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Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.

Background: Feedback is an essential part of clinical teaching and learning, yet it is often perceived as unsatisfactory in busy clinical settings. Clinical teachers need to balance the competing demands of clinical duty and feedback provision. The influence of the clinical environment and the mutual relationship between feedback giving and seeking has been inadequately investigated. This study therefore aimed to quantify the adequacy, perceptions, and influential factors of feedback provision during resident training in emergency departments (EDs)., Methods: A multicenter online questionnaire study was undertaken. The respondents comprised ED residents and clinical teachers from four teaching hospitals in Taiwan. The questionnaire was developed via an expert panel, and a pilot study ensured validity. Ninety clinical teachers and 54 residents participated., Results: The respondents reported that the majority of feedback, which usually lasted 1-5 min, was initiated by the clinical teachers. Feedback satisfaction was significantly lower for the clinical teachers than for the residents (clinical teachers M = 13.8, SD = 1.83; residents M = 15.3, SD = 2.14; p < 0.0001), and positive feedback was provided infrequently in clinical settings (31.1%). Both groups of participants admitted hesitating between providing/seeking feedback and completing clinical work. Being busy, the teachers' clinical abilities, the learners' attitudes, and the relationship between both parties were reported as the most influential factors in feedback provision., Conclusion: ED clinical feedback provision is often short, circumstantial, and initiated by clinical teachers. Providing or seeking feedback appears to be an important part of clinical learning in the context of uncertainty. The importance of the relationship between the feedback seeker and the provider highlights the interactive, reciprocal nature of clinical feedback provision.

Background: Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients., Method: A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed., Result: Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2-4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30-1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07-1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11-1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l., Conclusion: In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality.

Background: The unpredictable nature of patient visits poses considerable challenges to the staffing of emergency department (ED) medical personnel. There is a lack of common physician usage parameters at present., Objective: The aim of this study was to quantify the ED traffic intensity of patients and physicians using a queueing model approach., Methods: A retrospective administrative electronic data analysis was conducted in a tertiary medical center. All patients who registered at the ED in 2013 were included. Precisely recorded patient waiting time, service time, and disposition time were obtained. An M/M/s (Markovian patient arrival, Markovian patient service, s servers) queueing model was used, while taking account of the actual physician number and number of patients managed simultaneously. Physician utilization and performance indicators were measured., Results: A total of 148,581 patients were analyzed after exclusion. The overall mean waiting time, service time, and disposition time were 0.23 (standard deviation [SD] = 0.24), 2.31 (SD = 3.89), and 2.54 (SD = 3.90) hours, respectively. Hourly physician utilization (ρ), stratified by different patient entities, was ρ = 0.75 ± 0.17 for adult non-trauma, ρ = 0.75 ± 0.28 for pediatric, and ρ = 0.53 ± 0.18 for trauma (p = 0.0004). There was a surge of utility for pediatric non-trauma patients in the late evening (ρ = 1.4 at 11 pm). The distribution of number of patients in the system was derived and compared by different patient entities and time points., Conclusions: A queueing model was built to model traffic intensity of physicians and patients, the physician utility trend disclosed the fluctuation of manpower utility. The estimated parameters serve as important factors for developing tailored staffing policies for minimizing ED waiting and improving ED crowding., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: In this study, we attempted to identify differences in the outcomes of patients with severe trauma who were directly transported to our hospital, and those who were stabilised initially at other hospitals in south-central Taiwan., Methods: We performed a prospective observational study to review the records of 231 patients with major trauma (Injury Severity Scores (ISS) >15) who visited our hospital's emergency department from January 2010 to December 2010. Among these patients, 75 were referred from other hospitals. Logistic regression was performed to assess the effects of transfer on mortality., Results: Patients in the transfer group had a shorter interval between trauma and admission to the first hospital (25.3 min vs. 28.1 min), and the average interval between the two hospital arrivals was 138.3 min. Transfer from another hospital was not significantly correlated with mortality in this study (odds ratio: 1.124, 95% confidence interval: 0.276-4.578)., Conclusion: In trauma patients with ISS>15, there is no difference in mortality between those transferred from another hospital after initial stabilisation and those who visited our emergency department directly., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Overcrowding in hospitals, especially in EDs, is a serious problem in the United States, Europe, and Taiwan. However, the association between prolonged ED boarding stay and mortality in patients with necrotizing fasciitis remains underinvestigated., Methods: This was a retrospective study. A total of 195 patients were enrolled and analyzed. The sample was divided into 2 groups: nonmortality and mortality. A stepwise logistic regression model was developed to investigate 3 factors of clinical relevance predicting patient mortality., Result: The results of the stepwise logistic regression analysis revealed that hypotension (odds ratio [OR], 32.9; 95% confidence interval [CI], 6.9-156.0) and prolonged ED boarding stay (OR, 3.4; 95% CI 1.3-8.6) were both associated with higher mortality. Early operation (OR: 0.16; 95% CI: 0.06-0.45) was associated with lower mortality., Conclusion: Prolonged ED boarding stay was associated with increased mortality in patients with necrotizing fasciitis. Early operation (within 24 hours of ED arrival) was associated with decreased mortality.

Objective: The aim of the study was to identify risk factors for mortality in patients brought to the emergency department (ED) after blunt traumatic brain injury (TBI)., Methods: The medical records of such patients who visited the ED from June 2004 to May 2005 were retrospectively reviewed. Data (age, gender, initial Glasgow coma scale (GCS) scores, initial vital signs, brain computed tomography scan findings and cause of trauma) were collected from the records of 204 TBI patients, who were treated at the ED and needed intensive care. Among these patients, 48 died in the intensive care unit (ICU) of the hospital. Logistic regression was used to assess factors affecting mortality after trauma., Results: Age (odds ratio (OR) 1.04; 95% CI 1.01 to approximately 1.07), GCS score less than 9 (OR 19.29; 95% CI 5.04 to approximately 73.82) and skull bone fracture (OR 10.44; 95% CI 3.59 to approximately 30.38) were identified as possible risk factors of mortality in TBI patients., Conclusion: These predictors appear to be clinically relevant and may help improve ED triage of TBI patients in need of ICU care.