The Cost Analysis of Patients with Traffic Traumatic Injuries Presenting to Emergency Department; a Cross-sectional Study.

INTRODUCTION: Road traffic traumatic injuries are the leading cause of death especially among young men who are mostly vulnerable victims. This catastrophe is more complicated in low to middle-income countries. OBJECTIVE: This study assessed the financial costs of traffic casualties in a level-1 trauma university hospital. METHOD: One thousand trauma patients presenting to the emergency department of Shohaday-e-Tajrish Hospital were included in the study. The prehospital and hospital costs as well as the expenses of physiotherapy, rehabilitation, outpatient visits and further surgical interventions were considered as direct expenses. The costs of productivity loss were estimated as indirect expenses. RESULTS: The direct and indirect costs were assessed 27.4% and 72.6% of total, respectively. The mean age of permanent disability was 43 years old. The average expenses of temporary and permanent disabilities were 2934.4 million rials, equal to 106 thousand $ (nearly 4.2 million rials or 153 $ per patient) and 23.9 billion rials, equal to 866.3 thousand $ (1.1 billion rials or 39.2 thousand $ per person), respectively. CONCLUSION: The national burden of traffic injuries in Iran is significantly destructive as it consists of 2.19 % of Gross Domestic Product annually. Besides, young men are involved in most of the traffic accidents representing the need to establish rigorous preventive instructions and reduce human, and financial costs.

Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Program; a Prospective Cross Sectional Study.

INTRODUCTION: Emergency medicine physicians are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health. The present study was performed with the aim of determining the rate of depression and personality disorders in first-year emergency medicine residents and comparing it with the time they reach the 3rd year. METHODS: In the present prospective cross-sectional study, emergency medicine residents working in multiple teaching hospitals were included via census method and evaluated regarding the rate of depression and personality disorders using the standard MMPI-2 questionnaire upon admission to the program and graduation and their status regarding the evaluated disorders were compared between the 2 phases of evaluation. RESULTS: 99 residents with the mean age of 33.93 ± 5.92 years were evaluated. 85 (85.85%) rated their interest in their discipline as moderate to high. The rates of stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant. CONCLUSION: Considering the results of the present study, it seems that paying more attention to mental problems and decreasing environmental stressors of medical residents, especially emergency medicine residents, should be among the priorities of managers and policymakers of this discipline.

Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study.

INTRODUCTION: Electrolyte imbalances are very common among crushed earthquake victims but there is not enough data regarding their trend of changes. The present study was designed to evaluate the trend of changes in sodium, calcium, and phosphorus ions among crush syndrome patients. METHODS: In this retrospective cross-sectional study, using the database of Bam earthquake victims, which was developed by Iranian Society of Nephrology following Bam earthquake, Iran, 2003, the 10-day trend of sodium, calcium, and phosphorus ions changes in > 15 years old crush syndrome patients was evaluated. RESULTS: 118 patients with the mean age of 25.6 ± 6.9 years were studied (57.3 male). On the first day of admission, 52.5% (95% CI: 42.7 - 62.3) of the patients had hyponatremia, which reached 43.9% (95% CI: 28.5 - 59.3) on day 10. 100.0% of patients were hypocalcemic on admission and serum calcium level did not change dramatically during the 10 days of hospitalization. The prevalence of hyperphosphatemia on the first day was 90.5% (95% CI: 81.5 - 99.5) and on the 10th day of hospitalization 66.7% (95% CI: 48.5 - 84.8) of the patients were still affected. CONCLUSION: The results of the present study shows the 52.5% prevalence of hyponatremia, 100% hypocalcemia, and 90.5% hyperphosphatemia among crush syndrome patients of Bam earthquake victims on the first day of admission. Evaluation of 10-day trend shows a slow decreasing pattern of these imbalances as after 10 days, 43.9% still remain hyponatremic, 92.3% hypocalcemic, and 66.7% hypophosphatemic.

Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients.

