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.

Should Differential White Cell Counts be Reported as Percentages or Absolute Counts in Patients with Severe Acute Respiratory Syndrome?

Background

Severe acute respiratory syndrome (SARS) is associated with a lymphopenia, thrombocytopenia and neutrophilia and suspected cases may be admitted to hospital on the basis of such abnormalities. Laboratories may report changes as percentages or absolute counts.

Objective

To investigate whether absolute or percentage differential counts were more predictive of patients with SARS pneumonia.

Design

Prospective observational study.

Setting

SARS clinic of an emergency department in Hong Kong.

Subjects and methods

Whole blood and differential counts were performed on 506 patients presenting to a SARS screening clinic. Ninety-six patients subsequently developed SARS pneumonia.

Results

Sixty-nine patients had abnormal lymphocyte absolute counts on first attendance at clinic of which 37 (54%) developed SARS pneumonia. This compared with 142 subjects with abnormal percentage lymphocyte values of which 50 (35%) developed SARS pneumonia. The area under the ROC curve for absolute lymphocyte counts is 0.851 (95%CI 0.816 to 0.881) and for percentage lymphocytes is 0.736 (95%CI 0.694 to 0.775). The area under the ROC curve for absolute monocyte counts is 0.535 (95%CI 0.489 to 0.580) and for percentage monocytes is 0.635 (95%CI 0.591 to 0.678). The area under the ROC curve for absolute neutrophil counts is 0.591 (95%CI 0.546 to 0.636) and for percentage neutrophils is 0.703 (95%CI 0.660 to 0.744).

Conclusion

Reporting absolute rather than percentage values for differential leucocyte counts are more accurate predictors of SARS pneumonia.

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.

Training and Willingness to Perform Bystander Basic Life Support

Objectives

To evaluate the perceived ability and willingness of people to perform basic life support (BLS), to relate this to those most at risk of sudden cardiac death, and to identify groups of National Health Service (NHS) staff who could benefit from training in BLS.

Design

Prospective, survey.

Setting

The Accident and Emergency (A&E) department based at Glasgow Royal Infirmary.

Subjects

All patients, accompanying persons and NHS staff who were able, willing and waiting in the A&E department.

Methods

Subjects were asked to complete a proforma with questions relating to their experience and training in BLS. Their recognition of the importance of defibrillation in the light of current European guidelines for BLS was tested.

Results

718 proformas were completed. Fifty-seven percent non-clinical NHS staff had received no training in BLS. More than 50% subjects had relatives with risk factors of Ischaemic Heart Disease yet had no training in BLS. Seventy percent ambulance men and 50% clinical NHS personnel would perform mouth to mouth ventilation before calling an ambulance where they were required to perform BLS, as a bystander. Seventy percent non-clinical NHS personnel and non NHS subjects would call an ambulance first.

Conclusions

Non-clinical NHS personnel form a hospital based group that could be trained in BLS, some of whom could assume an instructor role. A proportion of clinical and emergency personnel would not prioritise an early call for a defibrillator over BLS in the out of hospital setting.

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.

Acute Infectious Diarrhoea in Adults: Identifying Clinical Parameters Associated with Specific Pathogens

Introduction

Infectious diarrhoea may be caused by viral, bacterial or protozoan agents. The objective of this study was to explore the possibility of correlating presenting clinical and demographic features with the specific types of stool pathogens subsequently identified.

Materials & Methods

A retrospective study was performed in the setting of an Accident & Emergency (A&E) department of an urban acute-care hospital in Hong Kong. The inclusion criteria were adults (age ≥16); presentation with features of acute infectious diarrhoea; treated as out-patients with or without observation; and with stool cultures requested from A&E. All consecutive culture-positive cases (n=130) satisfying the above criteria were included. The control-group (n=119) consisted of a random sample of culture-negative cases during the same study period. For each of the six pathogens identified, statistical analyses were performed to compare differences in clinical features amongst three groups: (i) cases positive for the specific pathogen; (ii) cases positive for other pathogens; and (iii) cases with negative culture.

Results

Salmonella was associated with significantly higher body temperatures at presentation. Vibrio parahaemolyticus (VP) was associated with a significantly shorter duration of diarrhoea and of abdominal pain at presentation. Other variables were not helpful in predicting the type of stool pathogen.

Conclusion

In patients presenting with acute infectious diarrhoea in an A&E setting in Hong Kong, Salmonella and VP may be suspected according to the clinical features identified in this study.

