Predictability of the emergency department triage system during the COVID-19 pandemic.

OBJECTIVE: Emergency department (ED) triage systems are used to classify the severity and urgency of emergency patients, and Korean medical institutions use the Korean Triage and Acuity Scale (KTAS). During the COVID-19 pandemic, appropriate treatment for emergency patients was delayed due to various circumstances, such as overcrowding of EDs, lack of medical workforce resources, and increased workload on medical staff. The purpose of this study was to evaluate the accuracy of the KTAS in predicting the urgency of emergency patients during the COVID-19 pandemic. METHODS: This study retrospectively reviewed patients who were treated in the ED during the pandemic period from January 2020 to June 2021. Patients were divided into COVID-19-screening negative (SN) and COVID-19-screening positive (SP) groups. We compared the predictability of the KTAS for urgent patients between the two groups. RESULTS: From a total of 107,480 patients, 62,776 patients (58.4%) were included in the SN group and 44,704 (41.6%) were included in the SP group. The odds ratios for severity variables at each KTAS level revealed a more evident discriminatory power of the KTAS for severity variables in the SN group (P<0.001). The predictability of the KTAS for severity variables was higher in the SN group than in the SP group (area under the curve, P<0.001). CONCLUSION: During the pandemic, the KTAS had low accuracy in predicting patients in critical condition in the ED. Therefore, in future pandemic periods, supplementation of the current ED triage system should be considered in order to accurately classify the severity of patients.

Development and Validation of the Korean Version of the Multidimensional Non-Suicidal Self-Injury Scar Scale.

OBJECTIVE: Non-Suicidal Self-Injury (NSSI) scars are common in individuals with NSSI experiences. However, little is known about NSSI scars because related tools are limited. This study aimed to develop and validate the Korean version of the multidimensional Non-Suicidal Self-Injury Scar Scale (K-NSSI-ScarS), consisting of three components: NSSI scar measurement, NSSI scar cognition, and NSSI scar concealment. METHODS: A total of 333 Korean adults with at least one NSSI scar and history of NSSI within the last 5 years (age: 18 to 39 years) completed the online survey. We conducted exploratory (n=133) and confirmatory (n=200) factor analyses of NSSI scar cognition. To measure the internal consistency of each subfactor of the scar cognition and scar concealment components, we used Cronbach's α. Kappa and intraclass correlation coefficients were used to measure the test-retest reliability of the entire scale. We also assessed the convergent and construct validity of the K-NSSI-ScarS. RESULTS: Factor analyses showed a 5-factor structure consisting of 23 items. Internal consistencies and test-retest reliability were excellent. The moderate correlation between the five subfactors of NSSI scar cognition and related concepts (e.g., acquired capability of suicide) confirmed the convergent validity. Lastly, moderate correlations were found between NSSI scar concealment, self-concealment, NSSI scar measurement information, and the five subfactors of NSSI scar cognition. CONCLUSION: The results verify the psychometric properties and support the necessity of a multidimensional NSSI scar scale.

Development and demonstration of the protective efficacy of a convertible respiratory barrier enclosure: a simulation study.

OBJECTIVE: The efficacy of previously developed respiratory barrier enclosures to limit healthcare workers' exposure to aerosols from COVID-19 patients remains unclear; in addition, the design of these devices is unsuitable for transportation or other emergency procedures. Therefore, we developed a novel negative pressure respiratory isolator to improve protection from patient-generated aerosols and evaluated its protective effect in conversion to systemic isolator. METHODS: This in vitro study simulated droplets by nebulizing 1% glycerol + 99% ethanol solution. We performed cardiopulmonary resuscitation (CPR) and converted a respiratory barrier enclosure into a systemic isolator with a respiratory barrier as well as a respiratory barrier with negative pressure generator (NPG), which were compared with control and room air. During the procedure, particles were counted for 30 seconds and the count was repeated 10 times. RESULTS: During CPR, the total number of particles in the respiratory barrier with NPG (280,529; interquartile range [IQR], 205,263-359,195; P=0.970) was similar to that in the control (308,789; IQR, 175,056-473,276). Using NPG with a respiratory barrier reduced the number of particles to 27,524 (IQR, 26,703- 28,905; P=0.001). Particle number during conversion of the respiratory barrier into a systemic isolator was also lower than in the control (25,845; IQR, 19,391- 29,772; P=0.001). CONCLUSION: The novel isolator was converted to a systemic isolator without air leakage. The aerosol-blocking effect of the isolator was quantified using a particle counter during CPR. Further studies comparing the barrier effect of isolators within various pressure differentials are warranted.

Improved patient mortality predictions in emergency departments with deep learning data-synthesis and ensemble models.

