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

Background: Adolescents, who aged between 10 and 19 years old, comprise about 20% of the world’s population. They are vulnerable to acquisition of sexually transmitted infections (STIs). Here, we aim to determine the demography and pattern of STIs among adolescents attending Genito-Urinary Medicine (GUM) Clinic, Hospital Kuala Lumpur (HKL). Methods: This is a retrospective study on all adolescents attending GUM clinic between 2014 and 2018. Data was obtained from case notes and further analysed. Results: A total of 111 adolescents attended GUM clinic between 2014 and 2018. The mean age was 18 years (range 12-19). The male to female ratio was 2.26:1. All patients were Malaysian. Only 2 were foreign nationals. The majority were Malays (85.3%) followed by Indians (11%) and Chinese (3.7%). About 46.8% were still schooling, 28.8% were employed and 23.4% were unemployed. About 8.3% had a history of substance abuse. The majority (67.6%) were heterosexual, about 17.1% were homosexual and 3.6% were bisexual. Nearly 95% engaged in unprotected sex. Majority (46%) had casual sex. The most frequent presenting symptoms for male and female adolescents were discharge (43.2%) followed by swelling/growth (23.4%). About 83% had confirmed STIs. The most common STIs among the male were gonorrhoea (44.1%), genital warts (23.4%) and non-gonococcal urethritis (14.7%). The most common STIs among the female were herpes genitalis (50%), genital warts (33.3%) and syphilis (8.3%). Six patients were infected with the human immunodeficiency virus (HIV). Conclusion The most common STI among adolescents between 2014 and 2018 was gonorrhoea for male and herpes genitalis for female.
Sexually Transmitted Diseases ; Adolescent ; Genitourinary Medicine Clinic Hospital Kuala Lumpur (Malaysia)

Background: Sexually transmitted infections (STIs) are common worldwide. This study aims to determine the patterns of STIs among attendees in the Genito-Urinary Medicine (GUM) clinic of Sarawak General Hospital (SGH). Methods: This is a retrospective study. Medical records of new cases referred to GUM clinic, SGH between the year 2018 and 2020 were reviewed. Demography data, diagnosis, and clinical characteristics of STIs were reviewed and analysed using SPSS software. Results: There was a total of 225 patients with newly diagnosed STIs. Their mean age was 30.9 years old. There were 124 (55.1%) males and 101 (44.9%) females. Nearly half (46.7%) of the patients were Malay, followed by Sarawak indigenous groups (33.3%), and Chinese (18.7%). Most patients (n=119, 52.9%) were single at the time of diagnosis. Three quarters (73.3%) of the patients were heterosexual, while 47 (20.9%) patients were homosexual or bisexual, and missing data in the remaining 5.8%. Anogenital wart was the commonest STI (49.8%), followed by syphilis (n=91, 40.4%), genital herpes (n=24,10.7%) and gonorrhoea (n= 15, 6.7%). The commonest symptoms were genital growth (n= 107, 47.6%), followed by pelvic discharge (n=22, 9.8%). Conclusion The most common STIs in our study are anogenital warts, syphilis, genital herpes and gonorrhea. Effective national sexuality education in Malaysia is paramount in reducing premarital sex and STIs. Human Papillomavirus (HPV) vaccines are effective to reduce genital warts and HPV related malignancies.
Sexually Transmitted Diseases ; Papillomavirus Vaccines ; Genito-Urinary Medicine Clinic, Sarawak General Hospital (Malaysia)

Kidney malignant tumor is a type of primary renal cell carcinoma, and mainly refers to renal cancer. The incidence of kidney cancer and the number of hospital cases in China have been increasing. Based on the clinical medicine information of patients in the hospital information system(HIS) database of 37 hospitals in China, the combined medication of patients with kidney malignant tumor were analyzed by Tabu search algorithm, so as to analyze the combined medication of patients with kidney malignant tumor in real world. A total of 7 095 patients with kidney malignant tumor were included, the ratio of males to females was 2.11∶1, and the ratio of male patients increased gradually with age. About 3 933 patients(55.43%) showed a superior effect among those patients. The common therapies of patients with kidney malignant tumor were anti-tumor therapies and symptomatic therapies, including anti-infection, regulation of electrolyte balance, sedation and analgesia, analgesic, regulation of gastrointestinal function. The whole population of patients with kidney malignant tumor were mostly treated with anti-tumor drugs combined with more symptomatic therapies, while the anti-tumor therapies of the superiority population of patients were less combined with other drugs, with less combined medication. The result may be related to the stage of tumor or individual response to the therapeutic regimen. No matter for the whole population or for the superiority population of patients with kidney malignant tumor, the therapies was mainly Western medicines. Based on the pathogenesis of deficiency in origin and excess in superficiality with kidney malignant tumor, Chinese subgroups with formula for clearing heat and removing toxicity, formula for vigorate Qi and replenish the blood, formula for regulate Qi and invigorate the blood, laxative and hemostatic were more commonly used. In the future, further studies shall be conducted for combined therapies for patients of different stages, so as to play the advantages of multi-target, overall regulation, toxicity reduction and efficacy enhancement of traditional Chinese medicine, improve the life quality of patients with kidney malignant tumor, prolong their life time, and improve the survival rate of patients.
Asian Continental Ancestry Group ; China ; Drugs, Chinese Herbal ; Female ; Hospital Information Systems ; Humans ; Kidney Neoplasms ; Male ; Medicine, Chinese Traditional

