Evaluation of the risk factors associated with emergency department boarding: A retrospective cross-sectional study

PURPOSE

Boarding is a common problem in the emergency department (ED) and is associated with poor health care and outcome. Imam Khomeini Hospital is the main healthcare center in Urmia, a metropolis in the northwest of Iran. Due to the overcrowding and high patient load, we aim to characterize the rate, cause and consequence of boarding in the ED of this center.

METHODS

All medical records of patients who presented to the ED of Imam Khomeini Hospital from August 1, 2017 to August 1, 2018 were retrospectively analyzed. Patients with uncompleted records were excluded. Boarding was defined as the inability to transfer the admitted ED patients to a downstream ward in ≥2 h after the admission order. Demographic data, boarding rate, mortality and triage levels (1-5) assessed by emergency severity index were collected and analyzed. The first present time of patients was classified into 4 ranges as 0:00-5:59, 6:00-11:59, 12:00-17:59 and 18:00-23:59. Descriptive, parametric and non-parametric statistical tests were performed and the risk of boarding was determined by Pearson Chi-square test.

RESULTS

Demographic data analysis showed that 941 (58.5%) male and 667 (41.5%) female, altogether 1608 patients were included in this study. Five patients (0.3%) died. The distribution of patients with the triage levels 1-5 was respectively 79 (4.9%), 1150 (71.5%), 374 (23.3%), 4 (0.2%) and 0 (0%). Most patients were of level 2. Only 75 (4.7%) patients required intensive care. The majority of patients (84.2%) were presented at weekdays. The maximum patient load was observed between 12:00-17:59. Of the 1608 patients, 340 (21.1%) experienced boarding within a mean admission time of 13.70 h. Among the 340-boarded patients, 20.1% belonged to surgery, 12.1% to orthopedics, 10.9% to neurosurgery and 10.3% to neurology. The boarding rate was higher in females, patients requiring intensive care and those with low triage levels. Compared with the non-boarded, the boarded patients had a higher mean age.

CONCLUSION

The boarding rate is higher in the older and female patients. Moreover, boarding is dependent on the downstream ward sections: patients requiring surgical management experience the maximum boarding rate.

Evaluation of preventable trauma death in emergency department of Imam Reza hospital

BACKGROUND

Trauma is considered as a worldwide problem despite socio-economic development. Motor vehicle accidents (MVAs) are the most important cause of trauma. Trauma related deaths are mostly preventable. This study aimed to investigate the causes and prevention of death in trauma patients.

METHODS

This retrospective, descriptive-analytic study assessed 100 trauma patients referred to our emergency department (ED) from January 2013 to Januanry 2015. The included patients were those with trauma died after arrival at our ED. Age, sex, cause of trauma, clinical causes of death, causes of death defined by autopsy, way of transfer to the ED, time of ambulance arrival at the scene of trauma, and time elapsed to enter the ED from the scene of trauma were studied.

RESULTS

In the 100 patients, 21 (21%) patients were female and 79 (79%) male. Forty-three patients were older than 60 years. Trauma was largely due to pedestrian accidents in 31% of the patients, and 33% had a hypo-volemic shock. About 80% of deaths were due to intra-cranial hemorrhage (ICH) or intra-ventricular hemorrhage (IVH), and spinal injuries were not preventable. Autopsy revealed that 28% of the patients suffered from internal injuries. Autopsy revealed that 19% of the deaths were not preventable and 81% were considered preventable. In our patients, 76 were transferred to the hospital by emergency medicine services (EMS). Analysis of time for ambulance arrival to the scene and frequency of death revealed that 52.2% of the deaths occurred between 11 and 15 minutes. Analysis of time for admission to the ED from the scene of trauma showed that 74.6% deaths occurred between 6 and 10 minutes.

CONCLUSIONS

The rate of hospital preventable deaths is about 80%, a high mortality rate, which denotes a lack of proper diagnosis and treatment. The time for arrival of EMS at the scene of trauma is longer than that in other countries.

Clinical findings provide criteria to evaluate priorities of ophthalmologic intervention in conscious multiple trauma patients

INTRODUCTION

Multiple trauma patients frequently suffer eye injuries, especially those patients with head traumas. We evaluated the accuracy of physical findings to determine the priorities of emergency ophthalmologic intervention in these patients.

PATIENTS AND METHODS

This study included all multiple trauma patients with ophthalmic trauma who had a GCS of 15 when they arrived at the emergency department during the period of March, 2008-March, 2009. First, we evaluated the patients according to the criteria of the study. Then, an ophthalmologist evaluated them.

RESULT

From March 2008-March 2009, 306 multiple trauma patients with ocular trauma came to our ED. The sensitivity and accuracy of emergency physicians in diagnosing the priority of ophthalmologic treatment were comparable to an ophthalmologist (measure of agreement in kappa=0.967).

DISCUSSION

The ability of an emergency physician or general surgeon to determine the actual need of early ophthalmologist intervention can improve decision making and saving both time and money. Our study suggests that it is possible to determine according to clinical findings the need of the patient to have ophthalmologic intervention without referring the patient to ophthalmologist examination.

