty. In this population, we identified a 42.2% (n=98) of frail with polypharmacy, 37.1% (n=86) of prefrail with polypharmacy. The correlation test showed that there is a significant relationship between fertility and polypharmacy (P˂0.001). Linear regression analysis showed the variables of age, education, living arrangement, hospitalization, and the number of medications used by the patient as predictors of frailty syndrome in the elderly referred to the emergency department. Conclusion: Number of drugs used, age, education, living arrangement and number of hospitalizations were predictors of frailty syndrome in the elderly. Considering the living conditions of the elderly and the prevention of unnecessary hospitalizations can reduce polypharmacy and ultimately a preventive strategy to prevent and manage frailty. Of course, further research is needed to confirm the possible benefits of reducing polypharmacy in the development, reversion, or delay of frailty.

The coronavirus disease (COVID-19) outbreak has become a global public health threat. The influx of COVID-19 patients has prolonged the length of stay (LOS) in the emergency department (ED) in the United States. Our objective is to develop a reliable prediction model for COVID-19 patient ED LOS and identify clinical factors, such as age and comorbidities, associated with LOS within a “4-hour target.” Data were collected from an urban, demographically diverse hospital in Detroit for all COVID-19 patients’ ED presentations from March 16 to December 29, 2020. We trained four machine learning models, namely logistic regression (LR), gradient boosting (GB), decision tree (DT), and random forest (RF), across different data processing stages to predict COVID-19 patients with an ED LOS of less than or greater than 4 hours. The analysis is inclusive of 3,301 COVID-19 patients with known ED LOS, and 16 significant clinical factors were incorporated. The GB model outperformed the baseline classifier (LR) and tree-based classifiers (DT and RF) with an accuracy of 85% and F1-score of 0.88 for predicting ED LOS in the testing data. No significant accuracy gains were achieved through further splitting. This study identified key independent factors from a combination of patient demographics, comorbidities, and ED operational data that predicted ED stay in patients with prolonged COVID-19. The prediction framework can serve as a decision-support tool to improve ED and hospital resource planning and inform patients about better ED LOS estimations.

IntroductionThe COVID-19 pandemic has had profound effects on access to care, including outpatient sexually transmitted infection (STI) testing and treatment. Many vulnerable populations already relied on the emergency department (ED) for much of their care prior to the pandemic. This study examines trends in STI testing and positivity before and during the pandemic at a large urban medical center and evaluates the role of the ED in providing STI care.MethodsThis is a retrospective review of all gonorrhea, chlamydia, and trichomonas tests from November 1, 2018, through July 31, 2021. Demographic information and location and results of STI testing were extracted from the electronic medical record. Trends in STI testing and positivity were examined for 16 month periods before and after the COVID-19 pandemic started (March 15, 2020), with the latter divided into the early pandemic period (EPP: March 15 -July 31, 2020) and late pandemic period (LPP: August 1, 2020 - July 31, 2021).ResultsTests per month decreased by 42.4% during the EPP, but rebounded by July 2020. During the EPP, the proportion of all STI testing originating in the ED increased from 21.4% pre-pandemic to 29.3%, and among pregnant women from 45.2% to 51.5%. Overall STI positivity rate increased from 4.4% pre-pandemic to 6.2% in the EPP. Parallel trends were observed for gonorrhea and chlamydia individually. The ED represented 50.5% of overall positive tests, and as much as 63.1% of positive testing during the EPP. The ED was the source of 73.4% of positive tests among pregnant women, which increased to 82.1% during the EPP.ConclusionsSTI trends from this large urban medical center paralleled national trends, with an early decrease in positive cases followed by a rebound by the end of May 2020. The ED represented an important source of testing for all patients, and especially for pregnant patients, throughout the study period, but even more so early in the pandemic. This suggests that more resources should be directed towards STI testing, education, and prevention in the ED, as well as to support linkage to outpatient primary and obstetric care during the ED visit.