The triage process in emergency departments (EDs) relies on the subjective assessment of medical practitioners, making it unreliable in certain aspects. There is a need for a more accurate and objective algorithm to determine the urgency of patients. This paper explores the application of advanced data-synthesis algorithms, machine learning (ML) algorithms, and ensemble models to predict patient mortality. Patients predicted to be at risk of mortality are in a highly critical condition, signifying an urgent need for immediate medical intervention. This paper aims to determine the most effective method for predicting mortality by enhancing the F1 score while maintaining high area under the receiver operating characteristic curve (AUC) score. This study used a dataset of 7325 patients who visited the Yonsei Severance Hospital's ED, located in Seoul, South Korea. The patients were divided into two groups: patients who deceased in the ED and patients who didn't. Various data-synthesis techniques, such as SMOTE, ADASYN, CTGAN, TVAE, CopulaGAN, and Gaussian Copula, were deployed to generate synthetic patient data. Twenty two ML models were then utilized, including tree-based algorithms like Decision tree, AdaBoost, LightGBM, CatBoost, XGBoost, NGBoost, TabNet, which are deep neural network algorithms, and statistical algorithms such as Support Vector Machine, Logistic Regression, Random Forest, k-nearest neighbors, and Gaussian Naive Bayes, as well as Ensemble Models which use the results from the ML models. Based on 21 patient information features used in the pandemic influenza triage algorithm (PITA), the models explained previously were applied to aim for the prediction of patient mortality. In evaluating ML algorithms using an imbalanced medical dataset, conventional metrics like accuracy scores or AUC can be misleading. This paper emphasizes the importance of using the F1 score as the primary performance measure, focusing on recall and specificity in detecting patient mortality. The highest-ranked model for predicting mortality utilized the Gaussian Copula data-synthesis technique and the CatBoost classifier, achieving an AUC of 0.9731 and an F1 score of 0.7059. These findings highlight the effectiveness of machine learning algorithms and data-synthesis techniques in improving the prediction performance of mortality in EDs.

Predictive indicators for determining red blood cell transfusion strategies in the emergency department.

BACKGROUND AND IMPORTANCE: Appropriate decision-making is critical for transfusions to prevent unnecessary adverse outcomes; however, transfusion in the emergency department (ED) can only be decided based on sparse evidence in a limited time window. OBJECTIVES: This study aimed to identify factors associated with appropriate red blood cell (RBC) transfusion in the ED by analyzing retrospective data of patients who received transfusions at a single center. OUTCOME MEASURES AND ANALYSIS: This study analyzed associations between transfusion appropriateness and sex, age, initial vital signs, an ED triage score [the Korean Triage and Acuity Scale (KTAS)], the length of stay, and the hemoglobin (Hb) concentration. MAIN RESULTS: Of 10 490 transfusions, 10 109 were deemed appropriate, and 381 were considered inappropriate. A younger age ( P  < 0.001) and a KTAS level of 3-5 ( P  = 0.028) were associated with inappropriate transfusions, after adjusting for O 2 saturation and the Hb level. CONCLUSIONS: In this single-center retrospective study, younger age and higher ED triage scores were associated with the appropriateness of RBC transfusions.

Efficiency, limitations, and familiarization of a novel negative pressure aerosol box for intubation: a simulation-based randomized crossover study.

OBJECTIVE: This study aimed to introduce a novel negative pressure aerosol box (Carrycure Isolator) and to test its efficiency and limitations, with the hope of suggesting improvements and further directions. METHODS: A novel aerosol box (Carrycure Isolator) was invented. A single-center, randomized, crossover simulation study of 28 emergency medicine physicians was designed. Three trials of each participant using an intubation manikin were conducted, including intubation without the aerosol box (trial A), intubation with the aerosol box (trial B), and intubation with the aerosol box after familiarization (trial C). The primary endpoint was the time to intubation. The secondary endpoints were first-attempt success, number of attempts, percentage of glottic opening score, and Cormack-Lehane view. Collected data were statistically analyzed for their significance. RESULTS: The median times to intubation of trials A, B, and C were 30.5 (interquartile range [IQR], 28.0-40.0 seconds), 59.0 (IQR, 50.0-75.5 seconds), and 34.0 seconds (IQR, 30.5-47.0 seconds), respectively. Post hoc analysis showed that the time to intubation in trial B was significantly longer than that in trial A (P<0.05), while that the time to intubation in trial C was significantly shorter than that in trial B (P<0.05). RESULTS: concerning secondary endpoints showed similar patterns. Participants reported performing intubation with Carrycure Isolator to be relatively difficult, necessitating significant arm movement and view restrictions while increasing their time to intubation. CONCLUSION: Physicians took a longer time to intubate a manikin using the Carrycure Isolator, a novel negative pressure aerosol box. However, the time was improved after a period of familiarization.

Recombinant Klotho Protein Ameliorates Myocardial Ischemia/Reperfusion Injury by Attenuating Sterile Inflammation.

