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There are only a few models developed for risk-stratifying COVID-19 patients with suspected pneumonia in the emergency department (ED). We aimed to develop and validate a model, the COVID-19 ED pneumonia mortality index (CoV-ED-PMI), for predicting mortality in this population. We retrospectively included adult COVID-19 patients who visited EDs of five study hospitals in Texas and who were diagnosed with suspected pneumonia between March and November 2020. The primary outcome was 1-month mortality after the index ED visit. In the derivation cohort, multivariable logistic regression was used to develop the CoV-ED-PMI model. In the chronologically split validation cohort, the discriminative performance of the CoV-ED-PMI was assessed by the area under the receiver operating characteristic curve (AUC) and compared with other existing models. A total of 1678 adult ED records were included for analysis. Of them, 180 patients sustained 1-month mortality. There were 1174 and 504 patients in the derivation and validation cohorts, respectively. Age, body mass index, chronic kidney disease, congestive heart failure, hepatitis, history of transplant, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and national early warning score were included in the CoV-ED-PMI. The model was validated with good discriminative performance (AUC: 0.83, 95% confidence interval [CI]: 0.79–0.87), which was significantly better than the CURB-65 (AUC: 0.74, 95% CI: 0.69–0.79, p-value

Introduction: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases. Methods: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March–November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases. Results: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality. Conclusion: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.

Background and importance Although factors related to a return emergency department (ED) visit have been reported, few studies have examined 'high-risk' return ED visits with serious adverse outcomes. Understanding factors associated with high-risk return ED visits may help with early recognition and prevention of these catastrophic events. Objectives We aimed to (1) estimate the incidence of high-risk return ED visits, and (2) to investigate time-varying factors associated with these revisits. Design Case-crossover study. Settings and participants We used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 651 815 ED visits over a 6-year period. Patient demographics and computerized triage information were extracted. Outcome measure and analysis A high-risk return ED visit was defined as a revisit within 72 h of the index visit with ICU admission, receiving emergency surgery, or with in-hospital cardiac arrest during the return ED visit. Time-varying factors associated with a return visit were identified. Main results There were 440 281 adult index visits, of which 19 675 (4.5%) return visits occurred within 72 h. Of them, 417 (0.1%) were high-risk revisits. Multivariable analysis showed that time-varying factors associated with an increased risk of high-risk revisits included the following: arrival by ambulance, dyspnea, or chest pain on ED presentation, triage level 1 or 2, acute change in levels of consciousness, tachycardia (>90/min), and high fever (>39°C). Conclusions We found a relatively small fraction of discharges (0.1%) developed serious adverse events during the return ED visits. We identified symptom-based and vital sign-based warning signs that may be used for patient self-monitoring at home, as well as new-onset signs during the return visit to alert healthcare providers for timely management of these high-risk revisits.

Background After years of setting up public automated external defibrillators (AEDs), the rate of bystander AED use remains low all over the world. This study aimed to assess the public awareness and willingness of bystanders to use AEDs and to investigate the awareness on the Good Samaritan Law (GSL) and the factors associated with the low rate of bystander AED use. Methods Using stratified random sampling, national telephone interviews were conducted using an author-designed structured questionnaire. The results were weighted to match the census data in Taiwan. The factors associated with public awareness and willingness of bystanders to use AEDs were analysed by logistic regression. Results Of the 1073 respondents, only 15.2% had the confidence to recognise public AEDs, and 5.3% of them had the confidence to use the AED. Concerns on immature technique and legal issues remain the most common barriers to AED use by bystanders. Moreover, only 30.8% thought that the public should use AEDs at the scene. Few respondents (9.6%) ever heard of the GSL in Taiwan, and less than 3% understood the meaning of GSL. Positive awareness on AEDs was associated with high willingness of bystanders to use AEDs. Respondents who were less likely to use AEDs as bystanders were healthcare personnel and women. Conclusion The importance of active awareness and the barriers to the use of AEDs among bystanders seemed to have been underestimated in the past years. The relatively low willingness to use AEDs among bystander healthcare providers and women needs further investigation.