BackgroundEpidemiological studies about acute poisoning are useful for developing clinical toxicology, especially those carried out in hospital emergency departments. We aimed to evaluate acute intoxication clinical and sociodemographic profile in South Aragon Hospital, Spain.MethodsWe carried out a retrospective cross-sectional study. We included 442 patients treated for acute poisoning in the emergency department during the 3 years 2015–2018. In the inferential analysis, the Chi-square test was used to compare proportions, and the Mann-Whitney U-test was used to compare ranges. A confidence level of 95 per cent was considered in all tests.ResultsThe mean age was 44.1 years. 57.2% were men. Drugs of abuse were present in 243 patients (55%), drugs in 172 (38.9%), chemicals in 57 (12.9%) and three patients (0.7%) were poisoned by mushrooms. Nine different drugs of abuse, 73 drugs, 15 chemical compounds and 2 varieties of mushrooms were registered. Of the intoxicated patients, 92.3% had symptoms, 84.2% received treatment and 78.7% were discharged from the emergency department.ConclusionsWe obtain a clear clinical and sociodemographic profile of intoxicated patients who come to the emergency department; the five toxins that cause most acute poisoning are: alcohol, benzodiazepines, antiarrhythmics, cannabis and carbon monoxide.

Background: Early detection and management of hypothermia are determinants in the consequences of the injury. Various factors are involved in the progress of accidental hypothermia in these patients. Objectives: This study was done to determine the prevalence of accidental hypothermia and its related factors in trauma patients admitted to the emergency department (ED). Methods: In this prospective observational study, 123 trauma patients, who were transferred to the ED of Ayatollah Mosavi hospital, Zanjan, Iran by emergency medical technicians during November 2018, were selected. The patients' core body temperature (CBT) was measured through a calibrated tympanic thermometer on admission, 30 minutes after admission, and at the time of leaving the ED. Personal, clinical, environmental, and caring variables were evaluated as factors associated with hypothermia. Data were analyzed using descriptive statistics and multiple linear regression by SPSS16. The significance level was considered to be 5%. Results: The prevalence of accidental hypothermia in the ED was 43.1%. The patient's arrival CBT (β: 0.333, P-value

Background: Early detection and management of hypothermia are determinants in the consequences of the injury. Various factors are involved in the progress of accidental hypothermia in these patients. Objectives: This study was done to determine the prevalence of accidental hypothermia and its related factors in trauma patients admitted to the emergency department (ED). Methods: In this prospective observational study, 123 trauma patients, who were transferred to the ED of Ayatollah Mosavi hospital, Zanjan, Iran by emergency medical technicians during November 2018, were selected. The patientschr('39') core body temperature (CBT) was measured through a calibrated tympanic thermometer on admission, 30 minutes after admission, and at the time of leaving the ED. Personal, clinical, environmental, and caring variables were evaluated as factors associated with hypothermia. Data were analyzed using descriptive statistics and multiple linear regression by SPSS16. The significance level was considered to be 5%. Results: The prevalence of accidental hypothermia in the ED was 43.1%. The patientchr('39')s arrival CBT (β: 0.333, P-value

Objective: To evaluate the utilization of the parenteral morphine in Emergency Department (ED) using the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) system. Methods: In this retrospective cross-sectional study, morphine administration was recorded in 4-year time period from January 2013 to December 2016 in the ED of a referral center. The dose of the administered morphine was evaluated using the ATC/DDD system. The ATC/DDD of the parenteral morphine was calculated based on the world health organization (WHO). The data was evaluated based on the different diagnosis and conditions using the ATC/DDD protocol. Results: In this study, 500 patients referred to ED with mean age of 48.29 ± 10.10 years were included. There were 306 (61.2%) men and 194 (38.8%) women among the patients. The lowest and highest DDD of parenteral morphine were 0.1 and 0.43, respectively. The utilization of parenteral morphine was significantly higher in men when compared to women (pppp Conclusion: The utilization of parenteral morphine in the ED of our center was higher than the WHO standard dosage. The morphine utilization was associated with male gender, opium addiction and TCA consumption.

