Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol

INTRODUCTION

Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs.

METHODS AND ANALYSIS

We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics.

ETHICS AND DISSEMINATION

The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities.

TRIAL REGISTRATION NUMBER

NCT05731349.

User perceptions of COVID-19 telemedicine testing services, disease risk, and pandemic preparedness: findings from a private clinic in Hong Kong

INTRODUCTION

During the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has been regarded as a method for providing safe access to healthcare. Here, we explored the experiences of individuals using telemedicine in Hong Kong during the COVID-19 pandemic to understand their risk perceptions and preparedness measures.

METHODS

We conducted a cross-sectional online survey of telemedicine users of private clinic-based COVID-19 testing services from 6 April to 11 May 2020. All users were invited to complete an anonymous online survey regarding COVID-19 risk perception and preparedness measures. The results of the survey were compared with the findings of a previous territory-wide survey.

RESULTS

In total, 141 of 187 telemedicine users agreed to participate; the response rate was 75.4%. Of the participants, 95.1% (116/122) believed that telemedicine consultations were useful. Nearly half of the participants (49.0%) agreed or strongly agreed that telemedicine consultations were appropriate during the COVID-19 pandemic. Most participants believed that telemedicine consultations could perform the functions of 'health protection, promotion and disease prevention' (73.6%) and 'diagnosis' (64.0%). Concerning the choice of telemedicine provider, almost all participants (99.2%) were willing to consult medical doctors; more than half of the participants (54.1%) were willing to consult registered nurses, but only 13.1% were willing to consult non-clinical staff who had been trained to provide telemedicine services.

CONCLUSION

The use of telemedicine for screening and patient education can be encouraged during the COVID-19 pandemic in Hong Kong.

RISC II is superior to TRISS in predicting 30-day mortality in blunt major trauma patients in Hong Kong

PURPOSE

Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK.

METHODS

This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models.

RESULTS

1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59 years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant.

CONCLUSION

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong.

Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study

INTRODUCTION

Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status.

METHODS

Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression.

RESULTS

726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition.

CONCLUSION

Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.

Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review

PURPOSE

This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses.

METHODS

Design was based on the PRISMA criteria and a systematic search of 6 databases was performed.

RESULTS

Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression.

CONCLUSIONS

Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

Cardiopulmonary resuscitation training in secondary education: A prospective cross-sectional survey of 110 Hong Kong secondary schools

Background:

Hong Kong rates of bystander cardiopulmonary resuscitation are very low by international standards. Several Hong Kong secondary schools have begun incorporating cardiopulmonary resuscitation training into their curriculums for teachers and students.

Objective:

This study aimed to explore secondary school cardiopulmonary resuscitation programs and better understand school principals’ attitudes toward cardiopulmonary resuscitation training.

Methods:

A cross-sectional survey was sent to all Hong Kong secondary school principals (public and private, except for special education schools) between December 2017 and March 2018. A self-administered questionnaire of 20 items focusing on school characteristics, details of any in-school cardiopulmonary resuscitation materials or training, attitudes toward teaching cardiopulmonary resuscitation, and any barriers or ways to promote school cardiopulmonary resuscitation training was given to all school principals in the territory. This study was approved by the Survey and Behavioural Research Ethics committee of the Chinese University of Hong Kong on September 13, 2017.

Results:

Out of the 506 schools contacted, 110 completed surveys were returned (21.7%). Cardiopulmonary resuscitation training was offered in 33.6% (37/110), while 92.7% (102/110) had an automatic external defibrillator. A majority (69.1% (76/110)) agreed or strongly agreed that cardiopulmonary resuscitation training should be compulsory for secondary school students. In schools where cardiopulmonary resuscitation was taught, most cardiopulmonary resuscitation students were aged 15–17 years, and most courses ran for < 5 h. Increased funding could encourage more schools to offer cardiopulmonary resuscitation training to students in the future.

Conclusion:

One-third (33.6%) of Hong Kong secondary schools offer cardiopulmonary resuscitation training. Increased funding may support school-based cardiopulmonary resuscitation instruction and improve rates of bystander cardiopulmonary resuscitation in the future.

Major trauma care in Hong Kong and Germany: a trauma registry data benchmark study

BACKGROUND

Trauma remains a leading cause of death and effective trauma management within a well-developed trauma system has been shown to reduce morbidity and mortality. A trauma registry, as an integral part of a mature trauma system, can be used to monitor the quality of trauma care and to provide a means to compare local versus international standards. Hong Kong and Germany both have highly developed health care services. We compared the performance of trauma systems including outcomes among major trauma victims (ISS > 15) over a 3-year period (2013-2015) in both settings using trauma registry data.

METHODS

This study was a retrospective analysis of prospectively collected data from trauma registries in Hong Kong and Germany. Data from 01/2013 to 12/2015 were extracted from the trauma registries of the five trauma centers in Hong Kong and the TraumaRegister DGU^® (TR-DGU). The study cohort included adults (≥ 18 years) with major trauma (ISS > 15). Data related to patient characteristics, nature of the injury, prognostic parameters to calculate the RISC II score, outcomes and clinical management were collected and compared.

