Age and sex-related differences in outcomes of OHCA patients after adjustment for sex-based in-hospital management disparities.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) survival differences due to sex remain controversial. Previous studies adjusted for prehospital variables, but not sex-based in-hospital management disparities. We aimed to investigate age and sex-related differences in survival outcomes in OHCA patients after adjustment for sex-based in-hospital management disparities. METHODS: This retrospective observational study used a prospective multicenter OHCA registry to review data of patients from October 2015 to December 2020. The primary outcome was good neurological outcome defined as cerebral performance category score 1 or 2. We performed multivariable logistic regression and restricted cubic spline analysis according to age. RESULTS: Totally, 8988 patients were analyzed. Women showed poorer prehospital characteristics and received fewer coronary angiography, percutaneous coronary interventions, targeted temperature management, and extracorporeal membrane oxygenation than men. Good neurological outcomes were lower in women than in men (5.8% vs. 12.2%, p < 0.001). After adjustment for age, prehospital variables, and in-hospital management, women were more likely to have good neurological outcomes than men (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 1.07-1.74, p = 0.012). The restricted cubic spline curve showed a reverse sigmoid pattern of adjusted predicted probability of outcomes and dynamic associations of sex and age-based outcomes. CONCLUSIONS: Women with OHCA were more likely to have good neurological outcome after adjusting for age, prehospital variables, and sex-based in-hospital management disparities. There were non-linear associations between sex and survival outcomes according to age and age-related sex-based differences.

Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index.

INTRODUCTION: Identifying patients with at a high risk of progressing to septic shock is essential. Due to systemic vasodilation in the pathophysiology of septic shock, the use of diastolic blood pressure (DBP) has emerged. We hypothesized that the initial shock index (SI) and diastolic SI (DSI) at the emergency department (ED) triage can predict septic shock. METHOD: This observational study used the prospectively collected sepsis registry. The primary outcome was progression to septic shock. Secondary outcomes were the time to vasopressor requirement, vasopressor dose, and severity according to SI and DSI. Patients were classified by tertiles according to the first principal component of shock index and diastolic shock index. RESULTS: A total of 1267 patients were included in the analysis. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock for DSI was 0.717, while that for SI was 0.707. The AUC for predicting progression to septic shock for DSI and SI were significantly higher than those for conventional early warning scores. Middle tertile showed adjusted Odd ratio (aOR) of 1.448 (95% CI 1.074-1.953), and that of upper tertile showed 3.704 (95% CI 2.299-4.111). CONCLUSION: The SI and DSI were significant predictors of progression to septic shock. Our findings suggest an association between DSI and vasopressor requirement. We propose stratifying lower tertile as being at low risk, middle tertile as being at intermediate risk, and upper tertile as being at high risk of progression to septic shock. This system can be applied simply at the ED triage.

Sex differences in in-hospital management in patients with sepsis and septic shock: a prospective multicenter observational study.