BACKGROUND: Determining etiologic causes and prognosis can significantly improve management of syncope patients. The present study aimed to compare the values of San Francisco, Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL), Boston, and Risk Stratification of Syncope in the Emergency Department (ROSE) score clinical decision rules in predicting the short-term serious outcome of syncope patients. MATERIALS AND METHODS: The present diagnostic accuracy study with 1-week follow-up was designed to evaluate the predictive values of the four mentioned clinical decision rules. Screening performance characteristics of each model in predicting mortality, myocardial infarction (MI), and cerebrovascular accidents (CVAs) were calculated and compared. To evaluate the value of each aforementioned model in predicting the outcome, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated and receiver-operating curve (ROC) curve analysis was done. RESULTS: A total of 187 patients (mean age: 64.2 ± 17.2 years) were enrolled in the study. Mortality, MI, and CVA were seen in 19 (10.2%), 12 (6.4%), and 36 (19.2%) patients, respectively. Area under the ROC curve for OESIL, San Francisco, Boston, and ROSE models in prediction the risk of 1-week mortality, MI, and CVA was in the 30-70% range, with no significant difference among models (P > 0.05). The pooled model did not show higher accuracy in prediction of mortality, MI, and CVA compared to others (P > 0.05). CONCLUSION: This study revealed the weakness of all four evaluated models in predicting short-term serious outcome of syncope patients referred to the emergency department without any significant advantage for one among others.

Accuracy of SOFA score in prediction of 30-day outcome of critically ill patients.

OBJECTIVES: Researchers have attempted to design various scoring systems to determine the severity and predict the outcome of critically ill patients. The present study aimed to evaluate the accuracy of SOFA score in predicting 1-month outcome of these patients in emergency department. METHODS: The present study is a prospective cross-sectional study of >18 year old non-trauma critically ill patients presented to EDs of 3 hospitals, Tehran, Iran, during October 2014 to October 2015. Baseline characteristics, SOFA score variables, and 1-month outcome of patients were recorded and screening performance characteristics of the score were calculated using STATA 11 software. RESULTS: 140 patients with the mean age of 68.36 ± 18.62 years (18-95) were included (53.5% male). The most common complaints were decrease in level of consciousness (76.43%) and sepsis (60.0%), were the most frequent final diagnoses. Mean SOFA score of the patients was 7.13 ± 2.36 (minimum 2 and maximum 16). 72 (51.43%) patients died during the following 30 days and 16 (11.43%) patients were affected with multiple organ failure. Area under the ROC curve of SOFA score in predicting mortality of studied patients was 0.73 (95%CI: 0.65-0.81) (Fig. 2). Table 2 depicts screening performance characteristics of this scale in prediction of 1-month mortality in the best cut-off point of ≥7. At this cut-off point, sensitivity and specificity of SOFA in predicting 1-month mortality were 75% and 63.23%, respectively. CONCLUSION: Findings of the present study showed that SOFA scoring system has fair accuracy in predicting 1-month mortality of critically ill patients. However, until a more reliable scoring system is developed, SOFA might be useful for narrative prediction of patient outcome considering its acceptable likelihood ratios.

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients.

INTRODUCTION: To date, many prognostic models have been proposed to predict the outcome of patients with traumatic brain injuries. External validation of these models in different populations is of great importance for their generalization. The present study was designed, aiming to determine the value of CRASH prognostic model in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients with traumatic brain injury. METHODS: In the present prospective diagnostic test study, calibration and discrimination of CRASH model were evaluated in head trauma patients referred to the emergency department. Variables required for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ER of 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUO were recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated. The data were analyzed using STATA version 11.0. RESULTS: In this study, 323 patients with the mean age of 34.0 ± 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and 6-month outcome were in the desirable range (P < 0.05). Area under the curve in the basic model for prediction of 14-DM and 6-MUO were 0.92 (95% CI: 0.89-0.96) and 0.92 (95% CI: 0.90-0.95), respectively. In addition, area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91-0.97) and 0.93 (95% CI: 0.91-0.96), respectively. There was no significant difference between the discriminations of the two models in prediction of 14-DM (p = 0.11) and 6-MUO (p = 0.1). CONCLUSION: The results of the present study showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DM and 6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models, using the basic model is recommended to simplify the risk calculations.