Aim Survival is the most consistently captured outcome across countries for out-of-hospital cardiac arrests (OHCA), with return of spontaneous circulation (ROSC) representing the earliest endpoint for ‘unbiased’ initial resuscitation success. The ROSC after cardiac arrest (RACA) score was developed to predict ROSC and has been validated in several European countries. In this study, we aimed to evaluate the performance of RACA in a Pan-Asian population. Methods We conducted a retrospective analysis of data collected in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. We included OHCA cases from seven communities (Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand, and United Arab Emirates) between January 2009 and December 2012. Paediatric cases, cases that were conveyed by non-emergency medical services (EMS), and cases with incomplete records were excluded from the study. Results The RACA score showed similar discrimination performance as the original German study and various European validation studies. However, it had poor calibration with the original constant regression coefficient, which was primarily due to the low ROSC rate (8.2%) in the PAROS cohort. The calibration performance of RACA significantly improved after the constant coefficient was modified to adjust for the disparity in ROSC rates between Asia and Europe. Conclusion This is the largest validation study of the RACA score. RACA consistently performs well in both Pan-Asian and European communities and can thus be a valuable tool for evaluating EMS systems. However, to implement it, the constant coefficient has to be modified in the RACA formula with local historical data.

Aim To summarise and compare the prognostic accuracy of the blood biomarkers of brain injury, including NSE and S-100B, for neurological outcomes in adult post-cardiac arrest patients. Methods We systematically searched PubMed and Embase databases from their inception to March 2019. We selected studies providing sufficient data of prognostic values of NSE or S-100B to predict neurological outcomes in adult post-cardiac arrest patients. We adopted QUADAS-2 to assess risk of bias and a Bayesian bivariate random-effects meta-analysis model to synthesise the prognostic data. The study protocol was registered with PROSPERO (CRD42018084933). Results We included 42 studies involving 4806 patients in the meta-analysis. The NSE was associated with a pooled sensitivity of 0.56 (95% credible interval [CrI], 0.47–0.65) and pooled specificity of 0.99 (95% CrI, 0.98–1.00). The S-100B was associated with a pooled sensitivity of 0.63 (95% CrI, 0.46–0.78) and pooled specificity of 0.97 (95% CrI, 0.92–1.00). The heterogeneity for NSE (I2, 22.4%) and S-100B (I2, 16.1%) was low and publication bias was not significant. In subgroup analyses, both biomarkers were associated with high specificity across all subgroups with regard to different populations (i.e. whether patients were out-of-hospital cardiac arrest or whether patients received targeted temperature management), different timings of measurement, and different timings of outcome assessment. Conclusions The prognostic performance was comparable between NSE and S-100B. Both biomarkers may be integrated into a multimodal neuroprognostication algorithm for post-cardiac arrest patients and institution-specific cut-off points for both biomarkers should be established.

Introduction: Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods: This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results: Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72-0.84), and lower costs (adjusted difference, -5,198 New Taiwan dollars, 95% CI, -6,224 to -4,172). Conclusion: Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

To investigate whether the effects of sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR) would be influenced by blood pH and administration timing. Adult patients experiencing in-hospital cardiac arrest (IHCA) from 2006 to 2015 were retrospectively screened. Early intra-arrest blood gas data were obtained within 10 min of CPR. Multivariable logistic regression analysis and generalised additive models were used for effect estimation and data exploration, respectively. A total of 1060 patients were included. Only 59 patients demonstrated favourable neurological status at hospital discharge. Blood pH ≤ 7.18 was inversely associated with favourable neurological outcome (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11–0.52; p value p value = 0.02). In the interaction analysis for survival to hospital discharge, significant interactions were noted between SB use and blood pH (Non-SB use × blood pH > 7.18; OR 1.56; 95% CI 1.01–2.41; p value = 0.05). SB should not be empirically administered for patients with IHCA since its effects may be influenced by blood pH and administration timing.