RESULTS

Datasets from 1,864 Hong Kong and 10,952 German trauma victims were retrieved from respective trauma registries. The unadjusted mortality in Hong Kong (22.4%) was higher compared to Germany (19.2%); the difference between observed and expected mortality was higher in Hong Kong (+ 2.7%) than in Germany (- 0.5%). The standardized mortality ratio (SMR) in Hong Kong and Germany were 1.138 (95% CI 1.033-1.252) and 0.974 (95% CI 0.933-1.016), respectively, and the adjusted death rate in Hong Kong was significantly higher compared to the calculated RISC II data. However, patients in Hong Kong were significantly older, had more pre-trauma co-morbidities, more head injuries, shorter hospital and ICU stays and lower ICU admission rates.

CONCLUSION

Hong Kong had a higher mortality rate and a statistically significantly higher standardized mortality ratio (SMR) after RISC II adjustment. However, multiple differences existed between trauma systems and patient characteristics.

Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study

BACKGROUND

Trauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong.

METHODS

We report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked.

RESULTS

119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up.

CONCLUSIONS

After injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.

Cross-sectional study on emergency department management of sepsis

INTRODUCTION

Emergency departments (EDs) play an important role in the early identification and management of sepsis. Little is known about local EDs' processes of care for sepsis, adoption of international recommendations, and the impact of the new Sepsis-3 definitions.

METHODS

Structured telephone interviews based on the United Kingdom Sepsis Trust 'Exemplar Standards for the Emergency Management of Sepsis' were conducted from January to August 2017 with nominated representatives of all responding public hospital EDs in Hong Kong, followed by a review of hospital/departmental sepsis guidelines by the investigators.

RESULTS

Sixteen of the 18 public EDs in Hong Kong participated in the study. Among various time-critical medical emergencies such as major trauma, sepsis was perceived by the interviewees to be the leading cause of in-hospital mortality and the second most important preventable cause of death. However, only seven EDs reported having departmental guidelines on sepsis care, with four adopting the Quick Sequential Organ Failure Assessment score or its modified versions. All responding EDs reported that antibiotics were stocked within their departments, and all EDs with sepsis guidelines mandated early intravenous antibiotic administration within 1 to 2 hours of detection. Reported major barriers to optimal sepsis care included lack of knowledge and experience, nursing human resources shortages, and difficulty identifying patients with sepsis in the ED setting.

CONCLUSION

There are considerable variations in sepsis care among EDs in Hong Kong. More training, resources, and research efforts should be directed to early ED sepsis care, to improve patient outcomes.

The PARIS score can reliably predict 7-day all-cause mortality for both acute medical and surgical patients: an international validation study

BACKGROUND

We believe errors in the risk assessment of acutely ill patients occur because only vital signs without concurrent functional capacity are considered. We, therefore, developed the PARIS risk score based on blood pressure, age, respiratory rate, loss of independence and oxygen saturation.

AIM

Validation of the PARIS score in four independent cohorts from three countries.

METHODS

Retrospective cohort study of acutely ill patients admitted to hospitals in Denmark, Ireland and Uganda. Vital signs and functional capacity (registered as ability to stand or walk or get into bed unaided) was recorded upon arrival. Patients were followed up for 7 days (Denmark and Ireland) or until discharge (Uganda) and mortality recorded. The discriminatory power (ability to identify patients at increased risk) was determined using area under the receiver operating characteristics curve (AUROC) and calibration (precision) using Hosmer-Lemeshow goodness of fit test.

RESULTS

Out of 14 447 patients, 327 (2.3%) died within 7 days: median age was 59 (39-75) years and 7458 (51.8%) were female. Seven-day mortality increased from 0.3% with a score of 0-26.7% with a score of 5. The score's AUROC as 0.833 [95% confidence interval (95% CI) 0.811-0.856], 0.817 (95% CI 0.792-0.842) and 0.894 (95% CI 0.813-0.974) for all patients, medical patients and surgical patients, respectively. However, except for surgical patients, calibration of the score was poor.

CONCLUSION

The PARIS score can identify both high and low risk acutely admitted medical and surgical patients, but calibration was poor for medical patients.

Health Status following Major Trauma in the West of Scotland: Pilot Descriptive Study

Background

Data on the long-term outcome of major trauma survivors in the United Kingdom (UK) is lacking. This pilot study aimed to investigate the health status of survivors of major trauma without significant head injury in the West of Scotland, and to compare the Short-Form 12 (SF12) questionnaire administered by telephone (TSF12) to the longer Short-Form 36 (SF36) questionnaire.

Methods

This was a descriptive, comparative, pilot clinical study. Eligible patients had an injury severity score (ISS) >15, sustained their injuries >2 years ago, abbreviated injury score (AIS) <2 for head trauma and were treated in two Glasgow hospitals. The Short-Form 36 (SF36) health status questionnaire was completed at home, and the Short-Form 12 (SF12) questionnaire was administered by telephone (TSF12).

