OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

OBJECTIVE: To explore the feasibility of establishing a temporary trauma team led by trauma experts in primary hospitals for disaster medical rescue. METHODS: In the coal mine flooding accident in Xiaoyi City, Shanxi Province on December 15, 2021, according to the local emergency plan and the characteristics of the accident, the trauma experts trained the medical staff from the local primary hospital on advanced trauma life support (ATLS) and damage control surgery (DCS) in the short time interval between the occurrence of the mine disaster and the admission of medical staff to the disaster scene. A temporary trauma team composed of trauma experts, ATLS team, and DCS team was formed to provide early diagnosis and treatment for survivors before and in the hospital. RESULTS: The miners were found on the 36th hour of the disaster. All 22 miners were male, and 2 died underground. Another 20 people were rescued 39－43 hours after the disaster, with a median age of 48 years (34-57 years). All the survivors suffered from hypothermia, dehydration, maceration of feet and other injuries. There were 18 cases of acute inhalation tracheobronchitis, 14 cases of electrolyte acid-base disturbance, 6 cases of trunk contusion, 1 case of psoas major hematoma, and 1 case of lower extremity hematoma. Deep vein thrombosis was in 4 cases. The ATLS team focused on injury assessment, rewarming and rehydration within 50－60 minutes before admission, and completed auxiliary examinations within 2 hours after admission to clarify the diagnosis. The DCS team evaluated 6 patients with mechanical blunt trunk injury and excluded the indication of emergency surgery. The trauma experts conducted the whole process of supervision and quality control of disaster rescue. The positive rate of capillary refill test in the all survivors at the third hour of admission was significantly lower than that immediately after being rescued (75.0% vs. 15.0%, P=0.000 3), and they were discharged 4－7 days after admission. CONCLUSION Under the leadership of trauma experts and relying on the medical staff of primary hospitals, it is feasible to establish and train a temporary trauma team with ATLS and DCS functions to participate in the medical rescue of disasters, which is in line with the current national conditions of China.
Humans ; Adult ; Middle Aged ; Male ; Rescue Work/organization & administration* ; China ; Disasters ; Patient Care Team/organization & administration* ; Wounds and Injuries/therapy* ; Advanced Trauma Life Support Care/organization & administration* ; Disaster Planning/organization & administration* ; Emergency Medical Services/organization & administration*

OBJECTIVE: To systematically summarize and analyze the project applications and funding in the field of Emergency and Critical Care Medicine by the Medical Science Department of the National Natural Science Foundation of China (NSFC) from 2010 to 2024, and to identify research hotspots and developmental trends, providing scientific references for the high-quality development of the Emergency and Critical Care Medicine in China. METHODS: Data on all project applications and funding in the field of Emergency and Critical Care Medicine (application code H16) from 2010 to 2024 were collected from the NSFC Grants System, including project application numbers, funding numbers and amounts, project categories, regional and affiliated institutions distributions. Keyword co-occurrence analysis was conducted using VOSviewer software to identify research hotspots, and results were presented using bar charts, pie charts, and Sankey diagrams. RESULTS: Over the past 15 years, the Emergency and Critical Care Medicine field of NSFC received 13 747 project applications and funded 1 781 projects, with a cumulative funding amount of 8.064 99 billion RMB. The annual number of applications increased from 296 in 2010 to 1 971 in 2024, representing an average annual growth rate of 40.42%. Similarly, the number of funded projects grew from 45 in 2010 to 175 in 2024, with an average annual growth rate of 20.63%, while annual funding rose from 20.01 million RMB in 2010 to 74.20 million RMB in 2024, reflecting an average annual growth rate of 19.34%. The majority of funded projects belonged to the General Program (774 projects), Young Scientists Fund (754 projects), and Regional Science Fund (163 projects), collectively accounting for 94.95% of total funded projects (1 691/1 781). Funding was concentrated in two primary research areas: Organ Dysfunction and Support (H1602, 751 projects) and Sepsis (H1601, 612 projects), together comprising 76.53% of total funded projects (1 363/1 781). The total number of funded projects (1 781 projects) in Emergency and Critical Care Medicine was fewer than the average across the subfields of Medical Science Department (4 181 projects). Shanghai (305 projects, 17.1%), Guangdong (222 projects, 12.5%), Jiangsu (154 projects, 8.6%), Zhejiang (149 projects, 8.4%), and Beijing (134 projects, 7.5%) ranked as the top five regions in terms of funded projects. Keyword co-occurrence analysis revealed that sepsis, organ injury, pulmonary injury and poisoning, and cardiopulmonary resuscitation were the main research hotspots in the field of Emergency and Critical Care Medicine over the past 15 years. CONCLUSION From 2010 to 2024, the NSFC funding for the field of Emergency and Critical Care Medicine has shown a significant upward trajectory, providing vital support for the rapid advancement of basic and applied research. This growth has played a crucial role in facilitating the high-quality development of Emergency and Critical Care Medicine in China.
China ; Critical Care/economics* ; Emergency Medicine/economics* ; Humans ; Foundations

