Impact of the COVID-19 Pandemic on the Loading and Quality of an Emergency Department in Taiwan: Enlightenment from a Low-Risk Country in a Public Health Crisis

Correlates of the Veterans Visiting Emergency Departments in Taiwan: A Comparison Before and After the Coronavirus Disease 2019 Pandemic

BACKGROUND

Taiwan has a substantial number of veterans, but knowledge regarding their emergency department (ED) visits during the coronavirus disease 2019 (COVID-19) pandemic remains limited. This study examined the characteristics of veterans' ED visits during Taiwan's COVID-19 epidemic.

METHODS

This was a cross-sectional study conducted at the ED of a large veteran medical center located in Taipei, Taiwan, from May 2018 to October 2021. We analyzed the numbers and features of visits in summer and autumn according to the first wave of the COVID-19 epidemic in Taiwan in 2021.

RESULTS

Medical institutions were positively associated with veteran status. Emergency department complaints of trauma (adjusted odds ratio [AOR] = 1.15, 95% CI: 1.06-1.25; summer P < .01) and chest pain/tightness (AOR = 1.65, 95% CI: 1.45-1.87; summer P < .01; AOR = 1.4, 95% CI: 1.26-1.55; P < .01) were associated with increased odds of being a veteran. Triage levels above 2 were positively associated with veteran status in the autumn model (AOR = 1.14, 95% CI: 1.07-1.22; P < .01). Patients hospitalized after ED visits were associated with reduced odds of veteran status (P < .01). Those who spent a long time in the ED were more likely to be veterans than those who spent a shorter time in the ED (P < .01). Veterans were less likely to visit the ED regardless of the time frame of the study period (P < .01), except during the COVID-19 outbreak in the autumn (2019-2020).

CONCLUSIONS

The distinctions in ED visits highlighted the individuality of veterans' medical needs. Our findings suggest that the veteran medical system can add to the focus on improving senior-friendly care, fall prevention, quality of life of institutionalized veterans, access for homeless veterans, and care for ambulatory care-sensitive conditions.

Analyzing COVID-19 and Air Pollution Effects on Pediatric Asthma Emergency Room Visits in Taiwan

(1) Background: An asthma exacerbation that is not relieved with medication typically requires an emergency room visit (ERV). The coronavirus disease 2019 (COVID-19) pandemic began in Taiwan in January of 2020. The influence of the COVID-19 pandemic on pediatric ERVs in Taiwan was limited. Our aim was to survey pediatric asthma ERVs in the COVID-19 era; (2) Methods: Data were collected from the health quality database of the Taiwanese National Health Insurance Administration from 2019 to 2021. Air pollution and climatic factors in Taipei were used to evaluate these relationships. Changes in the rates of pediatric asthma ERVs were assessed using logistic regression analysis. Poisson regression was used to evaluate the impact of air pollution and climate change; (3) Results: The rate of pediatric asthma ERVs declined in different areas and at different hospital levels including medical centers, regional and local hospitals. Some air pollutants (particulate matter ≤ 2.5 µm, particulate matter ≤ 10 µm, nitrogen dioxide, and carbon monoxide) reduced during the COVID-19 lockdown. Ozone increased the relative risk (RR) of pediatric asthma ERVs during the COVID-19 period by 1.094 (95% CI: 1.095-1.12) per 1 ppb increase; (4) Conclusions: The rate of pediatric asthma ERVs declined during the COVID-19 pandemic and ozone has harmful effects. Based on these results, the government could reduce the number of pediatric asthma ERVs through healthcare programs, thereby promoting children's health.

Symptom-based scoring technique by machine learning to predict COVID-19: a validation study

BACKGROUND

Coronavirus disease 2019 (COVID-19) surges, such as that which occurred when omicron variants emerged, may overwhelm healthcare systems. To function properly, such systems should balance detection and workloads by improving referrals using simple yet precise and sensitive diagnostic predictions. A symptom-based scoring system was developed using machine learning for the general population, but no validation has occurred in healthcare settings. We aimed to validate a COVID-19 scoring system using self-reported symptoms, including loss of smell and taste as major indicators.

METHODS

A cross-sectional study was conducted to evaluate medical records of patients admitted to Dr. Sardjito Hospital, Yogyakarta, Indonesia, from March 2020 to December 2021. Outcomes were defined by a reverse-transcription polymerase chain reaction (RT-PCR). We compared the symptom-based scoring system, as the index test, with antigen tests, antibody tests, and clinical judgements by primary care physicians. To validate use of the index test to improve referral, we evaluated positive predictive value (PPV) and sensitivity.

RESULTS

After clinical judgement with a PPV of 61% (n = 327/530, 95% confidence interval [CI]: 60% to 62%), confirmation with the index test resulted in the highest PPV of 85% (n = 30/35, 95% CI: 83% to 87%) but the lowest sensitivity (n = 30/180, 17%, 95% CI: 15% to 19%). If this confirmation was defined by either positive predictive scoring or antigen tests, the PPV was 92% (n = 55/60, 95% CI: 90% to 94%). Meanwhile, the sensitivity was 88% (n = 55/62, 95% CI: 87% to 89%), which was higher than that when using only antigen tests (n = 29/41, 71%, 95% CI: 69% to 73%).

CONCLUSIONS

The symptom-based COVID-19 predictive score was validated in healthcare settings for its precision and sensitivity. However, an impact study is needed to confirm if this can balance detection and workload for the next COVID-19 surge.

