Search

Objectives Virus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED). Design A prospective twin-center cohort study was conducted between January 2017 and March 2018. Setting and Participants Older adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test. Measures To evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score–matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. Results A total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P

Aging is a complex process involving functional decline, reduced physiological reserve, increased multimorbidity, and impaired homeostasis, all of which collectively generate various health risks for older adults. To predict short-term mortality of non-critical older patients in the observation room of the emergency department (ED) based on function-centric approach instead of disease-centric one.We conducted a prospective study enrolling 831 patients aged 75 years and older between 2018 and 2020. Comprehensive geriatric assessment was performed on all patients, and the results were integrated into the care planning process.In total 831 patients (mean age: 84.8 ± 5.8 years) were enrolled and the post-discharge mortality rate was 3.3% (28 deaths) after 3 months, and 5.4% (45 deaths) after 6 months. The independent predictors of 3-month mortality were malnutrition (adjusted odds ratio [OR], 4.77; p 0.05), incontinence (adjusted OR, 2.58; p 0.05) and multimorbidity (adjusted OR, 1.51; p 0.001). For 6-month mortality, malnutrition (adjusted OR, 4.20; p 0.01), multimorbidity (adjusted OR, 1.40; p 0.001) and activities of daily living (adjusted OR, 0.99; p 0.05) were all independent predictors.Although ED aims to treat acute and life-threatening conditions, older persons with geriatric syndromes are also at a substantially high risk of adverse outcomes, even mortality. Transitioning of the ED from disease-centric to function-centric services is important for responding to the changing health care needs of super-aged societies.

Background: The early integration of palliative care in the emergency department (ED-PC) provides several benefits, including improved quality of life with optimal comfort measures, and symptom control. Whether palliative care could affect the intensive care unit admissions, hospital care and resource utilization requires further investigation. Aim: To determine the differences in inpatient characteristics, hospital care, survival, and resource utilization between patients receiving palliative care (ED-PC) and usual care (UC). Design: Retrospective observational study. Setting/participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit at Taipei Veterans General Hospital from 1 February 2018 to 31 January 2020. Results: A total of 1273 patients were evaluated for unmet palliative care needs; 685 patients received ED-PC and 588 received UC. The palliative care patients were more severely frail (AOR 2.217 (1.295–3.797), p = 0.004), had functional deterioration with three ADLs (AOR 1.348 (1.040–1.748), p = 0.024), biopsychosocial discomfort (AOR 1.696 (1.315–2.187), p < 0.001), higher Taiwan Triage and Acuity Scale 1 (p = 0.024), higher in-hospital mortality (AOR 1.983 (1.540–2.555), p < 0.001), were four times more likely to sign an DNR (AOR 4.536 (2.522–8.158), p < 0.001), and were twice as likely to sign an DNR at admission (AOR 2.1331.619–2.811), p < 0.001). Palliative care patients received less epinephrine (AOR 0.424 (0.265–0.678), p < 0.001), more frequent withdrawal of an endotracheal tube (AOR 8.780 (1.122–68.720), p = 0.038), and more narcotics (AOR1.675 (1.132–2.477), p = 0.010). Palliative care patients exhibited lower 7-day, 30-day, and 90-day survival rates (p < 0.001). There was no significant difference in the hospital length of stay (LOS) (21.2 ± 26.6 vs. 21.7 ± 20.6, p = 0.709) nor total hospital expenses (293,169 ± 350,043 vs. 294,161 ± 315,275, p = 0.958). Conclusion: Acute critically ill patients receiving palliative care were more frail, more critical, and had higher in-hospital mortality. Palliative care patients received less epinephrine, more endotracheal extubation, and more narcotics. There was no difference in the hospital LOS or hospital costs between the palliative and usual care groups. The synthesis of ED-PC is new but achievable with potential benefits to align care with patient goals.

