Discharge against medical advice from the emergency department in a university hospital.

BACKGROUND: Patients discharged against medical advice (DAMA) act as a high-risk population for the Emergency Department (ED), regardless of their presentations, and can pose a serious burden for the hospital. This study examines the prevalence, demographic and clinical characteristics, reasons, and clinical outcomes of a small sample of DAMA patients in a teaching university hospital, including readmission, morbidity, and mortality. METHODS: A prospective, descriptive cross-sectional study was conducted in the ED of King Hamad University Hospital (KHUH) with 98,992 patient visits during a 1-year period from June 2018 to June 2019. Consenting DAMA patients were asked to complete a data collection form. RESULTS: Patients (n = 413) had a mean age of 44.1 years with a female majority (57.1%). The majority were categorized as triage level-3 (87.7%). The main reasons for DAMA included refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%), and children at home (14.8%), whereas the least selected reason was dissatisfaction with medical care (1.2%). Follow-up of DAMA patients revealed that 86 cases (20.8%) were readmitted to the ED within 72 h of which 41 (47.7%) cases were morbidity and 2 (2.3%) were mortality. Marital status was a predictor of DAMA patients who revisit the ED within 72 h. CONCLUSION: The results act as a pilot study to examine a small sample of DAMA patients' characteristics, diagnosis, and ED revisits. Hospitals should investigate further the DAMA population on a larger scale, reasons for refusing procedures, and utilize this knowledge to improve the healthcare process.

Out-of-hospital cardiac arrest in Bahrain: National retrospective cohort study.

Aim: There is limited research on Out-of-hospital cardiac arrest (OHCA) in the Gulf Cooperation Council (GCC) and especially in Bahrain. This is the first study to describe the incidence, characteristics, and outcomes of OHCA in Bahrain. Methods: This was a retrospective national observational study on OHCA patients in Bahrain using the Utstein framework for resuscitation. Data was collected between 1st July 2022 to 30th June 2023 from the electronic medical records of the only three governmental hospitals emergency departments (EDs) and National Ambulance (NA). Results: The annual incidence of OHCA attended by (Emergency Medical Services) EMS was nearly 21 per 100,000 population. The majority were males (n = 228, 68.8 %) with median age of 65 years (IQR=49-78). Most OHCA cases were witnessed (n = 265, 81 %), with (n = 247, 76 %) happened at home/residence. Rates for bystander CPR was low (n = 122, 36.8 %) and bystander automated external defibrillator (AED) was not performed in any of the cases. The OHCA cases transported by the NA was (n = 314, 94.8 %), with median response time of 9 min (IQR=7-12). However, only (n = 20, 6.0 %) were witnessed by EMS, and (n = 7, 2.1 %) received EMS defibrillation for shockable rhythms. First monitored rhythms included shockable rhythm in (n = 28, 8.5 %) versus non-shockable rhythm in (n = 303, 91.5 %). In the EDs, return of spontaneous circulation was achieved in (n = 60, 18.1 %) cases. But survival rate to hospital discharge at 30-day was (n = 4, 1.2 %) and survival rate to hospital discharge with good neurological outcomes was (n = 0, 0 %). Conclusion: In Bahrain the estimated annual incidence of OHCA is 21 individuals per 100,000 population, with a very low survival rate. Solutions should focus on community-level CPR and AED training, evaluating OHCA care provided by EMS, and establishing OHCA registry.

Prognostic accuracy of qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients presenting with suspected infection to the emergency department (PASSEM) Multicenter prospective external validation cohort study protocol.

BACKGROUND: Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. METHODS AND ANALYSIS: PASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. DISCUSSION: PASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region. STUDY REGISTRATION: The study is registered at ClinicalTrials.gov (NCT05172479).

Effects of COVID-19 on STEMI Patients: Single-Center Experience.

Aim: The purpose of this study is to assess the effect of the COVID-19 pandemic on the volume of ST-elevation myocardial infarction (STEMI) patients and also to assess changes in patient characteristics, door-in-to-door-out (DIDO) time, door-to-balloon time (D2B) time, and STEMI outcomes during the pandemic. Methods: Patient data were retrieved retrospectively from the electronic medical record system of King Hamad University Hospital and Mohammed Bin Khalifa Cardiac Centre in the Kingdom of Bahrain. Data were compared and analyzed for the two time periods: before the pandemic (January 2019-March 2020) and during the pandemic (April 2020June 2021). Results: There was a decline of 11.1% in patients who presented with STEMI during the pandemic. There were no major differences between the patient demographics and the baseline characteristics during the two study periods. Recommended DIDO time and D2B time could be achieved only for 7.1% and 35.7% of all STEMI cases during the pandemic. However, no significant differences were noted in the 30 days of mortality, reinfarction, cardiogenic shock, hospital length of stay, and return to the hospital within 30 days for the STEMI patients in the two time periods. Conclusions: There was a decline in patients who presented with STEMI during the pandemic. This was also associated with a lower number of STEMI cases achieving the recommended DIDO time and D2B time as compared to the prepandemic period. However, there was no significant difference in the patient outcomes in the two time periods.

Propafenone and propranolol dual toxicity.

Propranolol is a highly lipid-soluble beta-receptor antagonist and propafenone is a potent class 1c anti-arrhythmic agent with strong Na-channel blockade effect. We describe a novel case of dual overdose of propafenone and propranolol resulting in hypotension, generalized seizures, and reduced level of consciousness that was successfully treated. A 52-year-old female ingested 500 mg of propranolol and 1.5 g of propafenone. The patient was brought to the emergency department (ED) and exhibited signs of systemic toxicity and reduced level of consciousness. The patient was treated as a case of combined ß-blocker and propafenone toxicity using high dose insulin, NaHCO3, glucagon, atropine, and dopamine. She started improving and becoming more alert, with subsequent ECGs revealing normal sinus rhythm. The patient was discharged 4 days later. We believe that early administration of NaHCO3 should be administered in patients exhibiting signs of Na-channel blockade.