To investigate whether the optimal time to tracheal intubation (TTI) during cardiopulmonary resuscitation would differ by different blood gas phenotypes. Adult patients experiencing in-hospital cardiac arrest (IHCA) from 2006 to 2015 were retrospectively screened. Early intra-arrest blood gas analysis, performed within 10 min of resuscitation, was used to define different phenotypes. In total, 567 patients were included. Non-severe acidosis (pH≧7.15) was associated with favourable neurological outcome (odds ratio [OR]: 4.60, 95% confidence interval [CI] 1.63–12.95; p value = 0.004) and survival (OR: 3.25, 95% CI 1.72–6.15; p value 2: 35–45 mm Hg, HCO3− level: 22–26 mmol/L) × TTI ≦ 6.3 min (OR: 20.40, 95% CI 2.53–164.75; p value = 0.005) and non-severe acidosis × TTI ≦ 6.3 min (OR: 3.35, 95% CI 1.00–11.23; p value = 0.05) were associated with neurological recovery while metabolic acidosis × TTI ≦ 5.7 min (OR: 3.63, 95% CI 1.36–9.67; p value = 0.01) and hypercapnic acidosis × TTI ≦ 10.4 min (OR: 2.27, 95% CI 1.20–4.28; p value = 0.01) were associated with survival. Intra-arrest blood gas analysis may help guide TTI during for patients with IHCA.

Background: A low bystander cardiopulmonary resuscitation (CPR) rate is one of the factors associated with low cardiac arrest survival. This study aimed to assess knowledge, attitudes, and willingness towards performing CPR and the barriers for implementation of bystander-initiated CPR. Methods: Telephone interviews were conducted using an author-designed and validated structured questionnaire in Taiwan. After obtaining a stratified random sample from the census, the results were weighted to match population data. The factors affecting bystander-initiated CPR were analysed using logistic regression. Results: Of the 1073 respondents, half of them stated that they knew how to perform CPR correctly, although 86.7% indicated a willingness to perform CPR on strangers. The barriers to CPR performance reported by the respondents included fear of legal consequences (44%) and concern about harming patients (36.5%). Most participants expressed a willingness to attend only an hour-long CPR course. Respondents who were less likely to indicate a willingness to perform CPR were female, healthcare providers, those who had no cohabiting family members older than 65 years, those who had a history of a stroke, and those who expressed a negative attitude toward CPR. Conclusion: The expressed willingness to perform bystander CPR was high if the respondents possessed the required skills. Attempts should be made to recruit potential bystanders for CPR courses or education, targeting those respondent subgroups less likely to express willingness to perform CPR. The reason for lower bystander CPR willingness among healthcare providers deserves further investigation. Keywords: Cardiac arrest, Cardiopulmonary resuscitation (CPR), Willingness, Bystander CPR, Survey

Introduction: Within a few months coronavirus disease 2019 (COVID-19) evolved into a pandemic causing millions of cases worldwide, but it remains challenging to diagnose the disease in a timely fashion in the emergency department (ED). In this study we aimed to construct machine-learning (ML) models to predict severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection based on the clinical features of patients visiting an ED during the early COVID-19 pandemic. Methods: We retrospectively collected the data of all patients who received reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 at the ED of Baylor Scott & White All Saints Medical Center, Fort Worth, from February 23–May 12, 2020. The variables collected included patient demographics, ED triage data, clinical symptoms, and past medical history. The primary outcome was the confirmed diagnosis of COVID-19 (or SARS-CoV-2 infection) by a positive RT-PCR test result for SARS-CoV-2, and was used as the label for ML tasks. We used univariate analyses for feature selection, and variables with P