OBJECTIVE: To explore the implementation effect of hour-1 bundle for sepsis patients based on crisis resource management (CRM) system. METHODS: A historical control study was conducted. The hour-1 bundle for sepsis based on CRM was used to train 24 nurses in the emergency department from October 2022 to March 2023. Clinical data of sepsis patients admitted to the emergency department of the First People's Hospital of Zunyi from April 2022 to September 2023 were collected. The patients were divided into three groups based on different stages of CRM system construction: control group (before construction, from April to September in 2022), improvement group (during construction, from October 2022 to March 2023) and observation group (after construction, from April to September in 2023). The baseline data, implementation rate of hour-1 bundle [including blood culture, antibiotic usage, blood lactic acid (Lac) detection, fluid resuscitation, hypertensors usage], identification and diagnosis time, and prognosis parameters [including correction rate of hypoxemia, intensive care unit (ICU) occupancy rate, and 28-day survival rate]. Sepsis cognition survey and non-technical skill (NTS) evaluation of nurses in emergency department were conducted before and after training. RESULTS: Finally 43 cases were enrolled in the control group, improvement group and observation group, respectively. There was no statistically significant difference in baseline data including the gender, age, primary site, heart rate, systolic blood pressure, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, mechanical ventilation ratio among the three groups with comparability. With the gradual improvement of the CRM system, the implementation rate of 1-hour bundle was gradually increased, and the implementation rate in the control group, improvement group and observation group were 65.12% (28/43), 74.42% (32/43) and 88.37% (38/43), respectively, with statistically significant difference (P < 0.05). It was mainly reflected in the completion rate of blood culture, antibiotic usage rate, Lac detection rate and hypertensors usage rate within 1 hour, which were significantly higher in the observation group than those in the control group [completion rate of blood culture: 90.70% (39/43) vs. 62.79% (27/43), antibiotic usage rate: 88.37% (38/43) vs. 60.47% (26/43), Lac detection rate: 93.02% (40/43) vs. 72.09% (31/43), hypertensors usage rate: 88.37% (38/43) vs. 60.47% (26/43), all P < 0.05]. The fluid resuscitation rates within 1 hour in the three groups were all over 90%, with no statistically significant difference among the three groups. The recognition and diagnosis time in the observation group was significantly shorter than that in the control group and the improvement group (hours: 0.41±0.15 vs. 0.61±0.21, 0.51±0.18, both P < 0.05), the correction rate of hypoxemia and 28-day survival rate were significantly higher than those in the control group [correction rate of hypoxemia: 95.35% (41/43) vs. 74.42% (32/43), 28-day survival rate: 83.72% (36/43) vs. 60.47% (26/43), both P < 0.05], and ICU occupancy rate was significantly lower than that in the control group [72.09% (31/43) vs. 93.02% (40/43), P < 0.05]. After training in the CRM system, the score of the sepsis awareness survey questionnaire for emergency department nurses was significantly increased as compared with before training (60.42±5.29 vs. 44.17±9.21, P < 0.01), and NTS also showed significant improvement. CONCLUSION CRM plays a significant role in promoting the implementation of sepsis hour-1 bundle, which can improve the implementation rate of hour-1 bundle and NTS of medical staff, effectively improve patients' hypoxemia, reduce patients' ICU occupancy rate and 28-day risk of death.
Humans ; Sepsis/therapy* ; Emergency Service, Hospital ; Patient Care Bundles ; Intensive Care Units ; Female ; Male ; Middle Aged

