Acute care needs in an Indian emergency department： A retrospective analysis

BACKGROUND: Emergencies such as road traffic accidents(RTAs), acute myocardial infarction(AMI) and cerebrovascular accident(CVA) are the most common causes of death and disability in India. Robust emergency medicine(EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department(ED) is needed.METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences(KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35%(n=662) were male and 44.7%(n=534) were female. The majority(67.14%, n=803) were adults, while only 3.85%(n=46) were infants. The most common chief complaints were fever(21.5%, n=257), renal colic(7.3%, n=87), and dyspnea(6.9%, n=82). The most common ED diagnoses were gastrointestinal(15.5%, n=185), pulmonary(12.3%, n=147), tropical(11.1%, n=133), infectious disease and sepsis(9.9%, n=118), and trauma(8.4%, n=101).CONCLUSION: The patient demographics, diagnoses, and distribution of resources identifi ed by this study can help guide and shape Indian EM training programs and faculty development to more accurately refl ect the burden of acute disease in India.

Acute Care/Trauma Surgeon＇s role in obstetrical/ gynecologic emergencies (The OBCAT Alert)

BACKGROUND:Overwhelming hemorrhage or other intra-abdominal complications may be associated with obstetrical or gynecologic(OB/GYN) procedures and may require the surgical training of an Acute Care/Trauma Surgeon.The OB Critical Assessment Team(OBCAT Alert) was developed at our institution to facilitate a multidisciplinary response to complex OB/GYN cases.We sought to review and characterize the Acute Care/Trauma Surgeon's role in these cases.METHODS:We conducted a retrospective review of all emergency consults during an OB/GYN case at our institution from 2008 to 2015.An OBCAT is a hospital based alert system designed to immediately notify OB/GYN,anesthesiology,Acute Care/Trauma,the intensive care unit(ICU),and the blood bank of a potential emergency during an OB/GYN case.RESULTS:There were 7±3 OBCAT alerts/year.Seventeen patients required Acute Care/Trauma surgery intervention for hemorrhage.Thirteen patients required damage control packing during their hospitalization.Blood loss averaged 6.8±5.5 L and patients received a total of 21±14units during deliveries with hemorrhage.There were 17 other surgical interventions not related to hemorrhage;seven of these cases were related to adhesions or intestinal injury.Seven additional cases required evaluation post routine OB/GYN procedure;the most common reason was for severe wound complications.There were three deaths during this study period.CONCLUSION:Emergency OB/GYN cases are associated with high morbidity and may require damage control or other surgical techniques in cases of overwhelming hemorrhage.Acute Care/Trauma Surgeons have a key role in the treatment of these complex cases.

Impact of COVID-19 on presentation,management,and outcomes of acute care surgery for gallbladder disease and acute appendicitis

BACKGROUND The ongoing coronavirus disease 2019(COVID-19)pandemic has significantly disrupted both elective and acute medical care.Data from the early months suggest that acute care patient populations deferred presenting to the emergency department(ED),portending more severe disease at the time of presentation.Additionally,care for this patient population trended towards initial non-operative management.AIM To examine the presentation,management,and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.METHODS A retrospective chart review of patients diagnosed with acute cholecystitis,symptomatic cholelithiasis,or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June,2020 and in the same months of 2019.Patients were selected through a research repository using international classification of diseases(ICD)-9 and ICD-10 codes.Across both years,313 patients were identified with either type of gallbladder disease,while 361 patients were identified with acute appendicitis.The primary outcome was overall incidence of disease.Secondary outcomes included presentation,management,complications,and 30-d re-presentation rates.Relationships between different variables were explored using Pearson’s r correlation coefficient.Variables were compared using the Welch’s t-Test,Chi-squared tests,and Fisher’s exact test as appropriate.RESULTS Patients with gallbladder disease and appendicitis both had more severe presentations in 2020.With respect to gallbladder disease,more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort[50%(80)vs 35%(53);P=0.01].Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores[mean(SD)1.39(0.56)vs 1.16(0.44);P=0.02].With respect to appendicitis,more patients were diagnosed with a perforated appendix at presentation in 2020[20%(36)vs 16%(29);P=0.02]and a greater percentage were classified as emergent cases using the emergency severity index[63%(112)vs 13%(23);P<0.001].While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020[65%(104)vs 50%(76);P=0.02],no significant differences were observed in hospital admissions for patients with appendicitis.No significant differences were observed in length of hospital stay or operative rate for either group.However,for patients with appendicitis,30-d re-presentation rates were significantly higher in 2020[13%(23)vs 4%(8);P=0.01].CONCLUSION During the COVID-19 pandemic,patients presented with more severe gallbladder disease and appendicitis.These findings suggest that the pandemic has affected patients with acute surgical conditions.