Introduction This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA). Methods We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression. Results Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27–1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42–11.02, p: 0.02). That is, when the studies not accounting for the variable of “time to intervention” in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot. Conclusions The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Objectives Emergency department (ED) revisits had traditionally been used as a quality indicator, but focused more on the same hospital revisit (SHRV). Our study investigated the 72-hour ED revisits on SHRV and different hospital revisits (DHRV), and explored the predictors of DHRV. Methods 72-hour ED revisits were analyzed using Taiwan's National Health Insurance Research Database that contained one-third patient records from 2012 to 2013. Rates of SHRV and DHRV were calculated and compared among levels of hospital accreditation. Linear regression analyses were used to measure the correlation between revisit rates and average monthly volumes of the index ED. Multilevel logistic analyses were performed to evaluate the predictors of DHRV. Results There were 4 065 215 index ED visits. Of them, 234 826 (5.8%) were associated with 72-hour revisits and 36.7% of them occurred at different institutions. The revisit rates showed differences across distinct hospital levels. DHRV rates had significant inverse correlation with the average monthly volume of the index ED. Independent predictors associated with the increased odds of DHRV were: ED visits on weekend or holiday, or the index ED being at a local hospital. Conclusions About one in three ED revisits occurred in another hospital. SHRV rate alone would inevitably underestimate the true revisit rate. DHRV is associated with the hospital level and annual ED volume, and there is increased likelihood of DHRV if patient's index ED visit being a local hospital.

Objectives To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED). Methods This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. Results From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0–160.0 s). Among these, a median of 26.5 s (IQR: 0.0–59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0–101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59–33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51–44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44–12.61; p-value Conclusion Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.

To investigate the association between central obesity and outcomes following in-hospital cardiac arrest (IHCA). A single-centred retrospective study was conducted. Adult patients that experienced IHCA during 2006–2015 were screened. Body mass index (BMI) was calculated at hospital admission. Central obesity-related anthropometric parameters were measured by analysing computed tomography images. A total of 648 patients were included, with mean BMI of 23.0 kg/m2. The proportions of BMI-defined obesity in this cohort were underweight (13.1%), normal weight (41.4%), overweight (31.5%) and obesity (14.0%). The mean waist circumference was 85.9 cm with mean waist-to-height ratio (WHtR) of 0.53. The mean sagittal abdominal diameter was 21.2 cm with mean anterior and posterior abdominal subcutaneous adipose tissue (SAT) depths of 1.6 and 2.0 cm, respectively. Multivariate logistic regression analyses indicated BMI of 11.7–23.3 kg/m2 (odds ratio [OR]: 2.53, 95% confidence interval [CI]: 1.10–5.85; p-value = 0.03), WHtR of 0.49–0.59 (OR: 3.45, 95% CI: 1.56–7.65; p-value = 0.002) and anterior abdominal SAT depth

Aim Cardiopulmonary resuscitation (CPR) quality affects survival after cardiac arrest. We aimed to investigate if a smartwatch with real-time feedback can improve CPR quality by healthcare professionals. Methods An app providing real-time audiovisual feedback was developed for a smartwatch. Emergency Department (ED) professionals were recruited and randomly allocated to either the intervention group wearing a smartwatch with the preinstalled app, or to a control group. All participants were asked to perform a two-minute CPR on a manikin at a 30:2 compression-ventilation ratio. Primary outcomes were the mean CCR and CCD measured on the manikin. A secondary outcome was the percentage of chest compressions meeting both the guideline-recommended rate (100–120 min−1) and depth (50–60 mm) of high-quality CPR during a 2-min period. Differences between groups were evaluated with t-test, Chi-Square test, or Mann–Whitney U test depending on the distribution. Results Eighty participants were recruited. 40 people were assigned to the intervention and 40 to the control group. The compression rates (mean ± SD, min−1) were significantly faster (but above the guideline recommendation, P Conclusion Without real-time feedback, chest compressions tend to be too fast and too shallow. CPR quality can be improved with the assistance of a smartwatch providing real-time feedback.

