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This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients. We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS. Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7–13.4) and CFS score (OR, 5.8; 95% CI, 1.9–17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS. The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED. [ABSTRACT FROM AUTHOR]

Purpose: The quick Sepsis-Related Organ Failure Assessment (qSOFA) score was designed to predict mortality among sepsis patients. However, it has never been used to identify prolonged length of hospital stay (pLOS) in geriatric patients with influenza infection. We conducted this study to clarify this issue.Methods: We conducted a retrospective case-control study, including geriatric patients (aged ≥ 65 years) with influenza infection visiting the emergency department (ED) of a medical center between January 01, 2010 and December 31, 2015. The included patients were divided into two groups on the basis of their qSOFA score: qSOFA < 2, and qSOFA ≥ 2. Data regarding demographics, vital signs, qSOFA score, underlying diseases, subtypes of influenza, and outcomes were included in the analysis. We investigated the association between qSOFA score ≥ 2 and pLOS (>9 days) via logistic regression.Results: Four hundred and nine geriatric patients were included in this study with a mean age of 79.5 (standard deviation [SD], 8.3) years. The median length of stay (LOS) was 7.0 (interquartile range [IQR], 4-12) days, while the rate of pLOS (> 9 days) was 32%. The median LOS in the qSOFA ≥ 2 group, 11.0 (7-15) days, was longer than the qSOFA < 2 group, 6.0 (4-10) days (p-value <0.01). Logistic regression showed that qSOFA ≥ 2 predicts pLOS with an odds ratio of 3.78 (95% confidence interval, 2.04-6.97).Conclusion: qSOFA score ≥ 2 is a prompt and simple tool to predict pLOS in geriatric patients with influenza infection. [ABSTRACT FROM AUTHOR]

Background: The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue.Methods: We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65 years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality.Results: In total, 409 geriatric ED patients with mean age of 79.5 years and nearly equal sex ratio were recruited. The mean shock index ± standard deviation was 0.7 ± 0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39-19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer-Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%.Conclusions: A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza. [ABSTRACT FROM AUTHOR]

Background: Previous guidelines suggest up to 15 minutes of cardiopulmonary resuscitation (CPR) accompanied by other resuscitative interventions before terminating resuscitation of a traumatic cardiac arrest. The current study evaluated the duration of CPR according to outcome using the model of a county-based emergency medical services (EMS) system in Taiwan.Methods: This study was performed as a prospectively defined retrospective review from EMS records and cardiac arrest registration between June 2011 and November 2012 in Taoyuan, Taiwan.Results: A total of 396 patients were enrolled. Among the blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34 patients (8.6%). Of the patients, 18.4% were sent to intermediate to advanced level traumatic care hospitals. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved cerebral performance category 1 or 2. Among all patients who developed return of spontaneous circulation (ROSC), 14.3% of ROSC was achieved within 15 minutes since CPR. Except for 1, most patients who developed ROSC over 24 hours but did not survive to discharge received CPR more than 15 minutes. Four of 6 patients who survived to discharge achieved ROSC after CPR for more than 15 minutes (16, 18, 22, and 24 minutes). Three patients discharged with cerebral performance category 1 or 2 received CPR for 6, 16, and 18 minutes, respectively.Conclusions: Fifteen minutes of CPR before terminating resuscitation is inappropriate for patients undergoing traumatic cardiac arrsests, as longer duration resuscitation increases ROSC and survival. [ABSTRACT FROM AUTHOR]