A Systematic Review of Iranian Experiences in Seismo-Nephrology.

CONTEXT: Crush syndrome and its potentially life-threatening complications, such as acute kidney injury (AKI), are one of the most important medical problems of disaster victims. However, today, many unanswered questions abound about the potential risk factors of crush syndrome, predictive factors of AKI, proper amount of prophylactic hydration therapy, type of fluid, time of continuing fluid, intravenous versus oral hydration, etc. Therefore, this study was designed to review the findings on Iranian nephrologist experiences in diagnosis and management of traumatic rhabdomyolysis following the last two strong earthquakes of Bam (2003) and Manjil-Rudbar (1990). EVIDENCE ACQUISITION: The study was conducted according to the MOOSE reporting guideline. A literature review was conducted on the nephrologic aspects of earthquakes in Iran. Relevant articles were identified through a comprehensive search of online databases until 2014. The search was limited to articles studying the Iranian population published in English and Persian languages. The validated combination of MeSH terms and key words was used. In addition, a manual search was run among the references of all articles that met the entrance criteria and previous reviews. Only cohort, case-control, and cross-sectional studies were enrolled. Two reviewers independently reviewed the eligible studies, and another reviewer contributed in case of a disagreement. Basic information from each study was evaluated from the aspects of purpose and design, year of publication, methodology, main population, and source of data. The quality of the included studies was assessed using methods guide for effectiveness and comparative effectiveness reviews. Two reviewers independently rated each paper as "good", "fair", or "poor". RESULTS: A total of 1256 non-duplicate articles were identified, but only 35 potentially relevant papers were screened. Finally, 21 articles were found eligible and studied in details. In addition, one unpublished report was included. In the quality assessment, two articles had poor quality, and thus only 20 were finally included in the systematic review. No publication bias (coefficient = -2.28; 95% Confidence interval: -6.17 - 1.78; P = 0.26) was observed among the included studies. CONCLUSIONS: A few eligible articles on seismo-nephrology were found in Iran, and a limited number of current articles had poor or fair quality. As expected, the chaotic situation after mass disasters and the lack of documentation led to the loss of much important data on the diagnosis and management of victims. Lessons learned from the current researches can be used as a valuable guide for future studies.

The Role of Scoring Systems and Urine Dipstick in Prediction of Rhabdomyolysis-induced Acute Kidney Injury: a Systematic Review.

INTRODUCTION: During the past decade, using serum biomarkers and clinical decision rules for early prediction of rhabdomyolysis-induced acute kidney injury (AKI) has received much attention from researchers. This study aimed to broadly review the value of scoring systems and urine dipstick in prediction of rhabdomyolysis-induced AKI. MATERIALS AND METHODS: The study was designed based on the guidelines of the Meta-analysis of Observational Studies in Epidemiology statement. Search was done in electronic databases of MEDLINE, EMBASE, Cochrane Library, Scopus, and Google Scholar by 2 independent reviewers. Studies evaluating AKI risk factors in rhabdomyolysis patients with the aim of developing a scoring model as well as those assessing the role of urine dipstick in these patients were included. RESULTS: Of the 5997 articles found, 143 were potentially relevant studies. After studying their full texts, 6 articles were entered into the systematic review. Two studies had developed or validated scoring systems of the "rule of thumb," and the AKI index, and the Mangled Extremity Severity Score. Four studies were on the predictive value of urine dipstick in risk prediction of rhabdomyolysis-induced AKI, with favorable results. CONCLUSIONS: The findings of this systematic review showed that based on the available resources, using the prediction rules and urine dipstick could be considered as valuable screening tools for detection of patients at risk for AKI following rhabdomyolysis. Yet, the external validity of the mentioned tools should be assessed before their general application in routine practice.