Taiwan's National Health Insurance at the Emergency Department following the COVID-19 outbreak

Taiwan's National Health Insurance (NHI) is a widely acclaimed universal healthcare system. In the past few years, particularly following the COVID-19 outbreak, challenges related to maintaining the NHI system have surfaced. Since 2020, NHI has faced a series of challenges, including excessive patient visits to the hospital emergency department, a lack of an effective primary care and referral system, and a high turnover rate of healthcare workers. We review major problems related to Taiwan's NHI, emphasizing input from frontline healthcare workers. We provide recommendations for potential policies addressing the concerns around NHI, for example, strengthening the role of primary care services under the NHI administration, reducing the high turnover rate of healthcare workers, and increase the premium and copayments. We hope that this policy analysis may allow policymakers and scholars to understand both the merits and critical problems related to NHI from the clinical perspective.

Point-of-care artificial intelligence-enabled ECG for dyskalemia: a retrospective cohort analysis for accuracy and outcome prediction

Dyskalemias are common electrolyte disorders associated with high cardiovascular risk. Artificial intelligence (AI)-assisted electrocardiography (ECG) has been evaluated as an early-detection approach for dyskalemia. The aims of this study were to determine the clinical accuracy of AI-assisted ECG for dyskalemia and prognostic ability on clinical outcomes such as all-cause mortality, hospitalizations, and ED revisits. This retrospective cohort study was done at two hospitals within a health system from May 2019 to December 2020. In total, 26,499 patients with 34,803 emergency department (ED) visits to an academic medical center and 6492 ED visits from 4747 patients to a community hospital who had a 12-lead ECG to estimate ECG-K⁺ and serum laboratory potassium measurement (Lab-K⁺) within 1 h were included. ECG-K⁺ had mean absolute errors (MAEs) of ≤0.365 mmol/L. Area under receiver operating characteristic curves for ECG-K⁺ to predict moderate-to-severe hypokalemia (Lab-K⁺ ≤3 mmol/L) and moderate-to-severe hyperkalemia (Lab-K⁺ ≥ 6 mmol/L) were >0.85 and >0.95, respectively. The U-shaped relationships between K⁺ concentration and adverse outcomes were more prominent for ECG-K⁺ than for Lab-K⁺. ECG-K⁺ and Lab-K⁺ hyperkalemia were associated with high HRs for 30-day all-cause mortality. Compared to hypokalemic Lab-K⁺, patients with hypokalemic ECG-K⁺ had significantly higher risk for adverse outcomes after full confounder adjustment. In addition, patients with normal Lab-K⁺ but dyskalemic ECG-K⁺ (pseudo-positive) also exhibited more co-morbidities and had worse outcomes. Point-of-care bloodless AI ECG-K⁺ not only rapidly identified potentially severe hypo- and hyperkalemia, but also may serve as a biomarker for medical complexity and an independent predictor for adverse outcomes.

Effects of the COVID-19 Pandemic on Treatment Efficiency for Traumatic Brain Injury in the Emergency Department: A Multicenter Study in Taiwan

The coronavirus disease 2019 (COVID-19) pandemic has impacted emergency department (ED) practice, including the treatment of traumatic brain injury (TBI), which is commonly encountered in the ED. Our study aimed to evaluate TBI treatment efficiency in the ED during the COVID-19 pandemic. A retrospective observational study was conducted using the electronic medical records from three hospitals in metropolitan Taipei, Taiwan. The time from ED arrival to brain computed tomography (CT) and the time from ED arrival to surgical management were used as measures of treatment efficiency. TBI treatment efficiencies in the ED coinciding with a small-scale local COVID-19 outbreak in 2020 (P1) and large-scale community spread in 2021 (P2) were compared against the pre-pandemic efficiency recorded in 2019. The interval between ED arrival and brain CT was significantly shortened during P1 and P2 compared with the pre-pandemic interval, and no significant delay between ED arrival and surgical management was found, indicating increased treatment efficiency for TBI in the ED during the COVID-19 pandemic. Minimizing viral spread in the community and the hospital is vital to maintaining ED treatment efficiency and capacity. The ED should retain sufficient capacity to treat older patients with serious TBI during the COVID-19 pandemic.

Rapid Antigen Test Combined with Chest Computed Tomography to Rule Out COVID-19 in Patients Admitted to the Emergency Department

OBJECTIVE

Correct and timely identification of SARS-CoV-2-positive patients is critical in the emergency department (ED) prior to admission to medical wards. Antigen-detecting rapid diagnostic tests (Ag-RDTs) are a rapid alternative to Reverse-transcriptase polymerase chain reaction (RT-PCR) for the diagnosis of COVID-19 but have lower sensitivity.

METHODS

We evaluated the performance in real-life conditions of a strategy combining Ag-RDT and chest computed tomography (CT) to rule out COVID-19 infection in 1015 patients presenting in the ED between 16 November 2020 and 18 January 2021 in order to allow non-COVID-19 patients to be hospitalized in dedicated units directly. The combined strategy performed in the ED for patients with COVID-19 symptoms was assessed and compared with RT-PCR.

RESULTS

Compared with RT-PCR, the negative predictive value was 96.7% for Ag-RDT alone, 98.5% for Ag-RDT/CT combined, and increased to 100% for patients with low viral load.

CONCLUSION

A strategy combining Ag-RDT and chest CT is effective in ruling out COVID-19 in ED patients with high precision.