Background: We investigated independent mortality predictors of hyperglycemic crises and developed a prediction rule for emergency and critical care physicians to classify patients into mortality risk and disposition groups. Methods: This study was done in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled when they met the criteria of a hyperglycemic crisis. Data were separated into derivation and validation sets--the former were used to predict the latter. December 31, 2008, was the cutoff date. Thirty-day mortality was the primary endpoint. Results: We enrolled 295 patients who made 330 visits to the ED: derivation set = 235 visits (25 deaths: 10.6%), validation set = 95 visits (10 deaths: 10.5%). We found 6 independent mortality predictors: Absent tachycardia, Hypotension, Anemia, Severe coma, Cancer history, and Infection (AHA.SCI). After assigning weights to each predictor, we developed a Predicting Hyperglycemic crisis Death (PHD) score that stratifies patients into mortality-risk and disposition groups: low (0%) (95% CI, 0-0.02%): treatment in a general ward or the ED; intermediate (24.5%) (95% CI, 14.8-39.9%): the intensive care unit or a general ward; and high (59.5%) (95% CI, 42.2-74.8%): the intensive care unit. The area under the curve for the rule was 0.946 in the derivation set and 0.925 in the validation set. Conclusions: The PHD score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in adult patients with hyperglycemic crises. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study was to investigate if the electrocardiographic (ECG) abnormalities assessed early in the emergency department (ED) are associated with the in-hospital mortality of the patients with spontaneous subarachnoid hemorrhage (SAH). Methods: We studied prospectively a cohort of 222 adult patients with spontaneous SAH in an ED. A 12-lead ECG was performed for these patients in the ED. The patients were stratified into nonsurvivors and survivors based on the in-hospital mortality. The clinical characteristics, heart rate, corrected QT interval (QTc) and 7 predefined morphologic abnormalities were compared between these 2 groups of patients. Results: Compared with the survivors (n = 178), the nonsurvivors (n = 44) had significantly slower heart rate (75 ± 23 vs 83 ± 16, P = .018) and more prolonged QTc (492 ± 58 vs 458 ± 40, P = .001). There were significantly higher frequency of occurrence of ECG morphologic abnormalities (66% vs 37%, P = .001) and nonspecific ST- or T-wave changes (NSSTTCs; 32% vs 12%, P = .015) in the nonsurvivors compared with those in the survivors. Multiple logistic regression model identified QTc (odds ratio, 1.0; 95% confidence interval, 1.0-1.0; P = .005) and NSSTTC (odds ratio, 3.3; 95% confidence interval, 1.0-10.7; P = .047) as the significant ECG variables associated with in-hospital mortality. Conclusions: The occurrence of NSSTTC and prolonged QTc assessed early in the ED are independently associated with the in-hospital mortality in adult patients with spontaneous SAH. [Copyright &y& Elsevier]

Abstract: Objectives: The objective of this study is to investigate the role of sympathovagal balance in predicting inhospital mortality by assessing power spectral analysis of heart rate variability (HRV) among patients with nontraumatic subarachnoid hemorrhage (SAH) in an emergency department (ED). Methods: A cohort of 132 adult patients with spontaneous SAH in an ED was prospectively enrolled. A continuous 10-minute electrocardiography for off-line power spectral analysis of the HRV was recorded. Using the inhospital mortality, the patients were classified into 2 groups: nonsurvivors (n = 38) and survivors (n = 94). The HRV measures were compared between these 2 groups of patients. Results: Having compared the various measurements, the very low–frequency component, low-frequency component, normalized low-frequency component (LF%), and low-/high-frequency component ratio (LF/HF) were significantly lower, whereas the normalized high-frequency component was significantly higher among the nonsurvivors than among the survivors. A multiple logistic regression model identified LF/HF (odds ratio, 2.16; 95% confidence interval [CI], 1.18-3.97; P = .013) and LF% (odds ratio, 0.78; 95% CI, 0.69-0.88; P < .001) as independent variables that were able to predict inhospital mortality for patients with SAH in an ED. The receiver operating characteristic area for LF/HF in predicting inhospital mortality was 0.957 (95% CI, 0.914-1.000; P < .001), and the best cutoff points was 0.8 (sensitivity, 92.1%; specificity, 90.4%). Conclusions: Power spectral analysis of the HRV is able to predict inhospital mortality for patients after SAH in an ED. A tilt in the sympathovagal balance toward depressed sympathovagal balance, as indicated by HRV analysis, might contribute to the poor outcome among these patients. [Copyright &y& Elsevier]

We described a 14-year-old boy with initial presentation of recurrent intermittent abdominal pain, with subsequent development of jejunojejunum intussusception. The characteristic purpuric skin rash of Henoch-Schönlein purpura appeared later after the surgical manual reduction. When abdominal pain is the single initial manifestation in patients with undiagnosed Henoch-Schönlein purpura, emergency physicians should evaluate if the patient required early surgical intervention such as intussusception or perforation and always keep Henoch-Schönlein purpura as a possibility in mind. [ABSTRACT FROM AUTHOR]