Sex differences in the in-hospital management of sepsis exist. Previous studies either included patients with sepsis that was defined using previous definitions of sepsis or evaluated the 3-h bundle therapy. Therefore, this study sought to assess sex differences in 1-h bundle therapy and in-hospital management among patients with sepsis and septic shock, defined according to the Sepsis-3 definitions. This observational study used data from Korean Shock Society (KoSS) registry, a prospective multicenter sepsis registry. Adult patients with sepsis between June 2018 and December 2021 were included in this study. The primary outcome was adherence to 1-h bundle therapy. Propensity score matching (PSM) and multivariable logistic regression analyses were performed. Among 3264 patients with sepsis, 3129 were analyzed. PSM yielded 2380 matched patients (1190 men and 1190 women). After PSM, 1-h bundle therapy was performed less frequently in women than in men (13.0% vs. 19.2%; p < 0.001). Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently in women than in men (25.4% vs. 31.6%, p < 0.001), whereas adequate fluid resuscitation was performed more frequently in women than in men (96.8% vs. 95.0%, p = 0.029). In multivariable logistic regression analysis, 1-h bundle therapy was performed less frequently in women than in men [adjusted odds ratio (aOR) 1.559; 95% confidence interval (CI) 1.245-1.951; p < 0.001] after adjustment. Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently to women than men (aOR 1.339, 95% CI 1.118-1.605; p = 0.002), whereas adequate fluid resuscitation was performed more frequently for women than for men (aOR 0.629, 95% CI 0.413-0.959; p = 0.031). Invasive arterial blood pressure monitoring was performed less frequently in women than in men. Resuscitation fluid, vasopressor, steroid, central-line insertion, ICU admission, length of stay in the emergency department, mechanical ventilator use, and renal replacement therapy use were comparable for both the sexes. Among patients with sepsis and septic shock, 1-h bundle therapy was performed less frequently in women than in men. Continuous efforts are required to increase adherence to the 1-h bundle therapy and to decrease sex differences in the in-hospital management of patients with sepsis and septic shock.

The mortality of patients with sepsis increases in the first month of a new academic year.

Objective: Many studies have examined the July effect. However, little is known regarding the July effect in sepsis. We hypothesized that the July effect would result in worse outcomes in patients with sepsis. Methods: Prospectively collected patients with sepsis between January 2018 and December 2021 were used. In Korea, the new academic year starts on March 1, so the "July effect" appears in March. The primary outcome was 30-day mortality. Secondary outcomes included adherence to the Surviving Sepsis Campaign bundle. Outcomes were compared between March and other months. Multivariate Cox proportional hazard regression was performed to adjust confounders. Results: Total 843 patients were included. There were no significant differences in sepsis severity. The 30-day mortality in March was higher (49% vs. 28.5%; P < 0.001). However, there was no difference in bundle adherence in March (42.2% vs. 48.0%; P = 0.264). Multivariate Cox proportional hazard regression showed that July effect was associated with mortality in patients with sepsis [adjusted hazard ratio, 1.925; 95% confidence interval, 1.405-2.638; P < 0.001]. Conclusion: July effect was associated with 30-day mortality in patients with sepsis. However, bundle adherence was not different. These results suggest that the increase in mortality during the turnover period may be related to unmeasured in-hospital management. Intensive supervision and education of residents in care of patients with sepsis is needed in the beginning of training.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.

OBJECTIVES: Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax. METHODS: Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis. RESULTS: A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax. CONCLUSIONS: Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest.

Survival benefits of prehospital advanced airway and epinephrine in out-of-hospital cardiac arrest (OHCA) patients are controversial, but few studies evaluated this together. This study evaluated association of prehospital advanced airway and epinephrine with survival outcomes in OHCA patients. This was observational study using a prospective multicentre KoCARC registry. Adult OHCA patients between October 2015 and December 2021 were included. The variables of interest were prehospital managements, which was classified into basic life support (BLS)-only, BLS + advanced airway, and BLS + advanced airway + epinephrine. In total, 8217 patients were included in analysis. Survival to discharge and good neurological outcomes were lowest in the BLS + advanced airway + epinephrine group (22.1% in BLS-only vs 13.2% in BLS + advanced airway vs 7.5% in BLS + advanced airway + epinephrine, P < 0.001 and 17.1% in BLS-only vs 9.2% in BLS + advanced airway vs 4.3% in BLS + advanced airway + epinephrine, P < 0.001, respectively). BLS + advanced airway + epinephrine group was less likely to survive to discharge and have good neurological outcomes (aOR 0.39, 95% CI 0.28-0.55, P < 0.001 and aOR 0.33, 95% CI 0.21-0.51, P < 0.001, respectively) than BLS-only group after adjusting for potential confounders. In prehospital settings with intermediate EMS providers and prehospital advanced airway insertion is performed followed by epinephrine administration, prehospital management with BLS + advanced airway + epinephrine in OHCA patients was associated with lower survival to discharge rate compared to BLS-only.