Results

From 141 eligible patients (85% male, median age 35 years, median ISS 19 and median Ps 0.981), 13 patients completed the study. Despite small numbers, mean SF36 scores were significantly lower in four dimensions compared to UK means. SF36 summary scores were non-significantly below US and UK means. The TSF12 physical summary score was significantly below US and UK means. Correlations between the SF36 and TSF12, and SF12 intra-class correlations were high. One-way ANOVA showed significantly lower mental summary scores for patients with spinal injuries.

Conclusions

This small study suggests that non-head injured survivors of major trauma have lower health status than the UK average. The TSF12 appears to be a practical alternative to the conventional SF36 and warrants larger scale evaluation.

Pain and Pain Management in a Hong Kong Emergency Department

Background

The prevalence of pain is high in emergency departments (ED), according to previous studies. There is little information on the epidemiology of pain in Hong Kong EDs. This study aimed to explore the epidemiology of pain in a single academic ED in Hong Kong, and to evaluate the pain management policy in the ED.

Methods

Retrospective case review study with explicit record review of ED clinical records; records obtained by means of systematic sampling of a seven-consecutive-day period attendance. Data on the prevalence and location of pain, waiting time for drugs for pain relief, and pain drug prescription rates were obtained. Descriptive data analysis was performed.

Results

A total of 494 ED clinical records were reviewed. The prevalence of pain was 60.7% (300/494) during the study period. 72.3% (217/300) of patient attendances with pain had duration of pain not exceeding three days; 79.0% (237/300) of them were classified as ‘semi-urgent’ or ‘non-urgent’. 41.7% (125/300) of patients suffering from pain were given drugs for pain relief. The median time for patients to receive analgesic drugs was 56.0 (IQR 25.0-104.5) minutes after registration. Pain assessment using a numerical rating scale was positively associated with drug prescriptions for pain relief.

Conclusion

The prevalence of pain in ED patients was high, and comparable with the figures from studies in other EDs. Patients attending with pain had to wait more than 60 minutes for drugs for pain relief on average. (Hong Kong j.emerg.med. 2011;18:406-411)

Emergency Physicians' Preparedness for CBRNE Incidents in Hong Kong

Background

Recent terrorist attacks with biological and chemical weapons have caused much concern for the public. The purpose of this study was to assess emergency doctors' preparedness in handling Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) incidents.

Methods

This is a cross sectional survey of all emergency doctors working in public emergency departments (ED) in Hong Kong. Apart from the experience and confidence to handle these events, data on participants' willingness to participate in CBRNE incidents and training motivations were also analysed.

Results

Biological and radiological events were found to be the least commonly encountered. Few respondents reported they were confident to manage biological events (10.6% to 29.8%), despite 66% of respondents reported having prior training in CBRNE management.

Conclusions

This study demonstrates ED doctors' low confidence in managing specific CBRNE incidents. Current strengths identified include the good awareness of hospital emergency plans and high motivation to get more training.

The Epidemiology of Patients with Dizziness in an Emergency Department

Objectives

The aims of this prospective study were (1) to describe the patterns of presentation, causes and disposition of patients with dizziness in an emergency department (ED) and (2) to identify the factors that predict central vestibular disorder.

Methods

All adult patients (≥18 years) attending our ED with a chief complaint of dizziness were included. Demographic characteristics, presenting complaint, symptoms, past medical illnesses, physical findings, provisional diagnosis and disposition were recorded in a data collection sheet by the medical officers.

Results

A total of 104 consecutive dizzy patients were recruited from 12th to 19th December 2003. The incidence of adult patients with dizziness was 4.0% (104/2594). There were 34 (32.7%) male and 70 (67.3%) female patients; 64 (61.5%) patients were below 65 and 40 (38.5%) were above 65. Lightheadedness (61.5%), vertigo (31.7%) and disequilibrium (4.8%) were the most frequent complaints. Nausea and/or vomiting (32.7%) and raised blood pressure on arrival (23.1%) were the most common associated symptoms and physical finding respectively. Hypertension (38.5%) was the most common pre-existing medical illness. Of all patients, 63.5% had non-vestibular disorder, 31.7% had peripheral vestibular disorder and 4.8% had central vestibular disorder. A clinical diagnosis could be made in 52.9% of our dizzy patients and about 20 different diagnoses were made. The majority (82.7%) of the patients were discharged from the ED. A presenting complaint of lightheadedness, altered mental state, focal neurological signs, raised blood pressure and history of stroke were predictors of central vestibular disorder (p<0.05).

Conclusions

Lightheadedness and vertigo were the two commonest presentations of dizzy patients. Most dizzy patients had benign causes and could be discharged from the ED. Lightheadedness, focal neurological symptoms and signs, altered mental state, hypertension and previous stroke were factors that would help to diagnose central vestibular disorder.

Fatal Pulmonary Embolism in a Teenager: Case Report

Massive pulmonary embolism is unusual in young people. We present a case of massive pulmonary embolism in a teenage Chinese patient. Initially he presented to the emergency department with dyspnoea and fever. Influenza B was diagnosed during his four-day stay in the paediatric ward. One week later he suddenly collapsed and presented to the emergency department with chest pain, syncope and dyspnoea. Despite undergoing rapid assessment, along with prompt admission to intensive care and cardiopulmonary resuscitation, he died. Autopsy revealed massive pulmonary embolism, which is rare at this age. Computed tomography pulmonary angiography and early thrombolytic therapy may improve the outcome in similar cases.

