BACKGROUND: In 1996, our emergency department(ED) had 148.4 patients per day and an average time for managing simple and uncomplicated patients was 248 minutes. To relieve congestion, delay and conflict in ED, we have developed Fast Track to treat patients with minor illness rapidly and effectively. The Fast Track area is located in a separate area in front to the main department. The efficiency and effectiveness of new system and patients satisfaction were investigated. METHODS: All ambulatory patients(> 15 years of age) were triaged and treated at Fast Track by emergency physicians. Patients, triaged as severe illness, were moved directly to main ED and the other patients with minor illness were managed in Fast Track. We analysed the patients who were managed at Fast Track from Jan. 1st 1997 through Nov. 30th 1997. The total time staying in Fast Track from beginning of trige to final decision such as discharge or admission was recorded retrospectively. A questionnaire was obtained from random patients in the same period to evaluate the patient's satisfaction. RESULTS: The number of patients who were managed in Fast Track was 13,378, and it was 55.8% of all adult patients who visited ED during the period. The average staying time was decreased significantly with time, (140.9+/-2.9 minutes in June, 125.4+/-2.8 minutes in July, and 97.7+/-1.0 minutes after July). The 75 percentile weighted average time was also decreased significantly; 196 minutes in June, 107 minutes in July, 135 minutes from August to November(p<0.01). The questionnaire were obtained from 107 patients. The results were revealed that 90 of 107 patients(84.1%) were satisfied with emergency care at Fast Track, and the remaining patients expressed unsatisfied comments such as long waiting time(4.7%), overcrowding(1.9%), unsatisfactory care(1.9%). CONCLUSION: The Fast Track system could decrease patient's staying time and improve patient's satisfaction. In addition, the efficiency and effectiveness of the acute care in ED would be enhanced by managing minor illness in Fast Track rapidly and effectively.
Adult ; Emergencies* ; Emergency Medical Services ; Emergency Service, Hospital* ; Estrogens, Conjugated (USP) ; Humans ; Surveys and Questionnaires ; Retrospective Studies ; Tertiary Care Centers*

BACKGROUND: In the most of emergency department, the diagnosis of appendicitis has been carried by clinical history, physical examination and plain X-ray. But the diagnostic accuracy by these methods was so low that unnecessary operation was common performed, and sometimes the operation was delayed till the physicians could confirm the acute appendicitis clinically. Although many kinds of diagnostic tools such as CT scan, laparoscope, and etc, we believe that ultrasonography(US) would be a quick and sensitive diagnostic method for the evaluation of acute appendicitis in the Emergency Department. METHODS: Forty-seven patients who were clinically suspected as acute appendicitis were evaluated with the grayscaled US by emergency physician. The probe of US was placed on maximal tender point of abdomen, and the appendix image was evaluated while probe was pressed deeply and gentry. When the blind loop was fecund at maximal tender point of abdomen, we evaluated the diameter of appendix, the presence of compressibility, peri-aspen-diceal fluid collection and other mass effect. As soon as the ultrasonographic evidences of the appendicitis were noticed, the operations were done and pathologic report were reviewed later. RESULTS: Among the forty-seven patients, forty patients were diagnosed as a appendicitis by US, and most common ultrasonic findings were as follows; 1) non-compressible blind loop larger than 5 mm in diameter, 2) wall thickening more than 3 mm, 3) peri-appendiceal fluid collection, 4) periappendiceal mass. Among remaining 7 patients in whom we could not get any positive findings of appendicitis, abdominal CT scan was carried in 2 cases who had direct and rebound tenderness on right lower abdomen, and CT scan showed the evidences of the appendicitis. The other 5 cases without rebound tenderness were observed far 2 hours, and abdominal pain was disappeared lately. Finally forty-two patients were operated and confirmed as acute appendicitis by pathologic reports; 24 were reported as suppurative appendicitis, and 12 cases of gangrenous appendicitis, 3 cases of perforated appendicitis, and 3 cases were peri-appendiceal abscess. The specificity of US in the diagnosis of acute appendicitis was 71.4%, and the sensitivity was 95.2%. CONCLUSIONS : In some patients suspected appendicitis, emergency physicians could diagnosis acute appendicitis accurately and rapidly by use of ultrasonography. Although the US was an actuate imaging modality to diagnosis acute appendicitis and evaluate its complications, we recommend a laparotomy or abdominal Cf scan in the patients with negative US findings in spite of presence of peritoneal irritation signs such as rebound tenderness and/or muscle guarding on right lower abdomen.
Abdomen ; Abdominal Pain ; Abscess ; Appendicitis* ; Appendix ; Diagnosis ; Early Diagnosis* ; Emergencies* ; Emergency Service, Hospital* ; Humans ; Laparoscopes ; Laparotomy ; Physical Examination ; Sensitivity and Specificity ; Tomography, X-Ray Computed ; Ultrasonics ; Ultrasonography*