In this paper, we report a rare case of a 65-year-old Chinese male farmer who was brought to an emergency department (ED) with a puncture wound on the left ankle. One week after being treated, the patient returned to the ED and exhibited signs of diaphoresis, hypertension, and slight rigidity and pain in the neck region. Eight hours after being admitted to the surgical ward, the patient developed typical signs of generalised tetanus, including abdominal muscle rigidity, trismus, and dysphagia. This case is unique because of the early manifestation of autonomic dysfunction, which is not common in people with tetanus. Therefore, to establish an early diagnosis of tetanus, physicians in EDs must obtain detailed patient histories and recognise acute changes in vital signs. (Hong Kong j.emerg.med. 2014;21:392-395)

SummaryThe aim of this systematic review is to synthesize research studies involving the use of smart watch devices for healthcare.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was chosen as the systematic review methodology. We searched PubMed, CINAHL Plus, EMBASE, ACM, and IEEE Xplore. In order to include ongoing clinical trials, we also searched ClinicalTrials.gov. Two investigators evaluated the retrieved articles for inclusion. Discrepancies between investigators regarding article inclusion and extracted data were resolved through team discussion.356 articles were screened and 24 were selected for review. The most common publication venue was in conference proceedings (13, 54%). The majority of studies were published or presented in 2015 (19, 79%). We identified two registered clinical trials underway. A large proportion of the identified studies focused on applications involving health monitoring for the elderly (6, 25%). Five studies focused on patients with Parkinson’s disease and one on cardiac arrest. There were no studies which reported use of usability testing before implementation.Most of the reviewed studies focused on the chronically ill elderly. There was a lack of detailed description of user-centered design or usability testing before implementation. Based on our review, the most commonly used platform in healthcare research was that of the Android Wear. The clinical application of smart watches as assistive devices deserves further attention.Smart watches are unobtrusive and easy to wear. While smart watch technology supplied with biosensors has potential to be useful in a variety of healthcare applications, rigorous research with their use in clinical settings is needed.Citation: Lu T-C, Fu C-M, Ma M H-M, Fang C-C, Turner AM. Healthcare applications of smart watches: A systematic review.

We describe a Klebsiella pneumoniae-related liver abscess and unrecognized epidural abscess with or without endophthalmitis in 2 nondiabetic patients, both of whom suffered neurologic complications after invasive procedure. Although rare, we should keep these types of cases in mind when making a diagnosis in patients with both liver abscess and complaint of neck pain.

Emergency medical dispatchers are the entry points to the emergency medical services (EMS). The overall performances of the dispatchers are imperative determinants of the emergency medical services dispatching system. There is little data on the cultural and language impacts on emergency medical dispatch.This study examined the emotional content and cooperation score (ECCS) among Mandarin Chinese speaking callers for cardiac arrests, and evaluated the performances of emergency medical services dispatching system in Taipei.This retrospective, observational study examined dispatching audio recordings obtained from the Taipei City Fire Department Dispatching Center between January 2004 to April 2004. The tapes of call relating to adult (ageor=18 years), non-traumatic cases with a presumed or field diagnosis of out-of-hospital cardiac arrest (OHCA) underwent systemic review. The caller's ECCS and the dispatcher's performances, including interview skills, provision of telephone-assisted cardiopulmonary resuscitation (T-CPR), and dispatcher's ability to identify OHCA were examined. Interrater reliability for determining ECCS and interview skills were assessed using kappa statistic.A total of 199 audio recordings were reviewed. A mean ECCS of 1.42+/-0.64 (95% CI: 1.33-1.51) demonstrated that most callers were emotionally stable and cooperative when calling for help, even when facing cardiac arrest patients. There was a good association between ECCS and the sex of the callers (male 1.32 versus female 1.49; p0.05). In 82% of interviews, the interview skills of the dispatchers was high (4 or 5 points); while in one fifth the interview skills were suboptimal. About one third of the cases were provided with T-CPR by the dispatchers. The sensitivity and positive predictive value (PPV) for predicting OHCA by dispatchers were 96.9% and 97.9%, respectively. A kappa value of 0.65 and 0.68 were obtained for the interrater reliability of ECCS and interview skills.Most callers were found to be emotional stable and cooperative with dispatcher's interrogations when calling for cardiac arrest victims in this Mandarin speaking population. The dispatchers have shown satisfactory interview skills in approaching emergency calls and a good ability to identify OHCA. There is a low rate of T-CPR offered to the callers in the investigation. Efforts should be made to address the deficiencies in order to maximise the function of the EMS.