Feasibility Study Comparing Oral Paracetamol and Oral Non-Steroidal Anti-Inflammatory Drugs for Treating Pain after Musculoskeletal Injury: a Randomised, Double Blind, Controlled Trial

Objectives

To investigate the efficacy and safety of oral paracetamol compared with oral non-steroidal anti-inflammatory drugs (NSAIDs) or combination therapy in relieving pain after limb injury in an emergency department.

Design

Double blind, randomised, controlled study.

Setting

Emergency department of a university hospital in the New Territories of Hong Kong.

Subjects

50 adult patients with painful isolated limb injuries.

Main outcome measures

Primary outcome measures were pain relief at rest and with limb movement, and adverse events.

Results

There was no statistical difference in the mean reduction in pain score between oral paracetamol and oral NSAIDs in the first two hours of treatment or over three days. Patients' pain reduced significantly over three days but it was unclear whether this was due to natural healing rather than analgesic medication. There was no significant difference in pain relief between paracetamol and NSAIDs over three days treatment. All combinations appeared to be safe with no major adverse effects reported in the study.

Conclusion

Oral paracetamol may be as effective and as safe as moderate dose of NSAIDs in the management of musculoskeletal pain. A larger study is required to confirm this hypothesis.

Application of APACHE II in the Assessment, Classification of Severity and Predictive Ability of Chinese Patients Presenting to an Emergency Department Resuscitation Room

Objectives

To evaluate the use of APACHE II (Acute Physiology and Chronic Health Status Evaluation) in Chinese patients managed in the resuscitation room of an Accident & Emergency Department of one of the teaching hospitals in Hong Kong.

Design

Prospective study on Chinese patients.

Setting

Resuscitation Room in an Accident & Emergency Department of a university hospital in Hong Kong.

Patients and measurements

Consecutive patients managed in the resuscitation room between 14th August, 2000 and 20th August 2000 (excluding patients younger than 18 years old and patients who were not admitted to hospital after initial assessment and treatment). For each patient, demographic data, diagnosis, the chronic health points, and the worst physiological parameters in the A&E resuscitation room were recorded. The total APACHE II scores and the probability of death were calculated. The accuracy of APACHE II for predicting group mortality was assessed by receiver operating characteristic curve analysis and linear regression analysis.

Results

Of the 88 patients included in the study, 13 (15%) died and 75 (85%) survived. Significant factors associated with mortality included age, mean arterial pressure, heart rate, respiratory rate, arterial pH, serum sodium, Glasgow coma score, and chronic health points. For the three scoring subdivisions of APACHE II – total APS score, age points and chronic health points – higher mean values were found in those patients who died compared with patients who survived. Using logistic regression analysis, the APACHE II score determined in the emergency resuscitation room is a strong predictor of mortality (r2=0.712). At a cut off score of >28 the sensitivity is 100.0% (95% CI 100.0–100.0), specificity is 68.0% (95% CI 56.2–78.3), positive likelihood ratio is 3.13, positive predictive value is 35.1 and negative likelihood ratio is 100.0. Analysis of the ROC curve reveals an area under the curve of 0.910 (95% CI 0.829–0.960). In patients not admitted to ICU, there was a positive correlation between APACHE score and length of hospital stay in patient who survived (r=0.320, P=0.0075) and a negative correlation between APACHE score and length of hospital stay in patients who died (r=-0.760, P=0.0225).

Conclusions

The APACHE II scoring system may be usefully applied in emergency departments for predicting mortality, for classifying and assessing severity of disease, for evaluating performance and for planning departmental resource allocation.

Validation of a Modified Early Warning Score (Mews) in Emergency Department Observation Ward Patients

Objective

The Modified Early Warning Score (MEWS) is a simple physiological scoring system, which can easily be applied at the bedside. The ability of MEWS to identify patients at risk of deterioration in a busy ward was investigated.

Method

In a prospective cohort study, we applied MEWS to patients admitted to the 16-bed emergency department observation ward (EDOW) of a tertiary teaching hospital.

Results

Data on 427 consecutive EDOW admissions were collected from 7 June to 4 July 2004. Main outcome measures were death, intensive care unit (ICU) admission and inpatient hospital admission. Scores of > 4 were associated with increased risk of death (OR 54.4, 95% CI = 4.7–633.7), ICU admission (OR 12.7, 95% CI = 1.1–147.3) and hospital admission (OR 9.5, 95% CI = 3.3–27.9).