BACKGROUND : The proportion and absolute number of older patients admitted through the emergency department (ED) are increasing yearly. As people getting older, they are more likely to suffer from emergency situation of disease, disability, and trauma. Combining with the decrease in physiologic reserve, these added burdens make the elderly more vulnerable to any of the additional situations. Understanding the implications of these facts is crucial to one who is providing optimal triage and emergency care to elderly (aged 65 years or older) and adults (between 15year of age and 64 years of age). METHODS : We conducted an observational survey of emergency patients age 15 or older who admitted to emergency department of Asan Medical Center. A convenience sample of 3,481 were divided into 2 groups by 65 years of age, and final results (admission vs. discharge) after emergency care was compared. The admission rate according to between two groups. We calculated odds ratios of important outcomes by pooling data from individual trials using logistic regression analysis. RESULTS : Admission rate of elderly was higher than adults as 59.2% versus 36.4% (odds ratio=2.32) 95% CI=1.21~3.24). Although vital signs were within normal ranges, admission rate of elderly was significantly higher than adults as follows; normal range of systolic blood pressure (56.0% vs. 35.5%), normal range of respiration rate per minute (55.4% vs. 36.4%), alert status of mentality (34.2% vs. 54.7%). CONCLUSION : We could not define the severity of emergency patients only by using vital signs and/or clinical symptoms, especially to the elderly patients. Even though the vital signs of elderly patients. emergency physician should manage them carefully because of the high severity of clinical condition in elderly then we expected. Emergency Geriatric Assessment tools must be developed differently from general triage tools.
Adult ; Aged* ; Blood Pressure ; Chungcheongnam-do ; Emergencies* ; Emergency Medical Services ; Emergency Service, Hospital* ; Geriatric Assessment ; Humans ; Logistic Models ; Odds Ratio ; Reference Values ; Respiratory Rate ; Triage ; Vital Signs

BACKGROUNDS: Headache is one of the common symptoms complained by patients at the emergency department. Postural headache is the characteristic symptom that is aggravated at upright position and relieved at recumbent position. This postural headache is associated with low cerebrospinal fluid (CSF) pressure. Spontaneous intracranial hypotension(SIH) is an unusual syndrome of postural headache and low CSF pressure without a precipitating event. The diagnosis of SIH is confirmed by 60mmH2O or less CSF opening pressure on lumbar puncture. However, the cases of SIH with normal CSF opening pressure have been reported. so it is needed to complement the diagnostic criteria of SIH. METHODS: A retrospective descriptive study with reviewing medical records of 10 patients who had been admitted at Asan Medical Center from Apr. 1995 to Jul. 1999 was done. Analyses were done on 22 variables of age, sex, clinical symptoms, spinal analysis findings, radiologic findings and therapeutic modality. Fisher's exact test and Mann-Whitney test were applied for statistical analysis (p-value < 0.05). RESULTS: 1. The male to female ratio was 3 : 7, and the mean age was 37.30+/-5.96 years. 2. Postural headache was characteristic symptom & complained by all patients. 3. The mean CSF pressure was 22.8+/-30.8 mmH2O. 4. Brain MRI demonstrated the pachymeningeal enhancement in all patients. 5. Radioisotope cisternography demonstrated slow ascent of tracer to the cerebral convexity in 88.9% patients, early soft tissue uptake suggestive of CSF leakage & rapid urinary accumulation of tracer in 66.7% patients, respectively. 6. 90.0% of all patients were recovered with autologous epidural blood patches, and 10.0% were recovered with conservative management. CONCLUSION: The SIH is an unusual syndrome. but we can diagnose the SIH in the patient, complains of a postural headache, if any following two or more criteria are present. 1. 60mmH2O or less CSF opening pressure on lumbar puncture. 2. Brain MRI finding : the pachymeningeal enhancement. 3. Cisternography findings : slow ascent of tracer to the cerebral convexity, early soft tissue uptake suggestive of CSF leakage & rapid urinary accumulation of tracer.
Blood Patch, Epidural ; Brain ; Cerebrospinal Fluid ; Chungcheongnam-do ; Complement System Proteins ; Diagnosis ; Emergency Service, Hospital ; Female ; Headache ; Humans ; Intracranial Hypotension* ; Magnetic Resonance Imaging ; Male ; Medical Records ; Retrospective Studies ; Spinal Puncture