Summary Introduction Implementing prehospital advanced life support (ALS) services requires more medical and societal resources in training and equipment. The actual demand for ALS services in our communities was not clear. To ensure good use of expensive resources, it is important to evaluate the demand and appropriateness of ALS services before full-scale implementation takes place. Objective To evaluate the rate and characteristics of demand for ALS, and the appropriateness of ALS dispatch of the emergency medical service (EMS) system in metropolitan Taipei City. Methods A retrospective, cross-sectional analysis of the EMS records of Taipei City Fire Department from April 1999 to December 2000 was conducted. Stratified random sampling of all EMS records in the second week of January, April, July and October of 2000 were obtained, along with the corresponding ALS dispatch records. Retrospective ALS demand criteria, including the chief complaints, mechanisms of injury/illness, initial vital signs and types of care rendered, were developed to estimate the rate of ALS demand. ALS demand is expressed as the percentage of cases fulfilling ALS criteria over the total number of EMS cases. Appropriate ALS dispatches were those ALS dispatches determined as fulfilling the ALS demand criteria. Results Among the sampled 5433 EMS cases, 490 (9.02%) were determined as a demand for ALS care. ALS demands varied from region to region, and were higher during winter months and afternoon rush hours. There were 175 actual ALS dispatches, accounting for 3.22% of the sampled EMS services. The triage performance was suboptimal: the appropriateness of ALS dispatch was 37.14%; the overtriage rate was 72.86%. Conclusion Around nine percent of EMS calls demand ALS services. The current triage performance for proper ALS dispatch was suboptimal. A correct ALS dispatch protocol and more dispatcher training programmes should be established in the communities to ensure best use of valuable ALS resources.

Objectives: This was a study to evaluate the utilization of emergency medical services (EMS) systems during the outbreak of severe acute respiratory syndrome (SARS), and to assess the incidence of infection among emergency medical technicians (EMTs). Methods: This was a prospective, observational study conducted in the EMS system of Taipei, Taiwan. Probable/suspect cases of SARS were defined by World Health Organization criteria. SARS-related transports were categorized into 1) requests from hospitals for probable/suspect cases of SARS, 2) quarantined individuals, and 3) febrile persons. City ambulances were organized into teams A, B, and C for transports of different perceived risks. Data on the EMS volume, the transport category, the final SARS status of patients, and the EMT responsible for the transports were collected. The EMS projected volume was computed by previous years’ data and compared with that collected. The SARS incidence among EMTs was assessed by investigating probable SARS (P-SARS) and by surveying the seroprevalence of SARSassociated coronavirus (SARS-CoV) antibody. Results: From March 18 to June 19, 2003, there were 7,961 EMS transports, similar to the volume projected from previous years (7,506) (95% CI = 6,688 to 8,324). Of these, 1,760 (22.1%) were SARSrelated. When SARS-related transports were excluded, there was a 12.2% decrease (95% CI = 11.4% to 12.9%) in EMS activities. Requests from hospitals, quarantined individuals, and febrile citizens accounted for 23%, 18%, and 59% of SARS-related transports. Among the 397 P-SARS cases in the city of 2.65 million people (incidence 0.01%, 95% CI = 0.01% to 0.02%), 138 (35%) required EMS transports. Two EMTs working in team C, the team with the lowest risk, developed P-SARS. One of them died soon thereafter. The incidence of P-SARS was 0.6% (95% CI = 0.2% to 2.2%), or 0.1% (95% CI = 0.03% to 0.4%) per transport. SARS-CoV serology was available in 74.1% of EMTs who were alive. In addition to the surviving P-SARS EMT, one EMT from team A, the team with the highest risk, was seropositive. Combining P-SARS and the seropositive case, three EMTs were infected (incidence 1.3%, 95% CI = 0.4% to 3.6%). No patient transported by the infected EMTs developed SARS. The hospitals serving EMS by the infected EMTs had been involved in a clustered outbreak prior to the EMTs’ infections. Conclusions: During the outbreak of SARS, the overall EMS volume did not change significantly, but the non-SARS EMS activities decreased. Compared with the general population, EMS providers are at higher risk of contracting the SARS virus regardless of different perceived levels of risk. Standard protections and procedures for infection control should be strictly followed during transport and within the hospital environment. Key words: emergency medical services; severe acute respiratory syndrome; emergency medical technicians; utilization; incidence. ACADEMIC EMERGENCY MEDICINE 2004; 11:903‐911.