The value of serum creatine kinase in predicting the risk of rhabdomyolysis-induced acute kidney injury: a systematic review and meta-analysis.

INTRODUCTION: Identifying the potential effective factors of rhabdomyolysis-induced acute kidney injury (AKI) is of major importance for both treatment and logistic concerns. The present study aimed to evaluate the value of creatine kinase (CK) in predicting the risk of rhabdomyolysis-induced AKI through meta-analysis. METHODS: Two reviewers searched the electronic databases of Medline, EMBASE, Cochrane library, Scopus, and Google Scholar. Data regarding study design, patient characteristics, number of cases, mean and screening characteristics of CK, and final patient outcome were extracted from relevant studies. Pooled measures of standardized mean difference, OR, and diagnostic accuracy were calculated using STATA version 11.0. RESULT: 5997 non-redundant studies were found (143 potentially relevant). 27 articles met the inclusion criteria but 9 were excluded due to lack of data. The correlation between serum CK and AKI occurrence was stronger in traumatic cases (SMD = 1.34, 95 % CI = 1.25-1.42, I(2) = 94 %; p < 0.001). This correlation was more prominent in crush-induced AKI (adjusted OR = 14.7, 95 % CI = 7.63-28.52, I(2) = 0.0 %; p = 0.001). Area under the ROC curve of CK in predicting AKI occurrence was 0.75 (95 % CI = 0.71-0.79). CONCLUSION: The results of this meta-analysis declared the significant role of rhabdomyolysis etiology (traumatic/non-traumatic) in predictive performance of CK. There was a significant correlation between mean CK level and risk of crush-induced AKI. The pooled OR of CK was considerable, but its screening performance characteristics were not desirable.

Clinical decision rule to prevent unnecessary chest X-ray in patients with blunt multiple traumas.

BACKGROUND: Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients. METHODS: Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients (ß) of the variables, the Thoracic Injury Rule-out Criteria (TIRC) were designed. RESULTS: A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (ß = 0.8; 95% CI: 0.27-1.34; P = 0.003), crepitation (ß = 4.33; 95% CI: 1.65-7.0; P < 0.001), loss of consciousness (ß = 3.16; 95% CI: 2.44-3.88; P < 0.001), decrease in pulmonary sounds (ß = 2.67; 95% CI: 1.73-3.6; P < 0.001), chest wall pain (ß = 2.12; 95% CI: 1.63-2.61; P < 0.001) and tenderness (ß = 1.78; 95% CI: 1.26-2.27; P < 0.001), dyspnea (ß = 1.3; 95% CI: 0.41-2.18; P = 0.004) and abrasion (ß = 0.5; 95% CI: 0.22-0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings. CONCLUSIONS: Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.

Correlation of Blood Gas Parameters with Central Venous Pressure in Patients with Septic Shock; a Pilot Study.

OBJECTIVE: To determine the correlation between blood gas parameters and central venous pressure (CVP) in patients suffering from septic shock. METHODS: Forty adult patients with diagnosis of septic shock who were admitted to the emergency department (ED) of Shohadaye Tajrish Hospital affiliated with Shahid Beheshti University of Medical Sciences, and met inclusion and exclusion criteria were enrolled. For all patients, sampling was done for venous blood gas analysis, serum sodium and chlorine levels. At the time of sampling; blood pressure, pulse rate and CVP were recorded. Correlation between blood gas parameters and hemodynamic indices were. RESULTS: A significant direct correlation between CVP with anion gap (AG) and inversely with base deficit (BD) and bicarbonate. CVP also showed a relative correlation with pH, whereas it was not correlated with BD/ AG ratio and serum chlorine level. There was no significant association between CVP and clinical parameters including shock index (SI) and mean arterial pressure (MAP). CONCLUSION: It seems that some of non invasive blood gas parameters could be served as alternative to invasive measures such as CVP in treatment planning of patients referred to an ED with septic shock.