Background: Acute respiratory failure (ARF) is an important presentation in emergency department (ED). Intubation and mechanical ventilation (MV) are sometimes the ultimate decisions in such emergent situations. Many of these patients are unfortunately managed in an ED. This may endanger their outcome. This study was aimed to compare the outcome of critically ill patients with ARF under MV admitted to ED with patients admitted to ICU. Methods: All critically ill patients with ARF who were intubated and placed under MV were enrolled in this study. Cases were either admitted to ED or ICU. Demographic data, initial diagnosis, final diagnosis, length of hospital stay, one-month mortality rate, number of times patient was intubated and number of times patient was resuscitated were all recorded and compared between the 2 groups. Results: Out of all 172 patients admitted to ED and ICU, 74 (43%) were females and 98 (57%) were males. Patients had a mean±SD age of 64.2±18.1 years. ICU patients (85 patients (49.4%)) had a significantly longer hospital stay (p=0.048). ICU patients had significantly more resuscitation process (p=0.006). Mortality rate in ICU was significantly higher than ED. In the meanwhile, more patients in ED finally survived (p=0.004). Conclusion: In the present study, ICU patients were admitted longer to the ward than ED patients. Overall, ED mortality rate was lower than ICU. More patients finally survived in ED in comparison to ICU.

BackgroundGiven the scarcity of resources, the increasing use of emergency departments (ED) represents a major challenge for the care of emergency patients. Current health policy interventions focus on restructuring emergency care with the help of patient re-direction into outpatient treatment structures. A precise analysis of ED utilization, taking into account treatment urgency, is essential for demand-oriented adjustments of emergency care structures.MethodsTemporal and seasonal trends in the use of EDs were investigated, considering treatment urgency and hospital mortality. Secondary data of 287,119 ED visits between 2015 and 2017 of the two EDs of Charité Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum were analyzed.ResultEDs were used significantly more frequently on weekends than on weekdays (Mdn = 290 vs. 245 visits/day; p < 0.001). The proportion of less urgent, outpatient emergency visits on weekends was above average. Holiday periods were characterized by at least 6, and at most 176 additional ED visits. In a comparison of different holidays, most ED visits were observed at New Year (+68% above average). In addition, a significant increase in in-hospital mortality on holidays was evident among inpatients admitted to hospital via the ED (3.0 vs. 3.2%; p < 0.001), with New Year's Day being particularly striking (5.4%).ConclusionThese results suggest that, in particular, the resource planning of outpatient emergency treatment capacities on weekends and holidays should be adapted to the increased volume of non-urgent visits in EDs. Nevertheless, treatment capacities for the care of urgent, inpatient emergencies should not be disregarded and further research projects are necessary to investigate the causes of increased mortality during holiday periods.

Headaches are a frequent reason for presentation to the emergency department (ED) and can pose a great challenge for the attending physicians. First and foremost, the distinction between a primary and secondary headache with potentially life-threatening implications can be difficult. Moreover, it often occurs that no specific headache diagnosis is made at discharge from the ED. Therefore, in this present retrospective cross-sectional study, all patients who presented to the emergency department of the Department of Neurology at Rostock University Medical Centre with the main symptom of headache between November 2013 and November 2016 underwent a neurological examination and the extent to which warning symptoms (“red flags”) for a secondary headache as well as symptoms necessary for a correct headache diagnosis according to the ICHD-3 classification were recorded and documented. We could show that documentation of red flags and clinical characteristics is inadequate and does not allow proper diagnostic categorization. To facilitate concise documentation and rapid decision making we suggest a structured and standardized form for documenting the headache history and red flags in the ED.