BACKGROUND The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. METHODS This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. RESULTS A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). CONCLUSION The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age &gt, 85 years (adjusted odd ratios (AOR) 1.700, 1.027&ndash, 2.814), living in long-term care facilities (AOR 1.880, 1.066&ndash, 3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039&ndash, 4.358), &ldquo, medical staff would not be surprised if the patient died within 12 months&rdquo, (AOR 1.725, 1.193&ndash, 2.496), and patients&rsquo, family requesting palliative care (AOR 2.420, 1.187&ndash, 4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p &lt, 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p &lt, 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p &lt, 0.001), 30-day (p &lt, 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

BACKGROUND: Ever since coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, in December 2019, it has had a devastating effect on the world through exponential case growth and death tolls in at least 146 countries. Rapid response and timely modifications in the emergency department (ED) for infection control are paramount to maintaining basic medical services and preventing the spread of COVID-19. This study presents the unique measure of combining a fever screening station (FSS) and graded approach to isolation and testing in a Taiwanese medical center. METHODS: An FSS was immediately set up outside the ED on January 27, 2019. A graded approach was adopted to stratify patients into "high risk," "intermediate risk," and "undetermined risk" for both isolation and testing. RESULTS: A total of 3755 patients were screened at the FSS, with 80.3% visiting the ED from home, 70.9% having no travel history, 21.4% having traveled to Asia, and 10.0% of TVGH staff. Further, 54.9% had fever, 35.5% had respiratory symptoms, 3.2% had gastrointestinal symptoms, 0.6% experienced loss of smell, and 3.1% had no symptoms; 81.3% were discharged, 18.6% admitted, and 0.1% died. About 1.9% were admitted to the intensive care unit, 10.3% to the general ward, and 6.4% were isolated. Two patients tested positive for COVID-19 (0.1%) and 127 (3.4%) tested positive for atypical infection; 1471 patients were tested for COVID-19; 583 were stratified as high-risk, 781 as intermediate-risk, and 107 as undetermined-risk patients. CONCLUSION: Rapid response for infection control is a paramount in the ED to confront the COVID-19 outbreak. The FFS helped divide the flow of high- and intermediate-risk patients; it also decreased the ED workload during a surge of febrile patients. A graded approach to testing uses risk stratification to prevent nosocomial infection of asymptomatic patients. A graded approach to isolation enables efficient allocation of scarce medical resources according to risk stratification.

Handgrip strength is associated with mild cognitive impairment. Tumor necrosis factor [TNF]-α and interleukin [IL]-6 were pro-inflammatory cytokines influencing the severity of initial neurological deficit. Visfatin is a novel adipokine and has a strong correlation with inflammation. The relationships of TNF-α, IL-6 and visfatin are not consistent, and no study has investigated them in the elderly patients with cognitive impairment.This study included patients aged ≥75 years at the emergency department from August 2018 to February 2019. All patients underwent comprehensive geriatric assessment and blood tests for fasting plasma TNF-α, IL-6 and visfatin levels.We enrolled 106 elderly patients with a mean age of 87.3 years, including 62 (58.4%) patients in cognitive impairment group (Mini-Mental State Examination [MMSE] 24) and 44 (41.5%) patients in the non-cognitive impairment group. Compared to the non-cognitive impairment group, the cognitive impairment group had significantly lower handgrip strength, and significantly higher TNF-α, IL-6 and visfatin levels. TNF-α positively correlated with IL-6. Both TNF-α and IL-6 negatively correlated with Barthel index and MMSE. Handgrip strength negatively correlated with TNF-α but positively correlated with Barthel index and MMSE scores. Backward and stepwise multiple logistic regression analyses showed that the independent predictor for cognitive impairment was handgrip strength and age.The cognitive impairment group had significantly higher serum TNF-α, IL-6, and visfatin levels. The independent predictors of cognitive impairment were handgrip strength and age. Handgrip strength negatively correlated with TNF-α and IL-6 but positively with Barthel index and MMSE scores.

Background Older people present to the emergency department (ED) with distinct patterns and emergency care needs. This study aimed to use comprehensive geriatric assessment (CGA) surveying the patterns of ED visits among older patients and determine frailty associated with the risk of revisits/readmission. Methods This prospective study screened 2270 patients aged ≥75 years in the ED from August 2018 to February 2019. All patients underwent CGA. A 3-months follow-up was conducted to observe the hospital courses of admission and revisit/readmission. Results A total of 270 older patients were enrolled. The independent predictors of admission at initial ED visit were the risk of nutritional deficit and instrumental activities of daily living (IADL). In the admission group, the independent predictors of revisit/readmission were a fall in the past year and mobility difficulties. In the discharge group, the independent predictors of revisit/readmission were frailty and insomnia. Regardless if older patients were either admitted or discharged at the initial ED visit, the independent predictor of revisit/readmission for older patients was frailty. Conclusion Our study showed that frailty was the only independent predictor for revisit/readmission after ED discharge during the 3-month follow up. For ED physicians, malnutrition and IADL were independent predictors in recognizing whether the older patient should be admitted to the hospital. For discharged older ED patients, frailty was the independent predictor for the integration of community services for older patients to decrease the rate of revisit/readmission in 3 months.