INTRODUCTION: Paediatric patients admitted to the inpatient units from the emergency department (ED) are increasing, but the mean length of stay has fallen significantly. We aimed to determine the reasons behind paediatric one-day admissions in Singapore and to assess their necessity. METHODS: A retrospective study involving paediatric patients who were admitted from a general ED of an adult tertiary hospital to a paediatric tertiary hospital between 1 August 2018 and 30 April 2020. One-day admission was defined as an inpatient stay of less than 24 h from the time of admission to discharge. An unnecessary admission was defined as one with no diagnostic test ordered, intravenous medication administered, therapeutic procedure performed or specialty review made in the inpatient unit. Data were captured in a standardised form and analysed. RESULTS: There were 13,944 paediatric attendances - 1,160 (8.3%) paediatric patients were admitted. Among these, 481 (41.4%) were one-day admissions. Upper respiratory tract infection (62, 12.9%), gastroenteritis (60, 12.5%) and head injury (52, 10.8%) were the three most common conditions. The three most common reasons for ED admissions were inpatient treatment (203, 42.2%), inpatient monitoring (185, 38.5%) and inpatient diagnostic investigations (32, 12.3%). Ninety-six (20.0%) one-day admissions were unnecessary. CONCLUSION Paediatric one-day admissions present an opportunity to develop and implement interventions targeted at the healthcare system, the ED, the paediatric patient and their caregiver, in order to safely slow down and perhaps reverse the trend of increased hospital admissions.
Humans ; Retrospective Studies ; Singapore ; Child ; Emergency Service, Hospital/statistics & numerical data* ; Patient Admission/statistics & numerical data* ; Female ; Male ; Child, Preschool ; Length of Stay/statistics & numerical data* ; Infant ; Adolescent ; Tertiary Care Centers ; Hospitalization/statistics & numerical data* ; Infant, Newborn ; Gastroenteritis/therapy* ; Respiratory Tract Infections

INTRODUCTION: Foreign body (FB) ingestion is a common paediatric emergency. While guidelines exist for urgent intervention, less is known of the natural progress of FBs passing through the gastrointestinal tract (GIT). We reviewed these FB transit times in an outpatient cohort. METHODS: A retrospective review was performed on all children (≤18 years) treated for radiopaque FB ingestion at two major tertiary paediatric centres from 2015 to 2016. Demographic data, FB types, outcomes and hospital visits (emergency department [ED] and outpatient) were recorded. All cases discharged from the ED with outpatient follow-up were included. We excluded those who were not given follow-up appointments and those admitted to inpatient wards. We categorised the outcomes into confirmed passage (ascertained via abdominal X-ray or reported direct stool visualisation by patients/caregivers) and assumed passage (if patients did not attend follow-up appointments). RESULTS: Of the 2,122 ED visits for FB ingestion, 350 patients who were given outpatient follow-up appointments were reviewed (median age 4.35 years [range: 0.5-14.7], 196 [56%] male). The largest proportion (16%) was aged 1-2 years. Coins were the most common ingested FB, followed by toys. High-risk FB (magnets or batteries) formed 9% of cases ( n =33). The 50 th centile for FB retention was 8, 4 and 7 days for coins, batteries and other radiopaque FBs, respectively; all confirmed passages occurred at 37, 7 and 23 days, respectively. Overall, 197 (68%) patients defaulted on their last given follow-up. CONCLUSION This study provides insight into the transit times of FB ingested by children, which helps medical professionals to decide on the optimal time for follow-up visits and provide appropriate counsel to caregivers.
Adolescent ; Child ; Child, Preschool ; Female ; Humans ; Infant ; Male ; Eating ; Emergency Service, Hospital ; Foreign Bodies/diagnostic imaging* ; Gastrointestinal Tract/diagnostic imaging* ; Gastrointestinal Transit ; Retrospective Studies ; Singapore ; Tertiary Care Centers