Preferences and Perceptions of Patients Attending Emergency Departments with Low Acuity Problems in Hong Kong

Objective

To explore why patients in Hong Kong seek medical advice from the emergency department (ED) and to identify the methods by which patients would prefer to be updated on the likely waiting time for medical consultation in the ED.

Methods

The study recruited 249 semi-urgent and non-urgent patients in the ED of Prince of Wales Hospital from 26th September 2005 to 30th September 2005 inclusive. A convenience sample of subjects aged ≥15 years old in triage categories 4 or 5 were verbally consented and interviewed by research nurses using a standardized questionnaire.

Results

From 1715 potential patients, 249 were recruited ad hoc (mean age 44 years [SD18]; 123 females). About 63% indicated that an acceptable ED waiting time was less than or equal to two hours, and 88% felt that having individual number cards and using a number allocation screen in the ED waiting area would be useful. Perceived reasons for attending the ED rather than other health care providers such as primary health care or the general outpatient clinic (GOPC) included: a desire for more detailed investigations (56%); a perception that more professional medical advice was given in the ED (35%); patients were under the continuing care of the hospital (19%); and patients were referred to the ED by other health care professionals (11%). Notably, 26% of participants had considered attending the GOPC prior to attending the ED. Patients educated to tertiary level expected a shorter waiting time than those educated to lesser degrees (p=0.026, Kruskal-Wallis test). Suggestions were made on how to provide a more pleasant ED environment for the wait for consultations, which included the provision of a television screen with sound in the waiting area (43%), more comfortable chairs (37%) and health care promotion programs (32%).

Conclusion

Patients chose ED services because they believed they would receive more detailed investigations and more professional medical advice than available alternatives. Clear notification of the likely waiting times and enhancement of comfort before consultation are considered desirable by patients. Enhanced public education about the role of the ED and making alternatives to ED care more accessible may be useful in reducing inappropriate ED attendances in Hong Kong.

Undergraduate Emergency Medicine Training: Past, Present and Future

This article briefly reviews the development of emergency medicine (EM) in Hong Kong with particular focus on the parallel development of training in EM at the undergraduate level. The practice of EM in Hong Kong started more than 50 years ago but the development of the specialty progressed slowly until the 1980s. Since then, although there have been major advances in postgraduate training, the specialty still features poorly in undergraduate medical training. We compared emergency medicine training in Hong Kong, Australia, USA, UK and Singapore, in order to identify areas in the medical curriculum where EM could contribute more to undergraduate medical training. The growth of EM in Hong Kong depends on recruiting good trainees who are attracted by what they observe and what they learn during their undergraduate EM clerkship.

A Pilot Randomised Clinical Trial of 3-In-1 Femoral Nerve Block and Intravenous Morphine as Primary Analgesia for Patients Presenting to the Emergency Department with Fractured Hip

Background

Fractured neck of femur (NOF) is a leading cause of morbidity and mortality in the elderly. Published clinical guidelines suggest early adequate analgesia as a key management aim. The femoral nerve ‘3-in-1 block’ has previously been shown to provide effective analgesia for these patients in the peri- and post-operative phase of care. The aim of this study was to examine the use of the ‘3-in-1’ femoral nerve block as primary analgesia for patients with a fractured NOF presenting to the emergency department.

Methods

This was a single centre pragmatic randomised controlled open-label trial comparing femoral nerve block (using a ‘3-in-1’ technique) with intravenous (IV) morphine. A convenience sample of patients presenting to the emergency department of a district general hospital with a clinically or radiologically suspected fractured NOF were recruited. They were randomised to receive either 0.1 mg/kg IV bolus of morphine or a ‘3-in-1’ femoral nerve block with 30 ml of 0.5% plain bupivacaine. Visual analogue pain scores were noted prior to treatment and at 30 minutes, 2 hours, 6 hours and 12 hours after treatment. Immediate complications such as vascular puncture or the requirement for naloxone were noted.

Results

Forty patients were recruited, 22 patients were randomised to IV morphine and 18 patients were randomised to ‘3-in-1’ femoral nerve block. Complete data were available for 33 patients. There was no significant difference in initial median pain score (p=0.45). Analysis using the Wilcoxon test showed a significant decrease in pain score for the morphine group (p=0.01) and the nerve block group (p<0.01) at 30 minutes compared with baseline. Analysis using the Mann-Whitney U test between median pain scores at each time point showed a significant lower pain score in the nerve block group at 30 minutes (p=0.046). There were no immediate complications in either group.

Conclusion

Our results suggest that a ‘3-in-1’ femoral nerve block is at least as effective as IV morphine when used as primary analgesia for patients with fractured NOF. Our results suggest that the femoral nerve block may provide better analgesia at 30 minutes. Further larger scale randomised trials are warranted.