Prediction of Mortality Among Patients With Isolated Traumatic Brain Injury Using Machine Learning Models in Asian Countries: An International Multi-Center Cohort Study.

Abstract Traumatic brain injury (TBI) is a significant healthcare concern in several countries, accounting for a major burden of morbidity, mortality, disability, and socioeconomic losses. Although conventional prognostic models for patients with TBI have been validated, their performance has been limited. Therefore, we aimed to construct machine learning (ML) models to predict the clinical outcomes in adult patients with isolated TBI in Asian countries. The Pan-Asian Trauma Outcome Study registry was used in this study, and the data were prospectively collected from January 1, 2015, to December 31, 2020. Among a total of 6540 patients (≥ 15 years) with isolated moderate and severe TBI, 3276 (50.1%) patients were randomly included with stratification by outcomes and subgrouping variables for model evaluation, and 3264 (49.9%) patients were included for model training and validation. Logistic regression was considered as a baseline, and ML models were constructed and evaluated using the area under the precision-recall curve (AUPRC) as the primary outcome metric, area under the receiver operating characteristic curve (AUROC), and precision at fixed levels of recall. The contribution of the variables to the model prediction was measured using the SHapley Additive exPlanations (SHAP) method. The ML models outperformed logistic regression in predicting the in-hospital mortality. Among the tested models, the gradient-boosted decision tree showed the best performance (AUPRC, 0.746 [0.700-0.789]; AUROC, 0.940 [0.929-0.952]). The most powerful contributors to model prediction were the Glasgow Coma Scale, O2 saturation, transfusion, systolic and diastolic blood pressure, body temperature, and age. Our study suggests that ML techniques might perform better than conventional multi-variate models in predicting the outcomes among adult patients with isolated moderate and severe TBI.

Association between metformin and survival outcomes in in-hospital cardiac arrest patients with diabetes.

INTRODUCTION: Metformin has shown cardioprotective and neuroprotective effects in cardiac arrest and ischemia-reperfusion injury animal models. Therefore, this study aimed to determine the association between diabetes medication and survival outcomes in in-hospital cardiac arrest (IHCA) patients with type 2 DM (T2DM). METHODS: This retrospective observational study included adult IHCA patients with T2DM between April 2017 and March 2022. The variable of interest was administration of diabetes medications within 24 h before cardiac arrest. Multivariable logistic regression analysis was performed. RESULTS: In the 377 included patients, administration of metformin within 24 h before IHCA was associated with a higher rate of survival to discharge and good neurologic outcome (41.5% vs 11.7%, P < 0.001 and 18.9% vs 6.2%, P = 0.004, respectively). Administration of metformin within 24 h before IHCA was independently associated with survival to discharge and good neurologic outcome (aOR: 5.37, 95% CI: 2.13-13.53, P < 0.001 and aOR: 3.57, 95% CI: 1.14-11.17, P = 0.029). The rate of survival to discharge was the highest in patients who were administered 500-1000 mg/day metformin (P < 0.001). CONCLUSIONS: In IHCA patients with T2DM, administration of metformin within 24 h before IHCA was independently associated with survival to discharge.

Risk of hypertension and treatment on out-of-hospital cardiac arrest incidence: A case-control study.