BackgroundEmergency departments (ED) are an important intercept point for identifying suicide risk and connecting patients to care, however, more innovative, person-centered screening tools are needed. Natural language processing (NLP) -based machine learning (ML) techniques have shown promise to assess suicide risk, although whether NLP models perform well in differing geographic regions, at different time periods, or after large-scale events such as the COVID-19 pandemic is unknown.ObjectiveTo evaluate the performance of an NLP/ML suicide risk prediction model on newly collected language from the Southeastern United States using models previously tested on language collected in the Midwestern US.Method37 Suicidal and 33 non-suicidal patients from two EDs were interviewed to test a previously developed suicide risk prediction NLP/ML model. Model performance was evaluated with the area under the receiver operating characteristic curve (AUC) and Brier scores.ResultsNLP/ML models performed with an AUC of 0.81 (95% CI: 0.71–0.91) and Brier score of 0.23.ConclusionThe language-based suicide risk model performed with good discrimination when identifying the language of suicidal patients from a different part of the US and at a later time period than when the model was originally developed and trained.

Background: Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event. We aimed to identify clinically relevant subphenotypes at high risk of IHCA in the emergency department (ED).Methods: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory markers, and IHCA status. Group-based trajectory modeling was performed.Results: There were 37,697 adult ED patients with a total of 1,507,121 data points across all vital-sign categories. Three to four trajectory groups per vital-sign category were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, recurring tachypnea, and low and fluctuating oxygen saturation. The IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have higher levels of C-reactive protein, lactic acid, cardiac troponin I, and D-dimer. Multivariable analysis revealed that hypothermia (adjusted odds ratio [aOR], 2.20; 95% confidence interval [95%CI], 1.35–3.57) and recurring tachypnea (aOR 2.44; 95%CI, 1.24–4.79) were independently associated with IHCA.Conclusions: We identified five novel vital-sign sub-phenotypes associated with a higher likelihood of IHCA, with distinct patterns in clinical course and laboratory markers. A better understanding of the pre-IHCA vital-sign trajectories may help with the early identification of deteriorating patients.

Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis.Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7).Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were “uninterpretable” according to experts' consensus, 80 (46.8 %) were rated “normal” and 86 (50.3 %) “abnormal”. The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs.Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting.

The combination of the progressive growth of an aging population, increased life expectancy and a greater number of chronic diseases all contribute significantly to the growing demand for emergency medical care, and thus, causing saturation in Emergency Departments (EDs). This saturation is usually due to the admission of non-urgent patients, who constitute a high percentage of patients in an ED. The Agent-based Model (ABM) is one of the most important tools that helps to study complex systems and explores the emergent behavior of this type of department. Its simulation more accurately reflects the complexity of the operation of real systems. Our proposal is the design of an ABM to schedule the access of these non-critical patients into an ED, which can be useful for the service management dealing with the actual growing demand for emergency care. We suppose that a relocation of these non-critical patients within the expected input pattern, provided initially by historical records, enables a reduction in waiting time for all patients, and therefore, it will lead to an improvement in the quality of service. It would also allow us to avoid long waiting times. This research offers the availability of relevant knowledge for Emergency Department managers in order to help them make decisions to improve the quality of the service, in anticipation of the expected growing demand of the service in the very near future.

Introduction: Acute abdominal pain (AAP) is a medical emergency, characterized by pain arising from the abdominal area, of non-traumatic origin with a maximum duration of five days. Timely evaluation of acute abdominal pain (AAP) is important as it may determine the long-term prognosis. This study aims to evaluate various aspects of acute abdomen pain among patients who presented to the emergency department (ED) of Karnali Academy of Health Sciences (KAHS) in an attempt to determine the pattern and prevalence of AAP in a rural Karnali region of Nepal. Methodology: A hospital based retrospective study was conducted in KAHS. Data was collected from admission registers in ED that contained information of patients. Patients presenting to the ED during a period of six months (May 2020- October 2020) with acute abdominal pain, non-traumatic in origin were included in the study. Statistical analysis was done using SPSS version 17. Frequency and percentage was used for analysis Result: A total of 215 patients had visited the ED with acute abdomen. Acute gastritis (48.6%) was the most common cause of acute abdominal pain in ED followed by acute appendicitis (11.6%). A total of 70 cases (32.5%) had purely surgical nature of aetiology. Acute abdominal pain was seen equally distributed between both genders. Patients of AAP mostly belonged to the middle age group (44.6% in an age group of 15-30 years). Conclusion: Acid peptic disease in the form of acute gastritis is common among people living in rural Karnali region. Acute appendicitis represents the most common cause of acute abdomen, often requiring surgical intervention.