Differences in Injury Pattern and Mortality between Hong Kong Elderly and Younger Patients

Background

The rapidly aging population in Hong Kong is causing an impact on our health care system. In Hong Kong, 16.5% of emergency department trauma patients are aged ≥65 years.

Objective

We aim to compare factors associated with trauma and differences in trauma mortality between elderly (≥65 years) and younger adult patients (15 to 64 years) in Hong Kong.

Methods

A retrospective observational study was performed using trauma registry data from the Prince of Wales Hospital, a 1200–bed acute hospital which is a regional trauma centre.

Results

A total of 2172 patients (331 [15.2%] elderly and 1841 [84.8%] younger) were included. Male patients predominated in the younger adult group but not in the elderly group. Compared with younger patients, elderly patients had more low falls and pedestrian-vehicle crashes and sustained injuries to the head, neck and extremities more frequently. The odds ratio (OR) for death following trauma was 5.5 in the elderly group (95% confidence interval [CI] 3.4–8.9, p>0.0001). Mortality rates increased progressively with age (p>0.0001) and were higher in the elderly at all levels of Injury Severity Score (ISS). Age ≥65 years independently predicted mortality (OR=5.7, 95% CI 3.5–9.3, p>0.0001). The elderly had a higher co-morbidity rate (58.6% vs. 14.1%; p>0.01). There was a lower proportion of trauma call activations for the elderly group (38.6% vs. 53.3%; p>0.01).

Conclusion

Elderly trauma patients differ from younger adult trauma patients in injury patterns, modes of presentation of significant injuries and mortality rates. In particular, the high mortality of elderly trauma requires renewed prevention efforts and aggressive trauma care to maximise the chance of survival.

Management of Suspected Deep Venous Thrombosis in an Emergency Medicine Ward in Hong Kong

Introduction

Clinical signs and symptoms can vary for patients with deep venous thrombosis (DVT). DVT is an important diagnosis to recognise as it can lead to proximal embolism into the pulmonary circulation resulting in sudden collapse and death. The objective of this study is to describe the management of patients with suspected DVT in the emergency medicine ward (EMW) setting in Hong Kong using a standardised clinical pathway.

Methods

A retrospective review was conducted for patients with suspected DVT admitted to the EMW from April to December 2008 using a standardised protocol. The use of a clinical prediction rule and diagnostic tests (including the modified Well's score, D-dimer and ultrasound examination) and outcomes (including the length of stay and secondary admission rate) were investigated.

Results

A total of 100 patients with suspected DVT were admitted to the EMW in the nine-month study period. DVT was confirmed in 30% using ultrasonography. Fifty-two percent of patients were in the high-risk category according to the modified Well's score. Seventy-six percent of patients had positive D-dimer results. Ten percent of patients were safely discharged without an ultrasound examination. Mean length of stay in the EMW was 1.99 days. Thirteen percent of patients required second admission to other specialties.

Conclusions

This study suggests that a standardised clinical pathway based in the EMW can be used for patients with suspected DVT to reduce hospital admission.

Treatment and Outcome of Acute Cardiogenic Pulmonary Oedema Presenting to an Emergency Department in Hong Kong: Retrospective Cohort Study

Objectives

To explore the epidemiology, treatment and outcome of acute cardiogenic pulmonary oedema (ACPO) in a Hong Kong emergency department (ED).

Methods

This was a retrospective cohort study in a university hospital ED. Cases were identified from ED records and resuscitation room logbooks. The study extended from 1 September 2004 to 30 April 2005. Parametric tests and logistic regression were used to identify predictors of survival.

Results

A total of 140 patients were identified, with a mean age of 75 years and male:female ratio of 1:1.4. Mean values (range) on presentation were as follows: pulse rate 103 beats/minute (36–108); blood pressure (BP) 169/88 mmHg (77-274/20-162) and respiratory rate 31 breaths/minute (12–88). Past medical history included previous ACPO (12.1%), diabetes (45.7%), chronic obstructive pulmonary disease (9.3%), ischaemic heart disease (45.0%), hypertension (72.1%) and congestive heart failure (40.7%). On admission, 47.1% had pH<7.35 and 40.7% had PaCO2>5.5kPa. ED treatments included: sublingual nitrates (n=2), intravenous (IV) nitrates (n=89, median 10 mg/hr), IV frusemide (n=85, median 40 mg), IV morphine (n=25, median 3 mg). There were 21 patients on non-invasive ventilation; 27 intubations and 41 patients were admitted to the intensive care unit. Survival to discharge was 95.7%; and median length of hospital stay was 8 days. The 90-day all-cause hospital readmission rate was 30.0%. The 30-day mortality was 12.9% (n=18) and 90-day mortality was 29.3% (n=41). Logistic regression showed that past history of hypertension (p=0.0061), higher systolic BP on ED discharge (p=0.0102) and lower creatinine following treatment (p=0.035) were predictors of improved survival at 90 days.

Conclusion

ACPO commonly presents to the ED in Hong Kong and has a high 90-day mortality. Previous hypertension, higher systolic blood pressure on leaving the ED and lower creatinine following treatment predict improved survival at 90 days.