ABSTRACT: Hypertension (HTN) is a high risk factor for major cardiovascular adverse events. This study aimed to investigate the effect of HTN risk on out-of-hospital cardiac arrest (OHCA) incidence and determine whether the effect of HTN on OHCA incidence differs according to antihypertensive medication.This case-control study used the Korean Cardiac Arrest Resuscitation Consortium and Korean Community Health Survey (CHS). Cases were defined as emergency medical service-treated adult OHCA patients presumed to have a cardiac etiology from 2015 to 2017. Patients without information on HTN diagnosis were excluded from the study. The Korean CHS database's controls were matched at a 1:2 ratio with strata, including age, gender, and county of residence. Multivariable conditional logistic regression analysis was conducted to estimate HTN risk and antihypertensive treatment on OHCA incidence,A total of 2633 OHCA patients and 5266 community-based controls were enrolled in this study. Among them, 1176 (44.7%) patients and 2049 (38.9%) controls were diagnosed with HTN. HTN was associated with an increased risk of OHCA (adjusted odds ratio [AOR]: 1.19 [1.07-1.32]). On comparing HTN with or without the antihypertensive treatment group with the non-HTN-diagnosed group (as a reference), the HTN without treatment group had the highest AOR (95% confidence interval) (3.41 [2.74-4.24]). The AOR in the HTN treatment group was reduced to that in the non-HTN-diagnosed group (0.96 [0.86-1.08]).HTN increased OHCA risk, and the HTN without treatment group had the highest OHCA risk. Conversely, OHCA risk decreased to the non-HTN-diagnosed group level with HTN treatment.

Sex-related disparities in the in-hospital management of patients with out-of-hospital cardiac arrest.

AIM: We investigated sex-related differences in the in-hospital management of patients with out-of-hospital cardiac arrest (OHCA). METHODS: We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a prospective, multicenter OHCA registry. We enrolled adult patients with OHCA between October 2015 and June 2020. The primary outcomes were coronary angiography (CAG), percutaneous coronary intervention (PCI), targeted temperature management (TTM), and extracorporeal membrane oxygenation (ECMO) performed in the hospital. Propensity score matching (PSM) was performed to minimize differences in baseline demographics and characteristics. RESULTS: Among 12,321 patients in the KoCARC registry, we analyzed 8,177 with OHCA. PSM yielded 5,564 matched patients (2,782 women and men, respectively). In the unmatched cohort, women were less likely to undergo CAG, PCI, TTM, and ECMO. In the PSM cohort, women were less likely to undergo CAG and PCI (6.4% vs. 9.1%, p < 0.001 and 1.9% vs. 3.7%, p < 0.001). The duration of cardiopulmonary resuscitation was shorter in women (19 vs. 20 min, p < 0.001). TTM, ECMO use, and survival outcomes did not differ significantly between sexes. The subgroup analysis according to age showed that among patients aged < 65 years, women were less likely than men to undergo CAG and PCI (12.7% vs. 19.2%, p < 0.001 and 2.3% vs. 8.1%, p < 0.001). CONCLUSIONS: In the PSM cohort, women with OHCA underwent CAG and PCI less frequently than men, regardless of the initial rhythm. However, these sex-related differences narrowed with increasing age. Further studies are needed to confirm the sex-related disparities in the in-hospital management of patients with OHCA.

Factors affecting incorrect interpretation of abdominal computed tomography in non-traumatic patients by novice emergency physicians.

OBJECTIVE: Accurate interpretation of computed tomography (CT) scans is critical for patient care in the emergency department. We aimed to identify factors associated with an incorrect interpretation of abdominal CT by novice emergency residents and to analyze the characteristics of incorrectly interpreted scans. METHODS: This retrospective analysis of a prospective observational cohort was conducted at three urban emergency departments. Discrepancies between the interpretations by postgraduate year-1 (PGY-1) emergency residents and the final radiologists' reports were assessed by independent adjudicators. Potential factors associated with incorrect interpretation included patient age, sex, time of interpretation, and organ category. Adjusted odds ratios (aORs) for incorrect interpretation were calculated using multivariable logistic regression analysis. RESULTS: Among 1,628 eligible cases, 270 (16.6%) were incorrect. The urinary system was the most correctly interpreted organ system (95.8%, 365/381), while the biliary tract was the most incorrectly interpreted (28.4%, 48/169). Normal CT images showed high false-positive rates of incorrect interpretation (28.2%, 96/340). Organ category was found to be a major determinant of incorrect interpretation. Using the urinary system as a reference, the aOR for incorrect interpretation of biliary tract disease was 9.20 (95% confidence interval, 5.0-16.90) and the aOR for incorrectly interpreting normal CT images was 8.47 (95% confidence interval, 4.85-14.78). CONCLUSION: Biliary tract disease is a major factor associated with incorrect preliminary interpretations of abdominal CT scans by PGY-1 emergency residents. PGY-1 residents also showed high false-positive interpretation rates for normal CT images. Emergency residents' training should focus on these two areas to improve abdominal CT interpretation accuracy.