OBJECTIVE: Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, “Would you be surprised if this patient died in the next 30 days” could predict in-hospital mortality and resource utilization for hospitalized emergency department patients.METHODS: For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated.RESULTS: 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of ‘comfort measures’ orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses.CONCLUSION: The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely.
Emergencies ; Emergency Service, Hospital ; Hospital Mortality ; Humans ; Intensive Care Units ; Logistic Models ; Observational Study ; Palliative Care ; Palliative Medicine ; Sensitivity and Specificity ; Terminal Care

Lacerations are a common reason for patients to seek medical attention, and are often acutely managed in the emergency department. Recent studies pertaining to closure techniques, sedation and analgesia, advances in wound care, and various other topics have been published, which may enhance our understanding of this injury and improve our management practices. This article will review pertinent studies published in the past few years relevant to laceration management. Understanding the current literature and appreciating which areas warrant further investigation will help us optimize outcomes for patients who sustain laceration injuries.
Analgesia ; Emergencies ; Emergency Medicine ; Emergency Service, Hospital ; Humans ; Lacerations ; Wounds and Injuries

OBJECTIVE: This study was conducted to evaluate the concordance between the underlying causes of death (UCOD) on the death certificates written by three emergency physicians (EPs). We investigated errors on the death certificates committed by each EP.METHODS: This study included 106 patients issued a death certificate in the emergency department of an academic hospital. Three EPs reviewed the medical records retrospectively and completed 106 death certificates independently. The selection of the UCOD on the death certificates by each EP (EP-UCOD) was based on the general principle or selection rules. The gold standard UCOD (GS-UCOD) was determined for each patient by unanimous consent between three EPs. We also compared between the EP-UCOD and the GS-UCOD. In addition, we compared between UCODs of three EPs. The errors on the death certificates were investigated by each EP.RESULTS: The rates of concordance between EP-UCOD and the GS-UCOD were 86%, 81%, and 67% for EP-A, EP-B, and EP-C, respectively. The concordance rates between EP-A and EP-B were the highest overall percent agreement (0.783), and those between EP-A and EP-C were the lowest overall percent agreement (0.651). Although each EP had differences in the errors they committed, none of them listed the mode of dying as UCOD.CONCLUSION: This study confirmed that each EP wrote death certificates indicating different causes of death for the same decedents; however, the three EPs made fewer errors on the patients’ death certificates compared with those reported in previous studies.
Cause of Death ; Death Certificates ; Emergencies ; Emergency Medicine ; Emergency Service, Hospital ; Humans ; Medical Records ; Mortality ; Retrospective Studies

No abstract available.
Hospital Medicine ; Korea

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.
Education ; Hospital Medicine ; Hospitalists ; Humans ; Inpatients ; Internship and Residency ; Jurisprudence ; Korea ; Patient Care ; Pilot Projects ; Postoperative Complications ; Vacuum

A hospitalist system was introduced in Korea in September in 2016 to improve the quality of in-patient care and to cope with the shortage of medical residents. This study aimed to outline the current situation of internal medicine hospitalist and to suggest a development strategy. By May 2019, the number of hospitalists in Korea had increased to 124. Patient safety issues, resident law, and the shortage of medical residents has led to an increase in the demand for hospitalists in Korea. Internal medicine hospitalist care in Korea has been associated with patient satisfaction, length of stay, and waiting time in emergency departments. There are three different hospitalist ward models in the Korean health care system, and each hospital needs the model that fits its specific situation. In the general ward model, the role of the hospitalist is similar to that of the chief residents because the wards are categorized into nine subspecialty areas, such as internal medicine (including gastroenterology, pulmonology, and cardiology). In the short-term admission ward model, patients are usually turned around within 72 hours; therefore, the hospitalist is able to care for patients independently. After that, patients are discharged or admitted to a specialty ward. In integrated care model, patients from all specialty areas are admitted to the same ward; therefore, hospitalists care for patients independently. In this model, consultation with specialists is required. There were strengths and weaknesses in each model. Therefore, the models should be considered based on the hospital's function. This study found some problems in the present hospitalist system, including undefined roles and responsibilities, unclear future employment prospects, burnout due to patient' severity of illness, and inadequate payment systems for weekend and night work. To further develop the hospitalists system in Korea, the Korean government, the Korean associated of internal medicine, hospitals, and hospitalists must work together to solve the present problems.
Delivery of Health Care ; Emergency Service, Hospital ; Employment ; Gastroenterology ; Hospital Medicine ; Hospitalists ; Humans ; Internal Medicine ; Jurisprudence ; Korea ; Length of Stay ; Patient Safety ; Patient Satisfaction ; Patients' Rooms ; Pulmonary Medicine ; Specialization