Currently, no effective therapy and potential target have been elucidated for preventing myocardial ischemia and reperfusion injury (I/R). We hypothesized that the administration of recombinant klotho (rKL) protein could attenuate the sterile inflammation in peri-infarct regions by inhibiting the extracellular release of high mobility group box-1 (HMGB1). This hypothesis was examined using a rat coronary artery ligation model. Rats were divided into sham, sham+ rKL, I/R, and I/R+ rKL groups (n = 5/group). Administration of rKL protein reduced infarct volume and attenuated extracellular release of HMGB1 from peri-infarct tissue after myocardial I/R injury. The administration of rKL protein inhibited the expression of pro-inflammatory cytokines in the peri-infarct regions and significantly attenuated apoptosis and production of intracellular reactive oxygen species by myocardial I/R injury. Klotho treatment significantly reduced the increase in the levels of circulating HMGB1 in blood at 4 h after myocardial ischemia. rKL regulated the levels of inflammation-related proteins. This is the first study to suggest that exogenous administration of rKL exerts myocardial protection effects after I/R injury and provides new mechanistic insights into rKL that can provide the theoretical basis for clinical application of new adjunctive modality for critical care of acute myocardial infarction.

Characteristics of crashes and injuries on delivery motorcycles: A retrospective cohort study.

Objectives: The food delivery market is growing rapidly. As most delivery riders use motorcycles, motorcycle crashes will increase along with the growing delivery market size. This study aimed at examining the proportions of motorcycle crashes and characteristics of injuries incurred while using motorcycles for occupational purposes.Methods: This retrospective analysis included motorcycle crash patients aged 16 years or older, who were treated in 23 emergency rooms in Korea, between 2014 and 2018. Patients were divided into two groups: delivery riders (delivery group) and others (nondelivery group). Crash and injury characteristics were compared between the two groups. In addition, trends of patients in the delivery group were compared from 2014 to 2018.Results: This study examined 26,982 motorcycle crash patients, including 3894 (14.43%) patients in the delivery group and 23,088 (85.57%) in the nondelivery group. The number of patients in the delivery group increased drastically from 583 in 2014 to 1029 in 2018, whereas the number of patients in the nondelivery group did not considerably increase (4411 in 2014 and 4462 in 2018). The delivery group had a higher proportion of crashes caused by collisions with cars or other motorcycles (p < 0.001); however, injury severity was lower. The delivery group had a lower proportion of head and face injuries but a higher proportion of extremity injuries. Furthermore, 39.9% of all crashes in this group occurred between 17:00 and 21:00. Over time, there were neither any changes in the injury severities, nor any changes in the characteristics of the delivery group, with the exception of increases in both the proportion of motorist insurance and the proportion of wearing a helmet.Conclusions: The results indicated differences in characteristics between delivery motorcycle crashes and other motorcycle crashes. Although delivery motorcycle crash severity was low compared to other motorcycle crashes, the number of patients increased significantly. Therefore, to prevent crashes, it is necessary to improve the working environment. In addition, to prevent the extremity injuries of delivery riders, the policy of wearing extremity protective gears should be considered.

The elderly age criterion for increased in-hospital mortality in trauma patients: a retrospective cohort study.

BACKGROUND: With an aging population, the number of elderly individuals exposed to traumatic injuries is increasing. The elderly age criterion for traumatic injuries has been inconsistent in the literature. This study aimed at specifying the elderly age criterion when the traumatic mortality rate increases. METHODS: This is a multicenter retrospective cohort study that was conducted utilizing the data from the Emergency Department-based Injury In-depth Surveillance Registry of the Korea Disease Control and Prevention Agency, collected between January 2014 and December 2018 from 23 emergency departments. The outcome variable was in-hospital mortality. Multivariable logistic regression analysis was used to calculate the adjusted mortality rate for each age group. By using the shape-restricted regression splines method, the relationship between age and adjusted traumatic mortality was plotted and the point where the gradient of the graph had the greatest variation was calculated. RESULTS: A total of 637,491 adult trauma patients were included. The number of in-hospital deaths was 6504 (1.0%). The age at which mortality increased the most was 65.06 years old. The adjusted odds ratio for the in-hospital mortality rate with age in the ≤ 64-year-old subgroup was 1.038 (95% confidence interval (CI) 1.032-1.044) and in the ≥ 65-year-old subgroup was 1.059 (95% CI 1.050-1.068). The adjusted odds ratio for in-hospital mortality in the ≥ 65-year-old compared to the ≤ 64-year-old subgroup was 4.585 (95% CI 4.158-5.055, p < 0.001). CONCLUSIONS: This study found that the in-hospital mortality rate rose with increasing age and that the increase was the most rapid from the age of 65 years. We propose to define the elderly age criterion for traumatic injuries as ≥ 65 years of age.