Nurses Treating Patients in the Emergency Department? a Patient Survey

Background

Hong Kong residents are familiar with prolonged waiting times in emergency departments (ED), particularly with semi-urgent or non-urgent conditions. In the United Kingdom and Australasia, extended nurse practitioners are well established. The aim of this study was to identify whether Hong Kong patients would prefer treatment by ED nurses or traditional care by doctors under various waiting time conditions.

Methods

This was a prospective questionnaire study of patients who had been triaged into category 4 (semi-urgent) or 5 (non-urgent) during office hours from 20 to 27 June 2005. Following verbal consent, three waiting time scenarios were considered by the patient using an interviewer-administered structured questionnaire. Statistical analysis used the chi square test.

Results

Overall, 253 patients were approached and 249 patients [119 (47.8%) male; mean age 48 (SD 19.4) years] verbally agreed to participate (98.4%). Patients were classified into three age groups. When the waiting time for nurse treatment was four hours shorter than doctors, patients aged 15–30 and 31–64 years more often chose nurses (overall 59.3%) for treatment but those aged ≥65 years preferred doctors to nurses (58.1% in favour of doctors), despite the longer waiting time (p=0.013, chi square test). Men also preferred nursing treatment compared to women (p<0.001). When the waiting time for doctors was 4 hours shorter than nurses or the same, 99.2% and 95.5% chose doctors respectively.

Conclusion

When the waiting times are long, Hong Kong patients <65 years would prefer to see suitably trained nurses in preference to doctors. Consideration should be given to providing training for senior nurses to have an extended role in Hong Kong EDs.

Circulating human leucine-rich α-2-glycoprotein 1 mRNA and protein levels to detect acute appendicitis in patients with acute abdominal pain

BACKGROUND

Elevated levels of circulating plasma and urine leucine-rich-2-glycoprotein-1 (LRG1) protein has been found in patients with acute appendicitis (AA) and may be useful for diagnosis. This study aimed to investigate whether combined tests including circulating LRG1 mRNA levels improve the early diagnosis of AA.

METHODS

Between December 2011 and October 2012, a prospective study was conducted on patients aged 18years or older presenting to the ED with acute abdominal pain (<7days of symptom onset). Levels of whole blood LRG1 mRNA and plasma LRG1 protein taken from these patients within 24h of arrival (mean 12.4h) were analyzed. The primary outcome was AA.

RESULTS

Eighty-four patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35years; 41.6% males) were recruited. Median whole blood LRG1 mRNA and plasma LRG1 levels were higher in AA patients than in non-AA. Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA. In ROC analysis of LRG1 mRNA (normalized to GAPDH), LRG1 protein and Alvarado score for discriminating AA and non-AA, the areas under the curve (AUC) were 0.723, 0.742 and 0.805 respectively. The AUC of combination of normalized LRG1 mRNA, LRG1 protein and Alvarado score was 0.845.

CONCLUSION

A combination of modified whole blood LRG1 mRNA levels, plasma LRG1 protein and Alvarado score at the ED may be useful to diagnose simple and complicated AA from other causes of abdominal pain.

Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey

Objective

To estimate the prevalence of painful sex among women in Britain, and to explore associated sexual, relationship and health factors that should be considered in assessment.

Design

Multi‐stage, clustered and stratified population probability sample survey, using computer‐assisted self‐interview. Sample frame was the British Postcode Address File.

Setting

Participants interviewed at home between 2010 and 2012.

Sample

A total of 15 162 adults aged 16–74 years (8869 women). Data reported from 6669 sexually active women.

Methods

Age‐adjusted logistic regressions to examine associations between painful sex and indicators of sexual, relational, mental and physical health.

Main outcome measure

Physical pain as a result of sex for ≥3 months in the past year, plus measures of symptom severity.

Results

Painful sex was reported by 7.5% (95% CI 6.7–8.3) of sexually active women, of whom one‐quarter experienced symptoms very often or always, for ≥6 months, and causing distress. Reporting painful sex was strongly associated with other sexual function problems, notably vaginal dryness (age adjusted odds ratio 7.9; 6.17–10.12), anxiety about sex (6.34; 4.76–8.46) and lacking enjoyment in sex (6.12; 4.81–7.79). It was associated with sexual relationship factors [such as not sharing same level of interest in sex (2.56; 1.97–3.33)], as well as with adverse experiences such as non‐volitional sex (2.17; 1.68–2.80). Associations were also found with measures of psychological and physical health, including depressive symptoms (1.68; 1.28–2.21).

Conclusion

Painful sex is reported by a sizeable minority of women in Britain. Health professionals should be supported to undertake holistic assessment and treatment which takes account of the sexual, relationship and health context of symptoms.

Tweetable abstract

Painful sex—reported by 7.5% of women in Britain—is linked to poorer sexual, physical, relational and mental health.

Painful sex–reported by 7.5% of women in Britain–is linked to poorer sexual, physical, relational and mental health.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14518.