Objective The early partial pressures of arterial O2 (PaO2) and CO2 (PaCO2) have been found in animal studies to be correlated with neurological outcome after brain injury. However, the relationship of early PaO2 and PaCO2 to the neurological outcomes of resuscitated patients after cardiac arrest was still not clear. Methods This was a retrospective observational cohort study in a single medical center. Adult patients who had in-hospital cardiac arrest between 2006 and 2012 and achieved sustained return of spontaneous circulation (ROSC) (ROSC > 20 min without resumption of chest compression) were included. Multivariable logistic regression analysis was used to identify factors associated with favorable neurological outcome at hospital discharge. The first PaO2 and PaCO2 values measured after first sustained ROSC were used for analysis. Results Of the 550 included patients, 154 (28%) survived to hospital discharge and 74 (13.5%) achieved favorable neurological outcome. The mean time from sustained ROSC to the measurement of PaO2 and PaCO2 was 136.8 min. The mean PaO2 and PaCO2 were 167.4 mmHg and 40.3 mmHg, respectively. PaO2 between 70 and 240 mmHg (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.08–3.64) and PaCO2 levels (OR 0.98, 95% CI 0.95–0.99) were positively and inversely associated with favorable neurological outcome, respectively. Conclusions The early PaO2 and PaCO2 levels obtained after ROSC might be correlated with neurological outcome of patients with in-hospital cardiac arrest. However, because of the inherent limitations of the retrospective design, these results should be further validated in future studies.

Tension pneumoperitoneum is a potentially lethal complication of numerous iatrogenic procedures, including upper gastrointestinal (UGI) endoscopy. We report a 69-year-old man with UGI bleeding who developed tension pneumoperitoneum and cardiac arrest after UGI endoscopy. He was successfully resuscitated with needle decompression. Emergency surgery revealed a perforated gastric ulcer, and subtotal gastrectomy with Billroth II anastomosis was performed. Recovery was smooth and he was discharged from the hospital 18 days later. Tension pneumoperitoneum should be suspected in all patients who develop circulatory collapse with acutely distended abdomen after UGI endoscopy. Early identification relies on a high index of suspicion. Prompt treatment with needle decompression should not be delayed for confirmatory radiography once the clinical diagnosis is made.

Background: There is limited data about how appropriate medical care is in the emergency department (ED). Objectives: To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED. Methods: We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen κ statistic. Results: Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen κ statistic of 0.81. Conclusions: Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.

Summary Purpose of the study The Web-Based Registry System on In-hospital Resuscitation (WRSIR) is the first prospective, web-based, multi-site, and Utstein-based reporting system in Taiwan. This study was conducted to evaluate the feasibility of the system in one of the participating hospitals and identify prognostic factors associated with survival. Material and methods The WRSIR is an on-line registry system coded with the active server page (ASP) programming method. Information was gathered and entered on-line by trained staff using spreadsheets that could be automatically created according to the updated Utstein in-hospital template. Through the implementation of the system, in a tertiary teaching hospital we evaluated all adults with in-hospital cardiac arrest receiving cardiopulmonary resuscitation between 1 October 2004 and 30 September 2005. The main outcome measures were return of spontaneous circulation (ROSC), survival to hospital discharge, and cerebral performance category score at the time of discharge. Logistic regression analysis was performed to determine independent predictors of survival. Results A total of 330 cases experienced in-hospital resuscitation. ROSC occurred in 233 cases (71%) and 61 patients (18%) survived to hospital discharge. Thirty-five patients (58%) had a good neurological outcome with the cerebral performance category (CPC) score of 1 or 2 among survivors. The major predictor of ROSC was initial rhythm of VT/VF (adjusted OR 0.36, 95% CI 0.16–0.78). Conclusion This study examined the feasibility of a web-based registry system on in-hospital resuscitation using the Utstein style in an oriental country. It provides a comprehensive and standardised method for on-line registry of data collection, allowing individual hospitals to track each case for quality improvement. A further nationwide registry will enforce the possibility of data analysis and future perspective research of in-hospital resuscitation.

Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse reaction to neuroleptics, which is characterized by hyperthermia, extrapyramidal symptoms, altered consciousness and autonomic dysfunction. Although NMS is most commonly induced by the high-potency neuroleptics, its development has also been associated with the use of non-neuroleptic agents that block central dopamine pathways. A 68-year-old man with generalized anxiety disorder and depressive symptoms presented at the emergency department (ED) with high fever, tremor, muscle rigidity, rhabdomyolysis and altered mental status. NMS was considered to have been caused by the recent addition and subsequent dose increase in his treatment regimen of venlafaxine, a serotonin norepinephrine reuptake inhibitor. He was successfully treated with bromocriptine, lorazepam, and fluid hydration in the ED and intensive care unit.

Objective To review the incidence and clinical characteristics of spontaneous pneumothorax in patients with ankylosing spondylitis (AS). Methods This is a retrospective observational cohort study. Chest radiographs and medical records of patients with a diagnosis of AS from 1993 to 2003 in a tertiary referral centre were reviewed. Results A total of 1028 patients with a diagnosis of AS were identified from July 1993 to July 2003. Twenty-two patients had typical apical lung fibrotic changes in the chest radiographs (22/1028, 2.1%). Three of these patients (3/22, 13.6%) with lung disease had pneumothorax. Two patients had recurrences and received video-assisted thoracoscopic surgery (VATS) on the second attack. The third patient received talc pleurodesis on the first attack and did not have a recurrence. The incidence of spontaneous pneumothorax in patients with AS was 0.29% (3/1028) with an incidence density of 64.85/100,000 patient-yr (95% confidence interval: 66.17-63.57/100,000). Conclusion Spontaneous pneumothorax appears to be exceedingly rare in AS unless there is an underlying fibrocystic lung disease, in which case its occurrence is not uncommon. Cigarette smoking may be an important co-factor. Once developed, recurrences are common even after treatment. Prophylactic procedures should thus be considered for the first attack of spontaneous pneumothorax.

34-year-old male plumber presented to the Emerency Department (ED) for sudden onset of painful eft infraorbital swelling when he was blowing his ose. Two days before presentation, the patient struck is left eye on a pipe protruding from a wall when bruptly turning his head to the left. Due to the hollow tructure of the pipe, the injury was seemingly limited o an abrasion and contusion in the periorbital area ith sparing of the globe. After the injury, he visited n ophthalmologic clinic and treatment with topical edications was prescribed. On physical examination, there was superficial brasion over the left infraorbital region. The area ppeared swollen with palpable crepitus. Visual acuity as 20/20 in both eyes. Extraocular movements and unduscopic examinations of both eyes were normal. n orbital computed tomography (CT) scan showed bnormal air accumulated in the infraorbital area (Figre 1). A small medial orbital wall (lamina papyracea) racture was also noted with protrusion of soft tissue nto the ethmoid sinus (Figure 2). Oral antibiotic and nalgesic agents were prescribed and he was advised

Between March and July 2003, 671 cases of severe acute respiratory syndrome (SARS) were diagnosed in Taiwan with a total of 84 fatalities. After the epidemic, a serological survey was conducted involving the asymptomatic household contacts. Household contacts of 13 index patients were enrolled in the study. Contact history and clinical symptoms of the household contacts were recorded by standardized questionnaires. Blood samples of patients and household contacts were collected at least 28 days after symptom onset in the index patients or household exposure in the contacts for SARS-associated coronavirus (SARS-CoV) IgG testing. On the basis of this investigation, 29 persons (25 adults and 4 children) were identified as having had unprotected exposure to the index cases before infection-control practices were implemented. Laboratory evaluation of clinical specimens showed no evidence of transmission of SARS-CoV infection to any contacts. This investigation demonstrated that subclinical transmission among household contacts was low in the described setting.