It is crucial that policy makers, healthcare providers and relevant stakeholders understand how integrated care may be improved at our emergency departments (EDs) and what benefits that would bring. The potential that exists for right-siting care of special patient groups who could be managed in an ambulatory setting with the integration of a variety of hospital-based and community-based clinical support services is tremendous. This review describes the best practice and value of integrated care at the EDs. Local evidence is cited and compared with findings from overseas. The opportunities of care transition interventions among discharged patients are outlined, including that for paediatric patients, palliative care patients and patients with chronic diseases. This review also suggests ways to move forward to meet the aim of providing holistic care at EDs through integrated care programmes, innovation and research.
Humans ; Emergency Service, Hospital/organization & administration* ; Delivery of Health Care, Integrated ; Palliative Care ; Chronic Disease

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has caused significant mental distress in populations globally. At the frontline of the pandemic, emergency departments (EDs) are the prime setting to observe the effects of the pandemic on the mental health of the population. We aimed to describe the trend of mental health-related ED attendances at an acute hospital in Singapore before and during the various stages of the COVID-19 pandemic. METHODS: This is a retrospective, descriptive study of patients who presented to the ED between 1 January 2019 and 31 December 2020. Patients diagnosed with mental health-related systematised nomenclature of medicine who visited the ED during this period were identified and were placed into mental health diagnosis categories for analysis. A comparison was made between patients who presented before the pandemic (2019) and during the pandemic (2020). RESULTS: During the study periods, we identified 1,421 patients, of whom 27 were excluded due to non-mental health-related diagnoses, leaving 1,394 patients for analysis. There was a 36.7% increase in mental health-related ED presentations from 2019 to 2020. The proportion of higher-acuity mental health-related ED attendances and number of suicide attempts also increased. CONCLUSION Our study described an increase in the proportion of high-acuity mental health-related ED attendances during the COVID-19 pandemic. Emergency physicians must be cognisant of the effects of the pandemic on mental health. Further research should be conducted to better equip the healthcare system for handling all aspects of the pandemic.
Humans ; COVID-19/psychology* ; Emergency Service, Hospital/statistics & numerical data* ; Retrospective Studies ; Singapore/epidemiology* ; Male ; Female ; Adult ; Middle Aged ; Mental Disorders/diagnosis* ; Mental Health ; SARS-CoV-2 ; Tertiary Care Centers ; Pandemics ; Aged ; Suicide, Attempted/statistics & numerical data* ; Young Adult ; Adolescent

INTRODUCTION: The rising rate of adolescent suicide, and the burden of self-harm and mental health disorders, pose significant threats to Singapore's future health outcomes and human potential. This study sought to examine the risk profile and healthcare utilisation patterns of Singaporean adolescents who presented to the emergency department (ED) for suicidal or self-harm behaviour. METHOD: A retrospective review of medical records for patients aged 10 to 19 years who visited Singapore's KK Women's and Children's Hospital ED for suicidal or self-harm attempts from January to December 2021 was conducted. RESULTS: A total of 221 patients were identified, with a predominance of female patients (85.5%) over males (14.5%). The mean age was 14.2 ± 1.4 years. Intentional drug overdose (52.0%) was the most commonly used method. Significantly more females presented for intentional paracetamol overdose (46.6% versus [vs] 28.1%, P=0.049), whereas jumping from a height was more common among males (18.8% vs 5.8%, P=0.022). The most frequently observed mental health challenges were stress-related and emotional coping difficulties (50.7%), followed by mood and anxiety symptoms (53.4%). A history of self-harm and suicidal behaviours were the most common psychosocial risk factors. Within the year prior to their ED presentation, 15.4% had accessed healthcare services for mild medical ailments, 19.5% for medically unexplained symptoms, and 17.2% for previous self-harm or suicide attempts. CONCLUSION Most cases involved psychosocial and emotional regulation difficulties, some of which displayed sex-specific patterns, rather than complex psychiatric disorders. The identified predictive factors can help inform Singapore's National Mental Health and Well-being Strategy, to guide targeted and transdiagnostic interventions in schools and community settings.
Humans ; Adolescent ; Singapore/epidemiology* ; Female ; Male ; Suicide, Attempted/psychology* ; Emergency Service, Hospital/statistics & numerical data* ; Self-Injurious Behavior/psychology* ; Retrospective Studies ; Child ; Young Adult ; Drug Overdose/epidemiology* ; Risk Factors ; Acetaminophen/poisoning* ; Patient Acceptance of Health Care/statistics & numerical data* ; Sex Factors