BACKGROUND: Because systolic and diastolic dysfunction frequently coexist in acute myocardial infarction(AMI), we hypothesize that a combined measure of ventricular performance using Doppler echocardiography may be more sensitive and time-saving diagnostic tool for the evaluation of patients presenting with cardiogenic chest pain. METHOD AND RESULTS: Seventy-one patients with AMI (47 male, 59+/-11 years) and 45 patients with normal coronary artery (29 male, 52+/-11 years) were included in the study for measurement of cardiac performance index and established parameters of ventricular function using conventional echo-Doppler methods. a new derived index of cardiac performance: (ICT+IRT)/ET, was obtained by subtracting ejection time(ET) from the interval between cessation and onset of the mitral inflow velocity to give the sum of isovolumic contraction time(ICT) and isovolumic relaxation time(IRT). The mean value of the index was significantly different between normal and AMI(p<0.01). The degree of inter-group overlap was smaller for the index compared to other parameters. within functional groups, the value of the index did not appear to be related to heart rate, mean arterial pressure and the degree of mitral regurgitation. CONCLUSION: cardiac performance index is a conceptually new, simple and reproducible Doppler index of combined systolic and diastolic myocardial performance, and it is useful as screening test for patients with cardiac dysfunction due to AMI.
Arterial Pressure ; Chest Pain ; Coronary Vessels ; Echocardiography, Doppler ; Heart Rate ; Humans ; Male ; Mass Screening* ; Mitral Valve Insufficiency ; Myocardial Infarction* ; Relaxation ; Ventricular Function

BACKGROUND: Previous studies have indicated adenosine triphosphate (ATP) is as potent coronary vasodillator as adenosine (A). We designed this study to compare the vasomotion of coronary artery (CA) between the infusion of ATP and that of A (1). METHOD AND RESULTS: Ten patients with normal CA (6 male and 4 female) age ranging from 41 to 74 years (57+/-11) were studied at LAD and RCA for measurement of coronary flow reserve (CFR), time to maximum effect (Tmax), time to baseline (TBL) in CA during ATP and A infusion. Tmax was achieved earlier with ATP than A, and these results suggest that maximum vasodilation occurs faster with ATP. Side effect profile was similar in 2 patients with mild chest pain with ATP and A. CONCLUSION: Since it has appeared that vasodilatory effect of ATP was comparable to A which has been used in pharmacological stress test in many diagnostic modalities, ATP can be used safely in many clinical setting where A has been used.
Adenosine Triphosphate* ; Adenosine* ; Chest Pain ; Coronary Vessels ; Exercise Test ; Humans ; Male ; Vasodilation

BACKGROUND: Ropivacaine is a new local anesthetic approved for epidural analgesia. The addition of fentanyl improves analgesia from epidural ropivacaine. We studied the effects of two solutions of ropivacaine/fentanyl for postoperative pain after a total abdominal hysterectomy. METHODS: Twenty five female patients scheduled for an elective total abdominal hysterectomy were prospectively randomized to receive one of two solutions. Group 1 (n = 13) received 0.2% ropivacaine and 5 microgram/ml of fentanyl at a rate of 2 ml/hour (bolus: 10 ml). Group 2 (n = 12) received 0.08% ropivacaine and 2 microgram/ml fentanyl at a rate of 5 ml/h (bolus: 25 ml) postoperative for two days. After an epidural bolus injection, we assessed the blood pressure, pulse rate, respiratory rate, visual analog scale (VAS), level of sensory block, motor block and sedation score among the two groups. Additional analgesic requirements and side effects such as nausea, itching and urinary retention were assessed for 48 hours post operation. RESULTS: There were no significant differences in the blood pressure, pulse rate and respiratory rate between the two groups. The sum of VAS for 48 hours, the level of sensory block after an epidural bolus injection, additional analgesics, and the number of patients showing motor blockade were similar. Although statistically insignificant, the incidence of nausea, and urinary retention in group 2 was higher than group 1. CONCLSIONS: Both the continuous epidural infusion of 0.2% ropivacaine with fentanyl (2 ml/hour) and 0.08% ropivacaine with fentanyl (5 ml/h) showed similar quality of analgesia on postoperative pain. To reduce the side effect of fentanyl, the volume of ropivacaine/fentanyl solution is important.
Analgesia ; Analgesia, Epidural* ; Analgesics ; Blood Pressure ; Female ; Fentanyl ; Heart Rate ; Humans ; Hysterectomy ; Incidence ; Nausea ; Pain, Postoperative ; Prospective Studies ; Pruritus ; Respiratory Rate ; Urinary Retention ; Visual Analog Scale