Prognostic utility of lactate concentrations and kinetics to predict adverse events associated with acute drug overdose.

OBJECTIVE: Clinical research on drug intoxication is necessary for appropriate action in emergency departments (EDs). However, currently, there are no evident biomarkers for predicting adverse events (AEs) in patients with drug intoxication. We aimed to evaluate the prognostic value of serum lactate concentrations and lactate kinetics for AEs such as cardiogenic or respiratory failure in patients admitted to the ED with acute drug overdose. METHODS: We conducted a single-center retrospective study by reviewing the prospective suicide registry of patients visiting the ED. The primary outcome was composite AEs at any point during the ED visit or hospital stay. RESULTS: A total of 566 patients with acute drug overdose were enrolled in this study. Of these, 62 patients had AEs, whereas 363 patients did not, yielding an AE rate of 14.6%. The median 0 h lactate concentrations in the AE and non-AE groups were 2.7 [2.1-5.1] mmol/L and 2.1 [1.4-2.9] mmol/L, respectively (p < 0.001). The median 6 h lactate concentrations in the AE and non-AE groups were 2.0 [1.5-3.9] mmol/L and 1.3 [0.9-2.2] mmol/L, respectively (p < 0.001). The area under the curve of lactate at 0 h for predicting AEs was 0.705 (95% CI: 0.659-0.748). The optimal lactate cutoff point was 4.2 mmol/L (37.1% sensitivity, 92.8% specificity). Multivariable analysis using a stepwise backward method showed that the 0 h lactate concentration was associated with AEs in acute drug intoxication after adjusting for confounders (adjusted OR of 0 h lactate, 1.47; 95% CI, 1.23-1.77). However, the 6 h lactate concentrations, lactate clearance, and delta lactate levels did not predict the outcomes. CONCLUSION: Lactate concentrations and kinetics in patients admitted to the ED with an acute drug overdose exhibited limited prognostic utility in predicting AEs and should be interpreted with caution when considered for clinical decision-making.

Strategies to prevent COVID-19 transmission in the emergency department of a regional base hospital in Korea: From index patient until pandemic declaration.

OBJECTIVE: This study aimed to describe the timely strategies used to prevent the spread of the emerging coronavirus disease 2019 (COVID-19) and present the activities performed in a regional base hospital in South Korea, from the identification of the index patient until the pandemic declaration. METHODS: This is a descriptive study detailing the step-by-step guidelines implemented to manage COVID-19 in a regional tertiary base hospital from January to March 2020. We described our three-phase response to the COVID-19 outbreak as per the national and global quarantine procedures applied during each critical event and highlighted the activities implemented from the perspective of public health crisis preparedness involving emerging infectious diseases. RESULTS: During the COVID-19 outbreak in Korea, we improved and implemented a rapid and flexible screening system for visiting patients using patient history and radiological testing and created a separate isolation zone for patients under investigation. This active identification-isolation strategy has been effectively applied in the COVID-19 outbreak. CONCLUSIONS: The step-by-step enforced strategies to prevent the spread of COVID-19, though not perfect, adequately reduced the risk of transmission of the highly contagious infectious disease in the hospital while maintaining the emergency medical system.