Important role of acute care surgery during pandemic time

Pandemic impacts acute care surgery for diseases,such as gallbladder disease and acute appendicitis.At the early stage of coronavirus disease 2019(COVID-19)pandemic,the case number of patients needing surgery decreased in hospitals from different countries.This decline was associated with the stay-home order and fear of getting COVID-19 infection.However,recent reports show that the case number for acute surgery returns to the normal level,which is comparable to that before the beginning of the pandemic.In addition,a variety of diseases show more severe than the cases before the pandemic,which might be caused by factors such as lack of regular follow-up and screening diagnosis and infection of viruses.

Identifying the core competencies of backup nurses in the acute care hospital through a modified Delphi process

Background:The backup nurses are created to meet emergencies in the case of inadequate nursing staff and emergency circumstances,and there are no clear definitions of the core competencies for training and evaluation of backup nurses in the acute care hospitals in China.Methods:This study used a modified Delphi process where an initial list of potential competencies is established following a framework of training need analysis(TNA),literature review,and focus groups.This process generated as a list of 47 core competencies,which is presented to an expert panel(n=20)for consideration in two rounds.Results:As determined by the survey,a combination of 26 core competencies in three specified categories is identified:professional practice ability,critical thinking ability,and interpersonal skills.A total of 154.99 h is required to complete all 26 core competencies,and each item has a corresponding evaluation method.Conclusions:The core competencies provide a scientific basis for the hospital nursing managers to train and evaluate backup nurses,and it may ensure consistency in standards across the country.

Consistency of Nursing Directors, Nursing Supervisors, and Nursing Quality Specialists’ Perception about Nursing-Sensitive Indicators in Acute Care Settings

Introduction: Nursing-Sensitive Indicators (NSIs) is a critical concept for the advancement of the nursing profession. However, different managerial positions may have a different perspective on the appropriate NSIs that should be used in hospitals for the monitoring of nursing care quality. This study aims to find if there is a difference between three groups of nursing managerial positions on the appropriateness of NSIs for the monitoring of nursing care quality. Methods: Descriptive cross-sectional approach was employed to evaluate if there is a difference among the three managerial groups in their evaluation for the appropriateness of using a cluster of NSIs in acute care settings. The study was conducted in Jordan between February and March 2020. Result: The study participants were 60 nurses from different managerial positions. The mean scores of the participants were: directors of nursing (200.6), nursing supervisors (199.1), and nursing quality specialists (198.62). The findings revealed no statistical difference between the three groups of their evaluation of the appropriateness of the NSIs. Conclusion: Standardizing the nursing mangers perspectives of NSIs may advance utilization of the NSIs for the monitoring and reporting of nursing care quality. Implications for Nursing Management: Consistent understanding of the measures that can be used to monitor quality of nursing care can establish the foundation for quality measurement and quality improvement in acute care settings.

Intravenous fluid selection rationales in acute clinical management

BACKGROUND: Intravenous fluid(IVF) is commonly used in acute clinical management. This study aimed to review the choice and primary considerations in IVF prescriptions and to evaluate the adequacy of guidelines and trainings on it in the New Territories West Cluster(NTWC) of Hong Kong.METHODS: This is a descriptive study based on data collected from an online survey. Data were processed by SPSS for statistical analysis. This study focused on a general description and doctor-nurse between group comparison. Participants were asked the choice of IVF for nine acute clinical scenarios and provide reason. A 1–10 scale was used to assess the sufficiency of guideline, training and information, and time for revision on IVF prescription.RESULTS: 0.9% sodium chloride was the most familiar IVF(36%), followed by 5% Dextrose solution(26%). In the nine scenarios, the most chosen IVF was 0.9% sodium chloride(37%–61%). There was significant difference in the choice of IVF between doctors and nurses in 7 cases. The second most chosen IVF for doctors was Plasma-Lyte A while that for nurses was Gelofusine. Departmental practice was the most chosen reason to account for the prescription. The adequacy of guideline, information and training, and time for revision was rated 5. Doctors had significantly more time at work than nurses to update knowledge in IVF prescription(5.41 versus 4.57).CONCLUSION: 0.9% sodium chloride was mostly chosen. The choice of IVF was mainly based on departmental practice. Adequacy of guideline, information and training, and time for revision on IVF prescription were average, indicating significant training deficit.

A systematic review of dedicated models of care for emergency urological patients

Objective:To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients(EUPs).Methods:A search of Cochrane,Embase,Medline and grey literature from January 1,2000 to March 26,2019 was performed using methods pre-published on PROSPERO.Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines.Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs,which reported at least one secondary outcome.Studies were excluded if they examined pathways dedicated only to single presentations,such as torsion,or outpatient solutions,such as rapid access clinics.The primary outcome was the spectrum of models.Secondary outcomes were time-to-theatre,length of stay,complications and cost.Results:Seven studies were identified,totalling 487 patients.Six studies were conference abstracts,while one study was of full-text length but published in grey literature.Four distinct models were described.These included consultant urologists allocated solely to the care of EUPs(“Acute Urological Unit”)or dedicated registrars or operating theatres(“Hybrid structures”).In some services,EUPs bypassed emergency department assessment and were referred directly to urology(“Urological Assessment Unit”)or were managed by other dedicated means.Allocating services to EUPs was associated with reduced time-to-theatre,length of stay and hospital cost,and improved supervision of junior medical staff.Conclusion:Multiple dedicated models of care exist for EUPs.Low-level evidence suggests these may improve outcomes for patients,staff and hospitals.Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.