Background: Indexes of heart rate variability (HRV) appear to reflect severity and may have prognostic value in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We hypothesized that AECOPD without adequate treatment response would demonstrate impaired cardiac autonomic regulation and changes in HRV after emergency department (ED) treatment. Methods: A prospective study of measuring HRV in admitted and discharged patients with AECOPD shortly after ED arrival and again 24 h after treatment. Results: Total consecutive 33 patients (18 admitted and 15 discharged, age 77.1 ± 1.6 years) were enrolled. Among admitted patients, high frequency in normalized unit (HF%) was significantly lower (P 7.1 and ΔLF/HF% ≦−0.39. Conclusion: Patients with AECOPD requiring admission after ED treatment had a greater increase in HF% and greater decrease in LF/HF ratio compared to those discharged. Our study demonstrates patient with ΔHF% was >7.1 or a ΔLF/HF% ≦−0.39 require admission despite 24 h of ED treatment.

Protobothrops mucrosquamatus (Trimeresurus mucrosquamatus) is a medically important species of pit viper with a wide geographic distribution in Southeast Asia. Bites by P. mucrosquamatus mostly involve the extremities. Little is known about the toxic effects of P. mucrosquamatus envenoming to the head because of the infrequency of such occurrence. To better delineate the clinical manifestations of envenoming to the head, we report three patients who suffered from P. mucrosquamatus bites to the head and were treated successfully. All three patients developed progressive soft tissue swelling extending from head to neck, with two patients expanding further onto the anterior chest wall. Mild thrombocytopenia was noted in two patients. One patient had transient acute renal impairment and airway obstruction, necessitating emergent intubation. All three patients received high doses of species-specific antivenom with recovery within 1 week. No adverse reactions to antivenom were observed.

Background Steady increase in computed tomography (CT) utilisation in the ED was observed in countries such as the USA, Canada, China and Korea; however, limited empirical data are available regarding Taiwan. Objective The objective of the present study is to quantify and compare trends in CT utilisation in the ED over a 5 year period in a medical centre in Taiwan. Methods Electronic chart review was performed in a medical centre with an annual ED census of 80 000 patients. Subjects >20 years of age who underwent CT scans during ED visits from 1 January 2005 to 31 December 2009 were identified. Results Among the 333 673 adult ED visits, 43 635 received CT scans, with a utilisation rate of 131 per 1000. Within the 5 year span, patient volume increased by 7.7%, whereas CT utilisation increased by 42.7%. The rates of increase in patient volume and CT utilisation were 5.0% and 32.4% in non-trauma; 19.7% and 97.8% in trauma. CT scans were mostly performed on the head (47%), abdomen (36%), followed by chest (10%) and miscellaneous (7%). An increase of 168% in spinal CTs for trauma patients was observed. An increase in CT utilisation was found in all age groups with a proportionate increase with increasing age in both trauma and non-trauma. Conclusion ED CT utilisation has increased at a rate far exceeding the growth in ED patient volume. This may be attributed to the improved utility of CT in diagnosing serious pathology, more diagnostic indications for CT, ready availability and the necessity for diagnostic certainty in the ED.

Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p

Steady increase in computed tomography (CT) utilisation in the ED was observed in countries such as the USA, Canada, China and Korea; however, limited empirical data are available regarding Taiwan.The objective of the present study is to quantify and compare trends in CT utilisation in the ED over a 5 year period in a medical centre in Taiwan.Electronic chart review was performed in a medical centre with an annual ED census of 80 000 patients. Subjects20 years of age who underwent CT scans during ED visits from 1 January 2005 to 31 December 2009 were identified.Among the 333 673 adult ED visits, 43 635 received CT scans, with a utilisation rate of 131 per 1000. Within the 5 year span, patient volume increased by 7.7%, whereas CT utilisation increased by 42.7%. The rates of increase in patient volume and CT utilisation were 5.0% and 32.4% in non-trauma; 19.7% and 97.8% in trauma. CT scans were mostly performed on the head (47%), abdomen (36%), followed by chest (10%) and miscellaneous (7%). An increase of 168% in spinal CTs for trauma patients was observed. An increase in CT utilisation was found in all age groups with a proportionate increase with increasing age in both trauma and non-trauma.ED CT utilisation has increased at a rate far exceeding the growth in ED patient volume. This may be attributed to the improved utility of CT in diagnosing serious pathology, more diagnostic indications for CT, ready availability and the necessity for diagnostic certainty in the ED.