Background: Stroke is a devastating disease, but it is treatable with alteplase or tissue plasminogen activator (tPA). The effectiveness of tPA is highly time-dependent, meaning rapid treatment is critical. Fast treatment with tPA has been reported in many urban hospitals, but hospitals in rural locations struggle to reduce treatment times. This qualitative study examines current thrombolysis processes in one urban and two rural hospitals in Nova Scotia, Canada, by mapping and comparing the treatment process in these settings for acute ischemic stroke (AIS) patients, and by analyzing the healthcare professionals views on various treatment topics.Methods: Structured interviews were conducted with healthcare professionals involved in stroke treatment across the three sites. The interviews focused on the various activities in the thrombolysis treatment at each site. Additionally, participants were asked about the following 10 topics: comfort treating acute ischemic stroke patients; perceptions about tPA; appropriate tPA treatment window; stroke patient priority; tPA availability; patient consent; urban-rural treatment differences; efficiency of their treatment process; treatment delays; and suggested process improvements. Results were analyzed using the Framework Method, as well as through the development of process maps.Results: Twenty three healthcare professionals were interviewed at 2 rural hospitals and 1 urban hospital. Acute ischemic stroke patients are triaged as the highest or urgent priority at each included site. Physicians are more hesitant to treat with tPA in rural settings. A total of 11 urban-rural treatment differences were noted by the rural sites. Additionally, 11 patient-related and 29 system treatment delays were described. A process map was developed for each site, representing the arrival by ambulance and by private vehicle pathways.Conclusions: Guidelines and clear protocols are critical in reducing treatment times and ensuring consistent access to treatment. The majority of treatment delays encountered are system delays, which can be appropriately planned for to reduce delays within the care pathway. There is a general consensus that there is an urban-rural treatment gap for acute ischemic stroke patients in Nova Scotia, and that continuing education is key in rural hospitals to improve Emergency Department (ED) physician comfort with treating patients with tPA.

Objectives: Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED). Methods: This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained. Results: Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006]. Conclusion: Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level.

Abstract Background Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences. Methods A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies. Results Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29–62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05–1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex. Conclusion Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation. Trial registration PROSPERO CRD42017074845.

Abstract Background This study aimed to describe the pathological findings and to analyze clinical predictors of abnormal imaging findings in patients presenting to the emergency department (ED) with syncope. Methods The database was retrospectively reviewed for all patients who underwent cranial computed tomography (CT) or magnetic resonance imaging (MRI), having the symptom of syncope. Patients were included only if they were from the emergency department and excluded if were under 18 years of age, had known recent intracranial pathology, known brain tumor, or having a history of trauma. The primary outcome was assumed as abnormal head CT or MRI including intracranial hemorrhage, acute or subacute stroke, and newly diagnosed brain mass. Univariate and multivariate logistic regression analysis was utilized to determine the association between clinical variables and any significant pathology in either CT or MR scan. Results Total of 1230 syncope (717 men and 513 women; range, 18–92 years; mean, 54.5 years) as presenting symptoms were identified in patients receiving either cranial CT or MR scan in the ED. Abnormal findings related to the syncope were observed in 47 (3.8%) patients. The following predictor variables were found to be significantly correlated with acutely abnormal head CT and MRI: a focal neurologic deficit, history of malignancy, hypertension, and age greater than 60 years. Conclusions Our data offer that the identification of predictor variables has a potential to decrease the routine use of head CT and MRI in patients admitting to the ED with syncope.