Time of arrival and in-hospital evaluation processes among patients with acute ischemic stroke at Yozgat City Hospital in Turkey: A retrospective study

Objective: To reveal the factors leading to delay in the evaluation processes of patients with suspected acute ischemic stroke at Yozgat City Hospital in Turkey and suggest potential solutions. Methods: Patients who visited the emergency service of Yozgat City Hospital between 1 April 2017 and 1 July 2017 and those hospitalized with a diagnosis of ischemic stroke, were included in this retrospective study. The clinical information of the patients was collected via hospital files and telephone interviews. In addition, the potential association between arrival time and the clinical parameters was investigated. Results: A total of 87 patients were included. The median arrival time to emergency service was 5 (IQR=9) h. Forty-four percent of patients arrived within the first 4.5 h from symptom onset. However, intravenous thrombolytic treatment was performed in only 7% of the patients. The median time from arrival to neuroimaging performing was 20.0 (IQR=34) min. Fifty-one percent of patients were screened within the first 20 min from arrival to emergency service. There was no association between arrival time and transfer method of the patients. Conclusions: The main problem regarding acute stroke care in our region may be inefficient use of emergency ambulance. This study provides basis for measures to shorten the arrival time.

Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients

Background:Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging.Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries.Bowel anastomosis after traumarelated resection is associated with a high rate of leakage.The ability of the surgeon’s bare eye to determine bowel viability remains limited,and the need for a more standardized objective assessment has not yet been fulfilled.Hence,there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize traumaassociated complications.Indocyanine green(ICG)coupled with fluorescence angiography is a potential solution for this problem.ICG is a fluorescent dye that responds to near-infrared irradiation.Methods:We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery.Discussion:ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance.However,there is a paucity of information regarding the use of this technology to treat traumas.Recently,angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions,leading to fewer cases of anastomotic insufficiency.This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety.However,there is no consensus on the ideal dose,time,and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings.Conclusions:There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection.This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’operative care and safety in the field of trauma surgery.

Evaluating Health Planning Issues at the Community Level

This study was a brief review of issues related to health planning in the metropolitan area of Syracuse, New York. It suggested that population demographics and health care utilization can have an impact on the use of services at the community level. The study suggested that the utilization of services can be associated with patient demographics. In this study, younger populations were associated with lower use of hospital inpatient care. The data have also suggested that larger numbers of younger populations are not necessarily related to opportunities for expanding local health care providers. Younger populations can be associated with lower per capita use of services. The data demonstrated that there were substantial reductions in hospital discharges for adult medicine. Total discharges declined by 3999 patients between the seven months in 2019 and 2023. The data also demonstrated that there were notable reductions in hospital discharges for adult surgery.

Recurrent small bowel obstruction secondary to jejunal diverticular enterolith: A case report

BACKGROUND Small bowel diverticulosis is an uncommon condition which is usually asymptomatic and is discovered incidentally. One rare complication is enteroliths forming in the diverticula causing bowel obstruction. Only a few cases of such have been described in literature, and recurrence from this aetiology has not been reported previously. This case report outlines the management of a 68-year-old male who presented with recurrent small bowel obstruction secondary to jejunal diverticular enterolith impaction, seven months following a previous episode.CASE SUMMARY A 68-year-old male presented with symptoms of small bowel obstruction.Computed tomography(CT) of the abdomen demonstrated small bowel obstruction from an enterolith formed in one of his extensive jejunal diverticula. He required a laparotomy, an enterotomy proximal to the enterolith, removal of the enterolith, closure of the enterotomy, and resection of a segment of perforated ileum with stapled side-to-side anastomosis. Seven months later, he represented to emergency department with similar symptoms. Another CT scan of his abdomen revealed a recurrent small bowel obstruction secondary to enterolith impaction. He underwent another laparotomy in which it was evident that a large enterolith was impacted at the afferent limb of the previous small bowel anastomosis. A part of the anastomosis was excised to allow removal of the enterolith and the defect was closed with cutting linear stapler. In the following two years, the patient did not have a recurrent episode of enterolith-related bowel obstruction.CONCLUSION The pathophysiology underlying enterolith formation is unclear, so it is difficult to predict if or when enteroliths may form and cause bowel obstruction. More research could provide advice to prevent recurrent enterolith formation and its sequelae.