PURPOSE: The purpose of this study was to propose and test a predictive model that could explain and predict nursing productivity. METHODS: A survey using a structured questionnaire was conducted with 360 nurses in Korea. The data were analyzed using SPSS Windows 18.0 and AMOS 19.0 program. RESULTS: Based on the constructed model, burnout and organizational commitment were found to have direct effects on nurses' turnover intention and nursing productivity. While nursing work environment was found to have indirect effects on nurses' turnover intention and nursing productivity. CONCLUSION: This structural equational model is a comprehensive theoretical model that explains the related factors and their relationship with nursing productivity. Comprehensive organizational interventions to improve nursing productivity should focus on improving the nursing work environment. Findings from this study can be used to design appropriate strategies to decrease nurse turnover in Korea. Further studies are needed to prospectively verify these causal relationships with larger samples.
Adult ; Attitude of Health Personnel ; Burnout, Professional/psychology ; Female ; Humans ; Job Satisfaction ; *Models, Theoretical ; Nursing Staff, Hospital/*psychology ; Organizational Culture ; Personnel Turnover ; Questionnaires ; Republic of Korea

BACKGROUND: Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanisms. We evaluated the additive effects of ketamine (30 mg) on 0.5%, and 0.75% ropivacaine (total 30 ml) for an interscalene brachial plexus blockade (IBPB). METHODS: Thirty five adult patients scheduled for major forearm or hand surgery were prospectively randomized to receive one of the following solutions. Group 1 received 0.75% ropivacaine 28 ml with normal saline 2 ml, group 2 received 0.75% ropivacaine 28 ml with 5% ketamine 0.6 ml and normal saline 1.4 ml, group 3 received 0.75% ropivacaine 20 ml with normal saline 10 ml, and group 4 received 0.75% ropivacaine 20 ml with 5% ketamine 0.6 ml and normal saline 9.4 ml. At 1 minute intervals after IBPB, patients were assessed to determine loss of shoulder abduction, elbow flexion, wrist flexion and loss of pinprick in the deltoid, radial, median, and ulnar dermatomes. At 5 minute intervals after IBPB, pulse rate, blood pressure, sedation score and level of discomfort were assessed. Before discharge, patients were asked to document when incisional discomfort began and when full sensation and motor control returned to the arm. RESULTS: The onset time of loss of pinprick and motor blockade were similar. Duration of sensory and motor blockade were similar in all groups. Hemodynamic changes and sedation scores were not significantly different in all groups. CONCLUSIONS: We demonstrated that 30 mg of ketamine didn't enhance the onset and duration of sensory or motor blockade of ropivacaine during the 0.75% or 0.5% ropivacaine IBPB.
Adult ; Arm ; Blood Pressure ; Brachial Plexus* ; Bupivacaine ; Elbow ; Forearm ; Hand ; Heart Rate ; Hemodynamics ; Humans ; Ketamine* ; Prospective Studies ; Sensation ; Shoulder ; Wrist

BACKGROUND: Ultraviolet B (UVB) irradiation can induce apoptosis of melanocytes and melanoma cells. However, mechanism of UVB-induced apoptosis of melanoma cells is not clarified yet. OBJECTIVE: Our purpose was to study the molecular mechanism of UVB-induced apoptosis of melanoma cells. METHODS: G361 lightly pigmented melanoma cells were analyzed for apoptotic mechanism by flow cytometry and western blotting. RESULTS: G361 melanoma cells showed apoptotic features with gradual increment of UVB doses by MTT and flow cytometry. Western blotting disclosed activation of caspase-3 and poly (ADP-ribose) polymerase (PARP) after UVB irradiation. CONCLUSION: In this study, we showed that UVB-induced apoptosis of melanoma cells is mediated by PARP activation which is induced by caspase cascade.
Apoptosis* ; Blotting, Western ; Caspase 3 ; Caspases* ; Cell Line* ; Flow Cytometry ; Humans* ; Melanocytes ; Melanoma*