CONCLUSION

Defining specific criteria of ophthalmologic examinations can clarify the necessity of emergency ophthalmologic examination and intervention.

Using an Artificial Neural Networks (ANNs) Model for Prediction of Intensive Care Unit (ICU) Outcome and Length of Stay at Hospital in Traumatic Patients

INTRODUCTION

Currently applications of artificial neural network (ANN) models in outcome predicting of patients have made considerable strides in clinical medicine. This project aims to use a neural network for predicting survival and length of stay of patients in the ward and the intensive care unit (ICU) of trauma patients and to obtain predictive power of the current method.

MATERIALS AND METHODS

We used Neuro-Solution software (NS), a leading-edge neural network software for data mining to create highly accurate and predictive models using advanced preprocessing techniques, intelligent automated neural network topology through cutting-edge distributed computing. This ANN model was used based on back-propagation, feed forward, and fed by Trauma and injury severity score (TRISS) components, biochemical findings, risk factors and outcome of 95 patients. In the next step a trained ANN was used to predict outcome, ICU and ward length of stay for 30 test group patients by processing primary data.

RESULTS

The sensitivity and specificity of an ANN for predicting the outcome of traumatic patients in this study calculated 75% and 96.26%, respectively. 93.33% of outcome predictions obtained by ANN were correct. In 3.33% of predictions, results of ANN were optimistic and 3.33% of cases predicted ANN results were worse than the actual outcome of patients. Neither difference in average length of stay in the ward and ICU with predicted ANN results, were statistically significant. Correlation coefficient of two variables of ANN prediction and actual length of stay in hospital was equal to 0.643.

CONCLUSION

Using ANN model based on clinical and biochemical variables in patients with moderate to severe traumatic injury, resulted in satisfactory outcome prediction when applied to a test set.

Characteristics of Fatal Occupational Traumatic Injuries; Drama in East Azerbaijan Province of Iran

OBJECTIVES

To determine the characteristics and etiologies of occupational trauma associated mortality in Tabriz megacity, Northern Iran.

METHODS

In a cross-sectional study, we included all the recorded cases of occupational mortalities referring to Tabriz forensic medicine center, labor institute and Imam Reza and Sina hospitals between March 2011 and March 2012. We recorded the demographic and clinical characteristics including age, gender, type of occupational accident, experience of work and permanent or temporary jobs for all the cases. The death etiology was also recorded according to the forensic medicine report. The data are presented as descriptive analytics.

RESULTS

Overall we included 32 occupational trauma associated mortality out of whom 30 (93.8%) were men and 2 (6.2%) were women. The mean age of the patients was 44.1±16.3 years old with most of them (31.3%) being younger than 30 years old. The occupation was recorded to be structural in 13 (40.6%), industrial in 5 (15.6%), agricultural in 5 (15.6%) and office work in 6 (18.8%). In 20 (62.5%) patients the occupation was seasonal and in 12 (37.5%) was permanent. Summer was the most common season in which occupational trauma associated mortality was recorded (40.6%) followed by fall by 34.4% of all mortalities. Most frequent causes of occupational traumas were the result of nonuse of safety wares (71.9%), inattention during work time (84.4%) and inappropriate instructions (18.8%).

CONCLUSION

Most of the fatalities occurred in young and less-experienced workers, not having enough attention while working. Regarding this fact we conclude that with continuous education and supervision especially in young workers, most of the occupational accidents are preventable.

Success Rate of Pre-hospital Emergency Medical Service Personnel in Implementing Pre Hospital Trauma Life Support Guidelines on Traffic Accident Victims

OBJECTIVES

Road traffic injuries are responsible for a vast number of trauma-related deaths in middle- and low-income countries. Pre-hospital emergency medical service (PHEMS) provides care and transports the injured patients from the scene of accident to the destined hospital. The PHEMS providers and paramedics were recently trained in the Pre Hospital Trauma Life Support (PHTLS) guidelines to improve the outcome of trauma patients in developing countries. We decided to carry out a study on the success rate of PHEMS personnel in implementing PHTLS guidelines at the scene of trauma.

METHODS

Severe trauma patients who had been transferred to the emergency department were included in the study. Evaluations included transfer time, airway management, spinal immobilization, external bleeding management, intravenous (IV) line access, and fluid therapy. All evaluations were performed by an expert emergency physician in the emergency department.

RESULTS

The mean response time was 17.87±9.1 minutes. The PHEMS personnel immobilized cervical spine in 60.4% of patients, out of whom 16.7% were not properly immobilized. Out of 99 (98%) cases of established IV line access by the PHEMS providers, 57% were satisfactory. Fluid therapy, which was carried out in 99 (98%) patients by the PHEMS personnel, was appropriate in 92% of the cases.

CONCLUSIONS

PHEMS personnel need more education and supervising to provide services according to PHTLS guidelines.

Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks

Background

The intent of this study was to predict conversion of laparoscopic cholecystectomy (LC) to open surgery employing artificial neural networks (ANN).

Methods

The retrospective data of 793 patients who underwent LC in a teaching university hospital from 1997 to 2004 was collected. We employed linear discrimination analysis and ANN models to examine the predictability of the conversion. The models were validated using prospective data of 100 patients who underwent LC at the same hospital.

Results

The overall conversion rate was 9%. Conversion correlated with experience of surgeons, emergency LC, previous abdominal surgery, fever, leukocytosis, elevated bilirubin and alkaline phosphatase levels, and ultrasonographic detection of common bile duct stones. In the validation group, discriminant analysis formula diagnosed the conversion in 5 cases out of 9 (sensitivity: 56%; specificity: 82%); the ANN model diagnosed 6 cases (sensitivity: 67%; specificity: 99%).

Conclusion

The conversion of LC to open surgery is effectively predictable based on the preoperative health characteristics of patients using ANN.

A histopathological study of esophageal cancer on the western side of the Caspian littoral from 1994 to 2003

Esophageal cancer (EC) accounts for a considerable proportion of carcinomas of the upper gastrointestinal tract in the population of the Caspian littoral. The global histologic pattern of the disease has changed recently. The intent of this study was to determine the incidence of EC over the past decade in Eastern Azerbaijan--a north-western province of Iran--on the western side of the Caspian littoral and to assess the alteration of the histological pattern of the disease. In a retrospective study, all 1792 documented EC cases of all registered cancer, surgery, pathology, and radiotherapy centers of the province over a period of 9 years (from March 1994 to March 2003) were enrolled in the study. Data concerning demographic characteristics, EC risk factors, and histological findings were recorded. The incidence and the relative incidence of the pathological subtypes of EC in the population of the province were determined. The change in incidence rates and the interaction between main risk factors and tumor histology of the patients were assessed over the study years. The average incidence of EC in the over 30-year-old population of the province was 16.2 (12.7 for squamous cell carcinoma [SCC] and 1.9 for adenocarcinoma [AC]) cases per 100 000 person-years. Incidence of SCC, as well as AC, peaked at ages older than 65. Compared to women, men had higher incidences of AC and lower incidences of SCC; the average incidence rate of EC was equal in men and women. AC and SCC accounted for 12.8% and 86.9% of cases, respectively. Upper, middle and lower thirds of the esophagus were the location of tumors in 9.8%, 32.9% and 57.3% of cases, respectively. During the study period, incidence rates of EC and SCC tended to decrease. The incidence rate of EC from 1995 to 1998 was almost 30% higher than that of the period from 1999 to 2002. Incidence rate of EC on the western side of the Caspian littoral is moderately high, but much lower than that of the eastern Caspian littoral as it was three decades ago. The incidence of EC was lower in the second half than the first half of the study period. Unlike the global pattern of EC, the incidence of EC as well as SCC in women is as high as or higher than in men, which is identical to the pattern in the eastern Caspian littoral.

Efficacy and safety of early laparoscopic common bile duct exploration as primary procedure in acute cholangitis caused by common bile duct stones

INTRODUCTION

The elective laparoscopic management of common bile duct (CBD) stones is widely accepted; however, the urgent laparoscopic exploration of common bile duct (LCBDE) within the first 72 hours of acute cholangitis is not assessed extensively. Our aim was to study the safety and efficacy of urgent LCBDE in patients with acute cholangitis.

MATERIALS AND METHODS

In a single-center prospective study, 73 patients of a university hospital with acute gallstone cholangitis were operated on with laparoscopy or open surgery, based on a predetermined schedule concerning the presence of the skilled laparoscopic surgeon at the hospital. Patients with sever acute cholangitis (e.g., organ failure, shock, or peritonitis), pancreatitis, and suspected tumoral obstructions were excluded. The major outcomes, including mortality, complications of surgery, and the length of hospital and intensive care unit (ICU) stay, are reported in this paper.

RESULTS

In all 36 open surgery patients, a choledocotomy and T-tube placement procedure were performed. In laparoscopic patients, CBD clearance was approached by a transcystic and choledocotomy approach in 15 and 22 subjects, respectively. Eight (6 in the open and 2 in the laparoscopic group) choledocoduodenostomies were performed. Cholangitis was controlled sufficiently in all patients. Of 37 laparoscopies, 3 operations were converted into open surgeries. Operation time was longer in the laparoscopic group, compared to the open group (201 +/- 15 vs. 146 +/- 6.1 minutes; P < 0.01). The average ICU and hospital stay after an operation were significantly less than open surgery group. Total cost of treatment in laparoscopic group was less than 75% of that of the open surgery group. General complications were more common in the open surgery group. There was no mortality. One retained stone was discovered in the laparoscopic group.

CONCLUSIONS

Early one-stage LCBDE is an effective procedure as an initial and definite management of acute gallstone cholangitis, which prevents a second hospitalization and relapse problems.