Oral Prednisolone in the Treatment of Acute Gout: A Pragmatic, Multicenter, Double-Blind, Randomized Trial

BACKGROUND

Two recent double-blind, randomized, controlled trials (RCTs) showed that oral steroids and nonsteroidal anti-inflammatory drugs have similar analgesic effectiveness for management of gout, but the trials had small sample sizes and other methodological limitations.

OBJECTIVE

To compare the effectiveness and safety of oral prednisolone versus oral indomethacin in patients presenting to emergency departments (EDs) with acute gout.

DESIGN

Multicenter, double-blind, randomized equivalence trial. Patients were randomly assigned (1:1 ratio) to receive either indomethacin or prednisolone. (ISRCTN registry number: ISRCTN45724113).

SETTING

Four EDs in Hong Kong.

PARTICIPANTS

416 patients aged 18 years or older.

MEASUREMENTS

Analgesic effectiveness was defined as changes in pain (at rest or with activity) greater than 13 mm on a 100-mm visual analogue scale. Outcomes were measured during the first 2 hours in the ED and from days 1 to 14.

RESULTS

376 patients completed the study. Equivalent and clinically significant within-group reductions in mean pain score were observed with indomethacin and prednisolone in the ED (approximately 10 mm [rest] and 20 mm [activity]) and from days 1 to 14 (approximately 25 mm [rest] and 45 mm [activity]). No major adverse events occurred during the study. During the ED phase, patients in the indomethacin group had more minor adverse events than those in the prednisolone group (19% vs. 6%; P < 0.001). During days 1 to 14, 37% of patients in each group had minor adverse events.

LIMITATION

Diagnosis of gout was usually based on clinical criteria rather than examination of joint fluid.

CONCLUSION

Oral prednisolone and indomethacin had similar analgesic effectiveness among patients with acute gout. Prednisolone is a safe, effective first-line option for treatment of acute gout.

PRIMARY FUNDING SOURCE

Health and Health Services Research Grant Committee of the Hong Kong Government.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study

BACKGROUND

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome.

OBJECTIVES

To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong.

METHODS

Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome.

RESULTS

Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97).

CONCLUSION

For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Anthropometric and physiological measurements in healthy children

1. Normal ranges for ultrasonic cardiac output monitor-derived cardiovascular indices are derived for Chinese children aged 1 to 12 years in Hong Kong. 2. A simple formula for calculating stroke volume is constructed, but the error varies from 8 to 40%. 3. Stroke volume index and, to a lesser extent, the cardiac index generally increase from ages 1 to 5 years, but plateau or fall slightly thereafter.

Negative perceptions about condom use in a clinic population: comparisons by gender, race and age

We sought to elucidate the associations of 13 items assessing negative perceptions about condom use with gender, age and race in a sample of clinic attendees. Patients from four clinics, in three US cities, were recruited (N = 928). Data were collected using audio-computer-assisted self-interviewing. The primary measure was a 13-item adapted version of the Condom Barriers Scale. Logistic regression and chi-square tests were employed to relate the 13 items to gender, age and race. Gender, race and age all had significant associations with negative perceptions of condoms and their use. A primary finding was a large number of significant differences between men and women, with negative perceptions more common among women than among men. For African Americans, especially women, negative perceptions were more common among older participants than among younger participants. In conclusion, important demographic differences regarding negative perceptions may inform the tailoring of intervention efforts that seek to rectify negative perceptions about condoms and thus promote condom use among individuals at risk for sexually transmitted infections (STIs) in the USA. On the other hand, our findings also suggest that the majority of STI clinic attendees may hold positive perceptions about condoms and their use; maintaining and building upon these positive perceptions via education, counselling, and access is also important.

Children's Discomfort during Noninvasive Cardiac Output Monitoring by Suprasternal Ultrasonographic Transducer

Objectives

To investigate the level of discomfort/pain in children receiving Ultrasonic Cardiac Output Monitoring (USCOM), as compared to blood pressure measurement.

Methods

Healthy children, aged 3-12 years old, were recruited from kindergartens and schools as a part of the “Healthy children's vital signs and USCOM values” project. Oscillometric blood pressure was measured, followed by USCOM measurement. The discomfort experienced by the child during each intervention was assessed using the Wong-Baker FACES pain rating scale. The pain scores (scale from 0-5) were compared using Wilcoxon signed rank test. A difference in score of one point was considered to be clinically relevant. Gender differences in pain score were analysed using Mann-Whitney-U test.

Results

A total of 254 subjects (131 boys, 123 girls) were included. Mean age was 7.9 years with standard deviation (SD) of 2.4 years. The median pain score for USCOM measurement was 1.0 (95% CI=1.0 to 2.0) with interquartile range 1.0 to 2.0. The median pain score for BP measurement was 1.0 (95% CI,=1.0 to 1.0) with interquartile range 0.0 to 2.0. Overall, the pain score associated with USCOM was significantly higher than that associated with BP measurement. However, the difference fails to reach the minimum clinically significant difference of one-point. No significant difference was shown between boys and girls.

Conclusion

USCOM appears to be tolerated well by healthy children. The discomfort reported during USCOM measurement is comparable to that associated with blood pressure measurements.