An Exploration of Discrepancies and Concordances Between Hospital Disaster Directors and General Health Care Providers in Gyeonggi Province, South Korea: Quantitative Analysis of a Multicenter Cross-Sectional Survey Study.

OBJECTIVE: The purpose of this study was to investigate differences in the perception of disaster issues between disaster directors and general health care providers in Gyeonggi Province, South Korea. METHODS: The Gyeonggi provincial committee distributed a survey to acute care facility personnel. Survey topics included awareness of general disaster issues, hospital preparedness, and training priorities. The questionnaire comprised multiple choices and items scored on a 10-point Likert scale. We analyzed the discrepancies and characteristics of the responses. RESULTS: Completed surveys were returned from 43 (67%) of 64 directors and 145 (55.6%) of 261 health care providers. In the field of general awareness, the topic of how to triage in disaster response showed the greatest discrepancies. In the domain of hospital level disaster preparedness, individual opinions varied most within the topics of incident command, manual preparation. The responses to "accept additional patients in disaster situation" showed the biggest differences (> 21 versus 6~10). CONCLUSIONS: In this study, there were disaster topics with discrepancies and concordances in perception between disaster directors and general health care providers. The analysis would present baseline information for the development of better training programs for region-specific core competencies, knowledge, and skills required for the effective response.

Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio.

BACKGROUND: Acute pulmonary embolism (APE) is a major cause of death from cardiovascular disease. Right ventricular systolic dysfunction (RVD) caused by APE is closely related to a poor outcome. Early risk stratification of APE is a vital step in prognostic assessment. The objective of this study was to investigate the usefulness of computed tomographic pulmonary angiography (CTPA) measured right ventricular (RV)/ left ventricular (LV) diameter ratio by the emergency department (ED) specialists for early risk stratification of APE patients in ED. METHODS: The retrospective data of 229 APE patients were reviewed. Two ED specialists measured both RV and LV diameters on a single transverse scan perpendicular to the long axis of the heart. The patients were divided into two groups, RV/LV diameter ratio <1 and ratio >1. CTPA measured RV/LV diameter ratio were analyzed and compared with sPESI score, cardiac biomarkers such as N-Terminal Pro-B-Type Natriuretic Peptide (NT-pro-BNP), high sensitivity cardiac troponin T (hs-cTnT), and RVD measured by echocardiography (Echo). RESULTS: The mean age in RV/LV > 1 group was significantly higher than that of the other group (67.81±2.7 years vs. 60.68±3.2 years). Also, there were more hypertension patients (44.4% vs. 33.3%), and mean arterial pressure (MAP) was lower. A significantly higher ICU admission rate (28.05% vs. 11.61%) was shown in RV/LV >1 group, and five patients expired only in RV/LV > 1 group. RVD by Echo demonstrated the highest sensitivity, specificity, and negative predictive value (NPV) (values of 94.3%, 81.1%, 95.5%). RV/LV >1 diameter ratio by CTPA showed usefulness equivalent to cardiac biomarkers. RV/LV >1 patients' cardiac enzymes were higher, and there were more RVD in RV/LV >1 group. CONCLUSION: Simple measurement of RV/LV diameter ratio by ED specialist would be a help to the clinicians in identifying and stratifying the risk of the APE patients presenting in the ED.

Intensive Care Unit Capacity and Its Associated Risk Factors During the COVID-19 Surge in the Republic of Korea: Analysis Using Nationwide Health Claims Data.