The Risk of Venous Thromboembolism with Different Generation of Oral Contraceptives; a Systematic Review and Meta-Analysis.

INTRODUCTION: Oral contraceptives (OCs) are considered as one of the most common risk factor of venous thromboembolism (VTE) in childbearing age. Some of the recent researches indicate that the odds of VTE may be even higher with newer generations of OCs. The present meta-analysis was designed to evaluate the effect of different generation of OCs on the occurrence of VTE. METHODS: Two researchers independently ran a thorough search in Pubmed, ISI Web of Science, EMBASE, CINAHL and Scopus databases regarding study keywords including thromboembolic event, thromboembolism, embolism, thromboembolic, thrombotic and thrombosis, combined with oral contraceptive. The outcomes were the incidence of diagnosed thromboembolism, such as deep vein thrombosis, pulmonary embolism and cerebral venous thrombosis. Based on the heterogeneity of the studies, random effect model was used and pooled odds ratio was reported. RESULTS: Three cohort and 17 case-control studies with 13,265,228 subjects were entered into meta-analysis. Analysis showed that the odds of VTE in women taking OCs are more than three-fold (OR=3.13; 95% CI: 2.61-3.65). The risk of VTE in women taking first-, second- and third-generation OCs are 3.5 fold (OR=3.48; 95% CI: 2.01-4.94), 3 fold (OR=3.08; 95% CI: 2.43-3.74) and 4.3 fold (OR=4.35; CI: 3.69‒5.01), respectively. CONCLUSION: It seems that the risk of VTE is not same between different generations of OCs, so that third-generation has highest risk. Taking second and third-generation OCs increases the risk of VTE up to 3 and 4.3 fold, respectively. The researchers of the present study suggest that more trials be designed in relation to the effect of newer generations of OCs in different communities.

An Audit of Emergency Department Accreditation Based on Joint Commission International Standards (JCI).

INTRODUCTION: Despite thousands of years from creation of medical knowledge, it not much passes from founding the health care systems. Accreditation is an effective mechanism for performance evaluation, quality enhancement, and the safety of health care systems. This study was conducted to assess the results of emergency department (ED) accreditation in Shohadaye Tajrish Hospital, Tehran, Iran, 2013 in terms of domesticated standards of joint commission international (JCI) standards. METHODS: This cohort study with a four-month follow up was conducted in the ED of Shohadaye Tajrish Hospital in 2013. The standard evaluation checklist of Iran hospitals (based on JCI standards) included 24 heading and 337 subheading was used for this purpose. The effective possible causes of weak spots were found and their solutions considered. After correction, assessment of accreditation were repeated again. Finally, the achieved results of two periods were analyzed using SPSS version 20. RESULTS: Quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities had the score of below 50%. The mean of total score for accreditation in ED in the first period was 60.4±30.15 percent and in the second period 68.9±22.9 (p=0.005). Strategic plans, head of department, head nurse, resident physician, responsible nurse for the shift, and personnel file achieved the score of 100%. Of total headings below 50% in the first period just in two cases, collection and analysis of data with growth of 40% as well as competency and capability test for staffs with growth of 17%, were reached to more than 50%. CONCLUSION: Based on findings of the present study, the ED of Shohadaye Tajrish hospital reached the score of below 50% in six heading of quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities. While, the given score in strategic plans, head of department, head nurse, resident physician, responsible nurse for the shifts, and personnel file was 100%.

Spontaneous Spinal Epidural Hematoma; a Case Report.

Spontaneous spinal epidural hematoma (SSHE) is a rare entity can have several reasons. Its prevalence in population is 0.1 per 100,000 with the male to female ratio of 1/4:1. For the first time Jackson in 1869 reported a case of SSHE and after that, it was declared as several hundred cases in literatures. Here, a case of SSHE was reported in a 52-year-old male referred to emergency department following severe low back pain.