Conclusion

MEWS is suitable for bedside application in an EDOW setting and may help identify patients at risk of deterioration who require increased levels of care as hospital inpatients and in ICU. Where experienced staff is not available to closely monitor patients in an EDOW, the use of the MEWS system may aid close monitoring and identification of high-risk patients.

Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome

Introduction

Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong.

Materials & methods

Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed.

Results

There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non-operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non-operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis.

Conclusions

Non-operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.

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.

Smoking and Severe Acute Respiratory Syndrome

In April 2003, rumours spread that smoking protected patients from developing SARS (Severe Acute Respiratory Syndrome). In a case-control study of 447 patients who attended a SARS screening clinic, 63 patients were admitted with SARS. Although a higher proportion of SARS cases were non-smokers than smokers, the adjusted odds of non-smokers with SARS was 1.7 (p=0.54). There is no evidence that smoking protects patients from developing SARS.

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.

Out-of-Hospital Cardiac Arrest in a Teaching Hospital in Hong Kong: Descriptive Study Using the Utstein Style

Objective

To describe, using the Utstein template, the characteristics of patients presenting with out-of-hospital cardiac arrest to a university teaching hospital in the New Territories of Hong Kong, and to evaluate survival.

Design

Prospective study.

Setting

The emergency department of a teaching hospital in the New Territories, Hong Kong.

Participants

Patients older than 12 years with non-traumatic out-of-hospital cardiac arrest who were transported to the hospital between 1 July 2002 and 31 December 2002.

Main outcome measures

Demographic data, characteristics of cardiac arrest and response time intervals of the emergency medical service presented according to the Utstein style, and also survival to hospital discharge rate.

Results

A total of 124 patients were included (49.2% male; mean age 71.9 years). The majority of cardiac arrests occurred in patients' home. The overall bystander cardiopulmonary resuscitation (CPR) rate was 15.3% (19/124). The most common electrocardiographic rhythm at scene was asystole, whilst pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) was found in 18.0%. The overall survival was 0.8% (1/124), and survival to hospital discharge was significantly higher for patients with VF or pulseless VT than those patients with other rhythms of cardiac arrest (11.1% versus 0%). The median witnessed/recognised collapse to defibrillation time was 14 minutes. The median prehospital time interval from collapse/recognition to arrival at hospital was 33 minutes.

Conclusion

The prognosis of out-of-hospital cardiac arrest in Hong Kong was poor. Major improvements in every component of the chain of survival are necessary.

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.

Hypertension in the Emergency Department

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

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.

Risk factors for drug-resistant bacterial pneumonia in older patients hospitalized with pneumonia in a Chinese population

BACKGROUND

The relationship between healthcare-associated pneumonia (HCAP) and resistant bacteria is unclear. The aim of this study was to identify the risk factors for pneumonia caused by drug-resistant bacteria (DRB).

METHODS

A prospective cohort study was conducted at a tertiary teaching hospital in Hong Kong. Consecutive older patients (aged ≥65 years) were hospitalized with pneumonia from January 2004 to June 2005. DRB comprised methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae and Acinetobacter baumannii.

RESULTS

The entire cohort consisted of 1176 older patients. Of 472 (40.1%) patients with etiological diagnosis established, bacterial pneumonia was found in 354 (30.1%) cases. DRB were isolated in 48 patients: P. aeruginosa (41), MRSA (5) and ESBL producing enteric bacilli (3). Co-infection with P. aeruginosa and MRSA was found in one patient. The prevalence of DRB in culture-positive pneumonia was 20.1% (48/239). Patients with DRB were more likely to have limitation in activities of daily living, bronchiectasis, dementia, severe pneumonia, recent hospitalization and recent antibiotic use. Logistic regression revealed that bronchiectasis [relative risk (RR) 14.12, P = 0.002], recent hospitalization (RR 4.89, P < 0.001) and severe pneumonia (RR 2.42, P = 0.010) were independent predictors of drug-resistant bacterial pneumonia.

CONCLUSION

Recent hospitalization is the only risk factor for HCAP which is shown to be associated with DRB. Nursing home residence is not a risk factor. The concept of HCAP may not be totally applicable in Hong Kong where the prevalence of drug-resistant pathogens in pneumonia is low.

Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study

BACKGROUND AND STUDY AIMS

Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department.

PATIENTS AND METHODS

We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD). We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction.

RESULTS

The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ± 19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P = 0.035). There was no significant difference in the identification of peptic/inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P = 0.10, OR 0.39 95 %CI 0.11 - 1.15). Capsule endoscopy reached the duodenum in 45 /46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion.

CONCLUSIONS

In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD.