Evaluating acute medical admissions through emergency departments in Hong Kong: can one adjust for case-mix variation?

BACKGROUND

Healthcare systems are under pressure to efficiently and safely reduce acute care admissions to hospital. There is a need to develop a standardised system for assessing emergency department performance which takes into account case-mix variation. The objective of this study was to derive and validate a standardised tool for assessing variations in medical admissions through emergency departments in Hong Kong.

METHODS

Retrospective study of patients attending emergency departments of 14 acute hospitals in Hong Kong. Data were retrieved from a centralised administrative database.

RESULTS

Of 2,531,225 patients who attended emergency departments between 1 January 2001 and 31 December 2003, 780,444 (30.8%) were admitted to medical wards. A model derived from 2001 data shows well-calibrated admission probabilities, with an area under the receiver operating characteristic curve for probability of admission of 90.3 (95% CI ±0.11). The areas under the receiver operating characteristic curves for 2002 and 2003 validation sets were 89.9 (95% CI ±0.11) and 89.0 (95% CI ±0.12), respectively. With an averaged benchmark, reductions in medical admissions of up to 19% could be achieved, while under the most optimistic assumption, reductions of up 36% could be achieved.

CONCLUSIONS

A tool for benchmarking hospital medical admissions and minimising case-mix variation has been derived and validated in Hong Kong, but it requires further validation in other healthcare systems given the wide variations in admission thresholds internationally. This may be used as one potential method to evaluate the performance of emergency departments against a common standard.

A comparison of condom use errors and problems for heterosexual anal and vaginal intercourse

Condom use errors and problems were compared for anal and vaginal intercourse among a convenience sample of heterosexual men aged 18-66 years (n = 757). Men completed an online questionnaire for the last male condom use event for penile-anal (10.4%) or penile-vaginal (89.6%) intercourse. The prevalence of condom use errors and problems was similar regardless of intercourse type with a few exceptions; those reporting anal intercourse were significantly more likely to report using water-based (P < 0.001) and oil-based (P = 0.037) lubricant and to remove condoms before sex was finished (P < 0.001). The large majority of the sample (93.8%) reported at least one of the nine errors assessed and almost half (46.2%) reported at least one of the seven problems, indicating that many adults may need assistance with these issues. Condom use promotion programmes designed for heterosexual adults are needed that address condom use errors and problems for penile-anal as well as penile-vaginal intercourse.

What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?

AIM

To describe the relationship of gag and cough reflexes to Glasgow coma score (GCS) in Chinese adults requiring critical care.

METHOD

Prospective observational study of adult patients requiring treatment in the trauma or resuscitation rooms of the Emergency Department, Prince of Wales Hospital, Hong Kong. A long cotton bud to stimulate the posterior pharyngeal wall (gag reflex) and a soft tracheal suction catheter were introduced through the mouth to stimulate the laryngopharynx and elicit the cough reflex. Reflexes were classified as normal, attenuated or absent.

RESULTS

A total of 208 patients were recruited. Reduced gag and cough reflexes were found to be significantly related to reduced GCS (p=0.014 and 0.002, respectively). Of 33 patients with a GCS≤8, 12 (36.4%) had normal gag reflexes and 8 (24.2%) had normal cough reflexes. 23/62 (37.1%) patients with a GCS of 9-14 had absent gag reflexes, and 27 (43.5%) had absent cough reflexes. In patients with a normal GCS, 22.1% (25/113) had absent gag reflexes and 25.7% (29) had absent cough reflexes.

CONCLUSIONS

Our study has shown that in a Chinese population with a wide range of critical illness (but little trauma or intoxication), reduced GCS is significantly related to gag and cough reflexes. However, a considerable proportion of patients with a GCS≤8 have intact airway reflexes and may be capable of maintaining their own airway, whilst many patients with a GCS>8 have impaired airway reflexes and may be at risk of aspiration. This has important implications for airway management decisions.

Open-access colonoscopy: outcomes of referrals from the emergency department

AIM

The study investigated the diagnostic outcome of colonoscopy referrals from the emergency department (ED) via an open-access system.

METHOD

A retrospective cohort study over two years was performed on all patients under 65 years referred for open-access colonoscopy by the ED in a hospital with an annual ED attendance of 140,000. Patient characteristics and presenting symptoms were retrieved. Waiting times from presentation to colonoscopy were recorded.

RESULTS

Over a 2-year period, 266 patients were referred, of whom 37 defaulted, leaving 229 patients who had a colonoscopy. The mean age was 48.3 ± 11.3 (SD) and the female/male ratio was 229/125. The most frequent presenting symptoms included: rectal bleeding (n = 142, 62%), change of bowel habit (n = 47, 20.5%) and abdominal pain (n = 40, 17.5%). The median waiting time from presentation to colonoscopy was 17 (range 1-69) days. A positive colonoscopic finding was recorded in 45.4%, including colorectal cancer in 12 (5.2%).

CONCLUSION

The rate of a positive diagnoses from the ED-based colonoscopy referral service was comparable to that of the general Hong Kong population. This approach may help to reduce the waiting time for colonoscopy in a specialist colorectal clinic.