Hypokalemia-induced abnormal movements: case report.

INTRODUCTION: A sudden loss of consciousness followed by abnormal movements can be ictal or syncopal in origin. Transient response by the brain to sudden decrease of blood flow may cause sudden loss of consciousness followed by abnormal movements that mimic seizure. Dysrhythmia is one of the important and critical reasons of such events that should be differentiated from seizure. CASE PRESENTATION: In this case report we describe a 55 year-old woman admitted to our emergency department first with the impression of seizure. Eventually, it was realized that she had suffered from brain hypo-perfusion secondary to hypokalemia induced arrhythmia. Her arrhythmia was managed by unsynchronized biphasic shock in acute phase and also potassium replacement. She was then admitted to the CCU (Coronary Care Unit) where she received further care for medical management and drug dose adjustment and was discharged 4 days later. CONCLUSIONS: Syncope from arrhythmia most commonly results from ventricular tachycardia, which accounts for 11% of all cases of syncope. Torsades de point is a unique type of ventricular tachycardia, characterized by QRS complexes of changing amplitude proceeded by prolonged QT intervals and almost often followed by loss of consciousness and also seizure like movements. Prolonged QT interval which is an important provocative factor for torsades de point commonly results from interactions between drug therapy, myocardial ischemia, and electrolyte disturbances such as hypokalemia or hypomagnesaemia. Changes in the extracellular potassium level have predominant and profound influences on the function of the cardiovascular system that may provoke fatal demonstrations such as QT prolongation, ventricular arrhythmia and even cardiac arrest. Electrolyte assessment is particularly important in certain patient populations, such as the elderly in whom a variety of pathological states or conditions like dehydration or renal failure are more common. Early identification and correction of these disturbances are necessary to control either seizures or seizure-like movements and prevent permanent brain damage, as anticonvulsants alone are generally ineffective.

Utilization of Failure Mode and Effects Analysis (FMEA) Method in Increasing the Revenue of Emergency Department; a Prospective Cohort Study.

INTRODUCTION: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. METHODS: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. RESULTS: 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p<0.001). 111.0% increase in the ED revenue after solving of first priority problems revealed that they were extremely indispensable in decreasing the revenue (p<0.0001). CONCLUSION: The findings of the present study revealed that FMEA could be considered as an efficient model for increasing the revenue of emergency department. According to this model, not recording the services by the nursing unit, and lack of specific identifying code for the patients moving from ED to any other department, were the two first priority problems in decreasing our ED revenue.

Emergency Department Performance Indexes Before and After Establishment of Emergency Medicine.

INTRODUCTION: Emergency department performance index (EPI) greatly influences the function of other hospital's units and patient satisfaction. Recently, the Iranian Ministry of Health has defined specific national EPI containing five indexes. In the present study the performance indexes of emergency department (ED) in one educational hospital has been assessed before and after establishment of emergency medicine. METHODS: In the present cross-sectional study the ED of Shohadaye Tajrish Hospital, Tehran, Iran was assessed during one-year period from March 2012 to February 2013. The study was divided into two six-month periods of before and after establishment of emergency medicine. Five performance indexes including: the percentage of patients were disposed during 6-hour, leaved the ED in a 12-hour, had unsuccessful cardiopulmonary resuscitations (CPR), discharged against medical advice, and the mean time of triage were calculated using data of department of medical records on daily patients' files. Then, Mann-Whitney U test was used to make comparisons at P<0.05. RESULTS: The average triage time decreased from 6.04 minutes in the first six months to 1.5 minutes in the second six months (P=0.06). The percentage of patients leaving the ED in a 12-hour decreased from 97.3% to 90.4% (P=0.004). However, the percentage of disposed patients during 6-hour (P=0.2), unsuccessful CPR (P=0.34) and discharged against medical advice (P=0.42) did not differ between the two periods. CONCLUSION: It seems that establishment of emergency medicine could be able to improve ED performances indexes such as time to triage and leave in a 12-hour period.