Influenza virus load in hospitalised patients

1. Hospitalised patients with severe influenza have persistently high viral loads, for whom a different therapeutic approach may be needed. 2. Active screening of influenza infection should be performed in all high-risk patients hospitalised with febrile respiratory illness. Early diagnosis and treatment to suppress the high viral load may maximise clinical benefit. 3. For late presenting high risk patients with severe symptoms, their viral load may remain high, and initiation of antiviral treatment may still be worthwhile. 4. More stringent infection control measures, including strict droplet precautions and preferably isolation for an extended period of time may be necessary owing to prolonged viral shedding. 5. Randomised, controlled trials are indicated to address timing and dosage of treatment for severe influenza infection.

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.

Differences in the compliance with hospital infection control practices during the 2009 influenza H1N1 pandemic in three countries

BACKGROUND

In December 2009, the World Health Organization (WHO) issued updated guidelines on the prevention of H1N1 influenza virus in healthcare settings. In 2010, the WHO pandemic influenza alert level was still at phase 6.

AIM

To study the practice of infection control measures during the 2009 influenza H1N1 pandemic among healthcare workers (HCWs) in three countries.

METHODS

A standardized, self-administered anonymous questionnaire survey was conducted in 2010 among doctors, nurses and allied HCWs in 120 hospital-based clinical departments in Hong Kong, Singapore and the UK. Questions were asked on demographics; previous experience and perceived severity of influenza; infection control practices; uptake of seasonal influenza vaccination and H1N1 vaccination. Multiple logistic regression was used to test the independent association with different factors.

FINDINGS

A total of 2100 HCWs in the three countries participated. They reported high compliance (>80%) with infection control procedures regarded as standard for droplet-transmitted infections including wearing and changing gloves, and washing hands before and after patient contact. However, the reported use of masks with indirect or direct patient contact (surgical or N95 as required by their hospital) varied considerably (96.4% and 70.4% for Hong Kong; 82.3% and 87.7% for Singapore; 25.3% and 62.0% for the UK). Reported compliance was associated with job title, number of patient contacts and perceived severity of pandemics. There was no association between the uptake for seasonal or 2009 H1N1 vaccines and compliance.

CONCLUSIONS

Compliance with infection control measures for pandemic influenza appears to vary widely depending on the setting.

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.

Predicting massive blood transfusion using clinical scores post-trauma

BACKGROUND AND OBJECTIVES

Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score.

METHODS

A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores.

RESULTS

There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002).

CONCLUSIONS

The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.

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.

Validation of the APLS age-based vital signs reference ranges in a Chinese population

Reference ranges for vital signs may differ significantly among children of different ethnic origins.

AIM

(1) To validate the Advanced Paediatric Life Support (APLS) age-based vital signs reference ranges in Chinese children in Hong Kong. (2) To derive age-based centile curves for systolic blood pressure, heart rate and respiratory rate for Chinese children. (3) To summarize the reference ranges in a table format appropriate for applying APLS to ethnic Chinese patients.

METHOD

A cross-sectional study was performed on a population of healthy Chinese children recruited from 8 kindergartens and 6 primary schools in Hong Kong. Trained operators visit the sites to obtain measurements. Age-groups: small toddlers (12-23 months); pre-school (24-59 months); and school (60-143 months). Z-test was used to assess statistical significance for proportions of each parameter falling outside the APLS reference range. One-sample t-test was used for comparison with APLS means according to age-groups. LMS Chartmaker Pro v2.3 software was used to describe the data in centile curves.

RESULTS

A total of 1353 patients (55.1% boys) were included. For heart rate, systolic blood pressure and respiratory rate respectively, 34.1%, 55.9% and 55.7% of corresponding measurements were outside the APLS age-based reference ranges. In the 'pre-school' and 'school' age-groups, the mean value for blood pressure is significantly higher, and the mean values for heart rate and respiratory rate significantly lower, in comparison to APLS mean values.

CONCLUSION

Independently derived vital signs reference ranges are more appropriate for use when applying APLS to Chinese patients in Hong Kong.

EMS systems in China

The prehospital emergency service is the initial part of the Emergency Medical Service System (EMSS) in China, and is the de facto overall emergency medical service for China. As the EMSS in China continues to undergo rapid development, it faces the challenge of providing rapid response times with adequate coverage for this highly populated country. The recent Sichuan earthquake on 12 May 2008 tested the ability of the EMSS response. This article focuses on the prehospital emergency service of the EMSS and discusses the strengths and weaknesses of the current system.