OBJECTIVE: To identify risk factors for intensive care unit (ICU) admission and mechanical ventilator usage among confirmed coronavirus disease (COVID-19) patients and estimate the effects of mitigation efforts on ICU capacity in Korea. PATIENTS AND METHODS: Data on profiles and medical history of all confirmed COVID-19 patients in the past 1 year were extracted from the Korean National Health Insurance System's claims database to assess risk factors for ICU admission and ventilator use. We used a time-series epidemic model to estimate the ICU census in Daegu from the reported hospital data. FINDINGS: Multivariate regression analysis revealed male sex, old age, and residing in Daegu city as significant risk factors for ICU admission. The number of patients requiring ICU admission exceeded the bed capacity across all Daegu hospitals before March 9, 2020, and therefore, critically ill patients were transferred to nearby hospitals outside Daegu. This finding was consistent with our prediction that the ICU census in Daegu would peak on March 16, 2020, at 160 through mitigation efforts, without which it would have reached 300 by late March 2020. CONCLUSION: Older age and male sex were risk factors for ICU admission. In addition, the geographic location of the hospital seems to contribute to the severity of the COVID-19 patients admitted to the ICU and to the ICU capacity.

Application of the "Plan-Do-Study-Act" Model to Improve Survival after Cardiac Arrest in Korea: A Case Study.

OBJECTIVE: Low rates of bystander cardiopulmonary resuscitation (CPR) were identified as a shortcoming in the "chain of survival" for out-of-hospital cardiac arrest (OHCA) care in the Korean city of Ansan. This study sought to evaluate the effect of an initiative to increase bystander CPR and quality of out-of-hospital resuscitation on outcome from OHCA. The post-intervention data were used to determine the next quality improvement (QI) target as part of the "Plan-Do-Study-Act" (PDSA) model for QI. HYPOTHESIS: The study hypothesis was that bystander CPR, return of spontaneous circulation (ROSC), and survival to discharge after OHCA would increase in the post-intervention period. METHODS: This was a retrospective pre/post study. The data from the pre-intervention period were abstracted from 2008-2011 and the post-intervention period from 2012-2013. The effect of the intervention on the odds of ROSC and survival to hospital discharge was determined using a generalized estimating equation to account for confounders and the effect of clustering within medical centers. The analysis was then used to identify other factors associated with outcomes to determine the next targets for intervention in the chain of survival for cardiac arrest in this community. RESULTS: Rates of documented bystander CPR increased from 13% in the pre-intervention period to 37% in the post-intervention period. The overall rate of ROSC decreased from 18.4% to 14.3% (risk difference -4.1%; 95% CI, -7.1%-1.0%), whereas survival to hospital discharge increased from 3.9% to 5.0% (risk difference 1.1%; 95% CI, -1.8%-3.8%), and survival with good neurologic outcome increased from 0.8% to 1.6% (risk difference 0.8%; 95% CI, -0.8%-2.4%). In multivariable analyses, there was no association between the intervention and the rate of ROSC or survival to hospital discharge. The designated level of the treating hospital was a significant predictor of both survival and ROSC. CONCLUSION: In this case study, there were no observed improvements in outcomes from OHCA after the targeted intervention to improve out-of-hospital CPR. However, utilizing the PDSA model for QI, the designated level of the treating hospital was found to be a significant predictor of survival in the post-period, identifying the next target for intervention.

Diagnostic and prognostic value of interleukin-6, pentraxin 3, and procalcitonin levels among sepsis and septic shock patients: a prospective controlled study according to the Sepsis-3 definitions.