Abstract Background We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS). Methods The study was an observational cohort study performed at one Emergency Department (ED) in an urban university teaching hospital in Norway, with approximately 20,000 visits per year. All patients >16 years presenting with symptoms or clinical signs suggesting an infection (n = 1535) were prospectively included in the study from January 1 to December 31, 2012. At arrival in the ED, vital signs were recorded and all patients were triaged according to RETTS vital signs, presenting infection, and sepsis symptoms. These admission data were also used to calculate qSOFA and SIRS. Treatment outcome was later retrieved from the patients’ electronic records (EPR) and mortality data from the Norwegian population registry. Results Of the 1535 admitted patients, 108 (7.0%) fulfilled the Sepsis2 criteria for severe sepsis. The qSOFA score ≥2 identified only 33 (sensitivity 0.32, specificity 0.98) of the patients with severe sepsis, whilst the RETTS-alert ≥ orange identified 92 patients (sensitivity 0.85, specificity 0.55). Twenty-six patients died within 7 days of admission; four (15.4%) of them had a qSOFA ≥2, and 16 (61.5%) had RETTS ≥ orange alert. Of the 68 patients that died within 30 days, only eight (11.9%) scored ≥2 on the qSOFA, and 45 (66.1%) had a RETTS ≥ orange alert. Discussion In order to achieve timely treatment for sepsis, a sensitive screening tool is more important than a specific one. Our study is the fourth study were qSOFA finds few of the sepsis cases in prehospital or at arrival to the ED. We add information on the RETTS triage system, the two highest acuity levels together had a high sensitivity (85%) for identifying sepsis at arrival to the ED - and thus, RETTS should not be replaced by qSOFA as a screening and trigger tool for sepsis at arrival. Conclusion In this observational cohort study, qSOFA failed to identify two thirds of the patients admitted to an ED with severe sepsis. Further, qSOFA failed to be a risk stratification tool as the sensitivity to predict 7-day and 30-day mortality was low. The sensitivity was poorer than the other warning scores already in use at the study site, RETTS-triage and the SIRS criteria.

Syncope is a common presentation to Emergency Departments (EDs). Estimates on the frequency of visits (0.6–1.7%) and subsequent rates of hospitalizations (12–85%) vary according to country. The initial ED evaluation for syncope consists of a detailed history, physical examination and 12-lead electrocardiogram (ECG). The use of additional diagnostic testing and specialist evaluation should be based on this initial evaluation rather than an unstructured approach of broad-based testing. Risk stratification performed in the ED is important for estimating prognosis, triage decisions and to establish urgency of any further work-up. The primary approach to risk stratification focuses on identifying high- and low-risk predictors. The use of prediction tools may be used to aid in physician decision-making; however, they have not performed better than the clinical judgment of emergency room physicians. Following risk stratification, decision for hospitalization should be based on the seriousness of the underlying cause for syncope or based on high-risk features, or the severity of co-morbidities. For those deemed intermediate risk, access to specialist assessment and related testing may occur in a syncope unit in the emergency department, as an outpatient, or in a less formal care pathway and is highly dependent on the local healthcare system. For syncope patients presenting to the ED, ~0.8% die and 10.3% suffer a non-fatal severe outcome within 30 days.

Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs. Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos. Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia. Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care.

Background: Triple-rule-out (TRO) computed tomographic (CT) angiography is a recent technique for evaluation of the coronary arteries, aorta, pulmonary arteries, and adjacent intrathoracic structures simultaneously for patients with acute chest pain. Objectives: To assess the validity and efficacy of Triple-rule-out (TRO) computed tomographic (CT) angiography in diagnosis of different vascular causes of chest pain in the emergency department. Methods: Between April 2013 and December 2014, 40 patients presenting with non-specific acute chest pain to the emergency department performed Triple-rule-out (TRO) computed tomographic (CT) angiography utilizing a biphasic contrast injection technique. The CT angiographic images were interpreted prospectively for detection of any pulmonary, coronary or aortic vascular abnormalities. Results: The study revealed 20 cases (50%) with only coronary lesions, 5 cases (12.5%) with only pulmonary lesions, 10 cases (25%) with only aortic lesions and 3 cases (7.5%) with combined coronary/aortic lesions. 2 cases (5%) showed no significant vascular abnormality. Conclusion: An optimized TRO protocol with concomitant reduced radiation exposure and efficient contrast agent administration provides a reliable tool for evaluation of coronary, aortic and pulmonary arteries in the emergency department.