OBJECTIVE: To evaluate the predictive value of plasma heparin-binding protein (HBP) combined with albumin (Alb) for predicting 28-day mortality in patients with sepsis. METHODS: The clinical data of patients with sepsis admitted to the emergency intensive care unit (EICU) of the People's Hospital of Shenzhen Baoan District from March 2020 to March 2024 were retrospectively analyzed. The study began at the time of the first diagnosis of sepsis upon EICU admission and ended upon patient death or at 28 days. The gender, age, length of stay in EICU, underlying diseases, and infection sites were recorded. Within 24 hours of sepsis diagnosis, blood culture results, white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), blood lactate acid (Lac), HBP, Alb, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation II (APACHE II), mortality in emergency department sepsis score (MEDS), modified early warning score (MEWS), number of organ failures, use of vasopressors, application of mechanical ventilation, renal replacement therapy, and 28-day prognosis were recorded, the differences in these indicators between two groups were compared. Univariate and multivariate Logistic regression analyses were used to analyze the risk factors of 28-day mortality in patients with sepsis. Receiver operator characteristic curve (ROC curve) was drawn, and the area under the ROC curve (AUC) was calculated to evaluate the early predictive value of various risk factors for 28-day mortality in patients with sepsis. RESULTS: A total of 300 patients with sepsis were included, with 16 excluded, resulting in 284 patients being analyzed. Among them, 191 survived and 93 died within 28 days. There were no statistically significant differences between the two groups in terms of gender, age, underlying diseases, infection sites, blood culture positivity rate, number of organ failures, and length of stay in EICU. Univariate analysis showed that the rate of vasopressor use, the rate of mechanical ventilation, HBP, PCT, CRP, Lac, SOFA score, APACHE II score, MEDS score, and MEWS score were significantly higher in the death group than those in the survival group, while Alb was significantly lower in the death group than that in the survival group. Multivariate Logistic regression analysis showed that HBP and Alb were independent risk factors for predicting 28-day mortality in patients with sepsis [odds ratio (OR) and 95% confidence interval (95%CI) were 1.093 (0.989-1.128) and 1.174 (1.095-1.259), both P < 0.05]. ROC curve analysis showed that both HBP and Alb had certain predictive value for 28-day mortality in patients with sepsis [AUC and 95%CI were 0.820 (0.717-0.923) and 0.786 (0.682-0.890), both P < 0.05]. When the critical value of HBP was 117.50 μg/L, the sensitivity was 85.90%, and the specificity was 70.50%. When the critical value of Alb was 28.30 g/L, the sensitivity was 69.30%, and the specificity was 81.20%. When the two indexes were combined for diagnosis, the AUC was 0.881 (95%CI was 0.817-0.945, P < 0.001), the sensitivity was 92.70%, and the specificity was 76.80%. CONCLUSIONS HBP and Alb are independent risk factors for predicting 28-day mortality in patients with sepsis. The combined prediction efficiency of HBP and Alb for 28-day mortality in patients with sepsis is superior to a single indicator.
Humans ; Sepsis/diagnosis* ; Retrospective Studies ; Predictive Value of Tests ; Intensive Care Units ; Blood Proteins/analysis* ; Prognosis ; Antimicrobial Cationic Peptides/blood* ; APACHE ; Male ; Female ; Organ Dysfunction Scores ; ROC Curve ; Middle Aged ; C-Reactive Protein/analysis* ; Emergency Service, Hospital ; Aged ; Hospital Mortality ; Serum Albumin/analysis*