Emergency air medical transport (EAMT) is indispensable for acutely or critically ill patients in remote areas. We determined patient-level and transport-specific factors associated with all-cause mortality after EAMT. We conducted a population-based, retrospective cohort study using a prospective registry consisting of clinical/medical records. Study inclusion criteria consisted of all adults undergoing EAMT from Kinmen hospital to the ED of Taipei Veterans General Hospital (TVGH) between January 1, 2006 and December 31, 2012. The primary outcome assessments were 7-day and 30-day mortality. A total of 370 patients transported to TVGH were enrolled in the study with a mean age of 54.5 ± 21.5 (SD) years and with a male predominance (71.6%). The average in-transit time was 1.4 ± 0.4 hours. The 7-day, 30-day, and in-hospital mortality rates were 10.3%, 14.1%, and 14.9%. Among them 33.5% (124/370) were categorized under neurological etiologies, whereas 24.9% (90/370) cardiovascular, followed by 16.2% (60/370) trauma patients. Independent predictors associated with 7-day all-cause mortality were age (odds ratio [OR] 1.043, 95% confidence interval [CI] 1.016–1.070), Glasgow Coma Scale (GCS) (OR 0.730, 95% CI 0.650–0.821), and hematocrit level (OR 0.930, 95% CI 0.878–0.985). Independent predictors associated with 30-day all-cause mortality were age (OR 1.028, 95% CI 1.007–1.049), GCS (OR 0.686, 95% CI 0.600–0.785), hematocrit (OR 0.940, 95% CI 0.895–0.988), hemodynamic instability (OR 5.088 95% CI 1.769–14.635), and endotracheal intubation (OR 0.131 95% CI 0.030–0.569). The 7-day and 30-day mortality were not significantly related to transport-specific factors, such as length of flight, type of paramedic crew on board, or day and season of transport. Clinical patient-level factors, as opposed to transport-level factors, were associated with 7- and 30-day all-cause mortality in patients undergoing interfacility EAMT from Kinmen to Taiwan.

Introduction : 3, 4-methylenedioxymethamphetamine (MDMA) is a popular psychoactive amphetamine derivative with the potential to induce life-threatening hyponatremia. The absence of exposure history and typical toxidromes however make the prompt diagnosis of MDMA-induced hyponatremic coma difficult and easily overlooked. Case Report : A 24-year-old female presented to the emergency department with an altered mental status. Physical examinations, laboratory workup and brain imaging study were remarkable for severe hyponatremia (serum sodium 116 mmol/L) and diffuse brain edema only. Her family denied that she had used any illicit drugs. The diagnosis of MDMA-related hyponatremic coma was not made until six days later when toxicologic screen confirmed the presence of high concentration of MDMA (7,767 ng/ml) in the patient’s urine. Conclusion : Our case demonstrates the difficulty in the correct diagnosis of MDMA-induced hyponatremic coma in the absence of MDMA exposure history and typical sympathom imetic effects. A high index of suspicion and prompt toxicological screen are thus important in the diagnosis of MDMA-related severe hypontremia.

Presentation of acute ST segment elevation myocardial infarction in the setting of acute subclavian artery thrombosis in a patient who underwent coronary artery bypass grafting with a left internal mammary artery graft, which is not believed to have been previously described. We report a 75-year-old woman with presentations of dizziness, nausea, left-arm numbness, and a cold left hand, who later had chest pain develop. Acute ST segment elevation myocardial infarction was diagnosed, and both a computed tomography and an angiography disclosed a thrombus extending from the proximal portion of the left subclavian artery to the orifice of the left internal mammary artery. The patient was free from the previously listed symptoms after undergoing emergent thrombectomy, with complete extraction of the long thrombus from the subclavian artery. Unfortunately, she died of pneumonia and septic shock 1 1/2 months later.