BACKGROUND: This study investigated the clinical value of interleukin-6 (IL-6), pentraxin 3 (PTX3), and procalcitonin (PCT) in patients with sepsis and septic shock diagnosed according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). METHODS: Serum levels of IL-6, PTX3, and PCT were measured in 142 enrolled subjects (51 with sepsis, 46 with septic shock, and 45 as controls). Follow-up IL-6 and PTX3 levels were measured in patients with initial septic shock within 24 h of hospital discharge. Optimal cut-off values were determined for sepsis and septic shock, and prognostic values were evaluated. RESULTS: Serum IL-6 levels could discriminate sepsis (area under the curve [AUC], 0.83-0.94, P <  0.001; cut-off value, 52.60 pg/mL, 80.4% sensitivity, 88.9% specificity) from controls and could distinguish septic shock (AUC, 0.71-0.89; cut-off value, 348.92 pg/mL, 76.1% sensitivity, 78.4% specificity) from sepsis. Twenty-eight-day mortality was significantly higher in the group with high IL-6 (≥ 348.92 pg/mL) than in the group with low IL-6 (< 348.92 pg/mL) (P = 0.008). IL-6 was an independent risk factor for 28-day mortality among overall patients (hazard ratio, 1.0004; 95% confidence interval, 1.0003-1.0005; p = 0.024). In septic shock patients, both the initial and follow-up PTX3 levels were consistently significantly higher in patients who died than in those who recovered (initial p = 0.004; follow-up P <  0.001). CONCLUSIONS: The diagnostic and prognostic value of IL-6 was superior to those of PTX3 and PCT for sepsis and septic shock.

Effect of team-based cardiopulmonary resuscitation training for emergency medical service providers on pre-hospital return of spontaneous circulation in out-of-hospital cardiac arrest patients.

OBJECTIVE: This study aimed to assess whether team-based cardiopulmonary resuscitation (CPR) training for emergency medical service (EMS) providers improved the pre-hospital return of spontaneous circulation (ROSC) rates of non-traumatic adult out-of-hospital cardiac arrest (OHCA) patients. METHODS: This was a before-and-after study an evaluating educational intervention for community EMS providers, which was conducted in Gyeonggi province, South Korea. Team-based CPR training was conducted from January to March 2016 for every level 1 and level 2 EMS provider in the study area. Non-traumatic EMS treated OHCA patients from July to December 2015 and from July to December 2016 were enrolled and used for the analysis. The primary outcome was pre-hospital ROSC rates before and after the training period. A multivariable logistic regression model with an interaction term (period × dispatch type) was used to determine the adjusted odds ratios (aORs) according to the dispatch type (single vs. multi-tiered). RESULTS: Of the 2125 OHCA cases included, 1072 (50.4%) and 1053 (49.6%) were categorized in the before- and after-training groups, respectively, and the pre-hospital ROSC rates were 6.6% and 12.6%, respectively. In the multivariable logistic regression analysis, the aOR for pre-hospital ROSC was 2.07 (95% CI, 1.32-3.25) in the after-training period. In the interaction model (period × type of dispatch), the aORs for pre-hospital ROSC were 2.00 (95% CI, 1.01-3.98) and 2.13 (95% CI, 1.20-3.79) in the single- and multi-tiered dispatch groups, respectively, during the after-training period. CONCLUSION: Team-based CPR training for EMS providers in a large community EMS system improved the pre-hospital ROSC rates of OHCA patients.

Effect of rapid influenza diagnostic tests on patient management in an emergency department.

OBJECTIVE: We evaluated the effect of rapid influenza diagnostic tests (RIDTs) on patient management in an emergency department for 3 years after 2009, and also identified factors associated with the choice of treatment for patients with influenza-like illnesses. METHODS: The study period consisted of three influenza epidemic seasons. Patients older than 15 years who underwent RIDTs in the emergency department and were then discharged without admission were included. RESULTS: A total of 453 patients were enrolled, 114 of whom had positive RIDT results. Antiviral medication was prescribed to 103 patients (90.4%) who had positive RIDT results, while 1 patient (0.3%) who tested negative was treated with antivirals (P<0.001). Conservative care was administered to 11 RIDT-positive patients (9.6%) and 244 RIDT-negative patients (72.0%) (P<0.001). Symptom onset in less than 48 hours, being older than 65 years, and the presence of comorbidities were not associated with the administration of antiviral therapy. CONCLUSION: RIDT results had a critical effect on physician decision-making regarding antiviral treatment for patients with influenza-like illnesses in the emergency department. However, symptom onset in less than 48 hours, old age, and comorbidities, which are all indications for antiviral therapy, were not found to influence the administration of antiviral treatment.