Introduction: Asthma is a continuous significant health problem. Strategies for treating exacerbations are best adapted and implemented at a local level. Severe exacerbations are potentially life threatening, and their treatment requires close supervision. The severity of the exacerbation determines the treatment administered. Indices of severity, particularly peak expiratory flow (PEF), pulse rate, respiratory rate, and pulse oximetry should be monitored during treatment. Aim of the work: The aim of this work was to assess the effect of the implementation of the Global Initiative for Asthma (GINA) guidelines in the prognosis and the outcome of asthma exacerbation in the emergency department. Subjects and methods: The study was conducted on one hundred asthmatic patients. All patients were informed about the study and gave their consents. Patients were subjected to full history taking and clinical evaluation. Investigations were done in the form of peak flow rate (PFR) measurement, pulse oximetry assessment, ABG analysis (for only 17 patients), chest X-ray (it is not routinely recommended) and complete blood count (if needed). Then patients were classified according to their attacks. All patients were managed according to GINA guidelines. Results: Older patients were significantly suffering from severe to life threatening attacks than younger patients. We found that 12% of patients had occupational related asthma in relation to 88% of patients had non-occupational related asthma. There were no statistical significant differences between classification of severity of current attack and previous emergency department (ED) visits/year. There were no statistical significant differences between the studied groups regarding temperature. Systolic and diastolic blood pressure had statistically significant lower values in patients with severe to life threatening attacks than those with mild to moderate attacks. Severe to life threatening group had respiratory rate higher than mild to moderate group. Mild to moderate group had PEF and SaO2% higher than severe to life threatening group. PEF was statistically higher post treatment than pre treatment. Three patients of 17 had PaCo2 >45 mmHg with hypoxemia and respiratory acidosis and they admitted to the intensive care unit (ICU). All patients in ED were assisted to determine the severity of asthma concomitant with administration of initial treatment (plan A), which is oxygen to achieve O2 saturation ⩾92%, inhaled B2 adrenergic bronchodilator and an oral or intravenous dose of corticosteroids. Five patients met a good response so they enter in (plan C1). Seventy-five patients met with the criteria of moderate episode they go to plan B1, 68 patients of them (about 90%) had a good response within 2 h so go to plan C1 and the rest 7 patients (10%) had an incomplete response go to plan C2. Twenty patients met with criteria of severe episode, 17 of them (85%) with incomplete response move to plan C2, and the rest 3 patients (15%) had a poor response and moved to plan C3, no improvement noticed so they were admitted to the ICU. Hospitalization was done to 11 patients who met a poor response (plan C2), 86 patients were discharged from the ED (73 patients from plan C1 and 13 patients from plan C2). Severe to life threatening group stayed in ED longer than mild to moderate group. Conclusions and recommendations: All patients presenting in the emergency department with asthma exacerbations should be evaluated and triaged immediately and must be treated according to their severity of classification using GINA guidelines. Measurements of airflow obstruction, using peak expiratory flow, can help to guide therapy for acute asthma. Continuous monitoring of oxyhaemoglobin saturation by pulse oximetry should be undertaken for all patients with acute exacerbation of asthma. We must; educate patients in ED about the nature of asthma and its therapy, educate patients how to use inhalers, encourage patients to use spirometer at home and discharge each patient with ED-asthma discharge plan.

The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center. Methods: Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared. Results: At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%). Conclusion: The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.