[The Comparative Effectiveness of Using Cold Water Oral Spray and Cold Saline Oral Spray for Thirst Relief in Patients With Endotracheal Intubation in the Intensive Care Unit].

BACKGROUND: Thirst is a common symptom among patients with endotracheal intubation in the intensive care unit (ICU), with an estimated prevalence of 88%. PURPOSE: This study was designed to compare the effectiveness of cold saline spray and cold water spray in alleviating thirst, and to explore the maintenance and sustained effects of both groups in relieving thirst among patients with endotracheal intubation in the ICU. METHODS: Patients with indwelling tracheal tubes in the medical ICU were recruited from one medical center in northern Taiwan and randomly assigned to either the cold saline (n = 18) or cold water (n = 18) group. The cold saline group received three rounds of cold saline spray at a temperature of 2°C - 8°C. Each round consisted of 10 sprays directed toward each of the four surfaces of the oral cavity followed by a 5-minute wait period. This process was repeated three times, with 30-minute intervals between interventions. The cold water group received the same intervention steps using a cold water spray at 2°C - 8°C. Thirst intensity was measured using a numeric rating scale before and after each of the three interventions in both groups. Demographic and relevant physiological data were collected on the participants by reviewing their medical records. RESULTS: Both of the interventions were found to effectively alleviate thirst intensity, with no significant difference between the two groups in terms of thirst intensity reduction after each intervention detected. Only the cold water spray had a maintenance effect, while the two groups had a continuous sustained effect in alleviating thirst intensity. CONCLUSIONS: Both of the interventions effectively alleviated thirst, and the cold water spray had both maintenance and sustained effects in alleviating thirst intensity. Based on the results, the cold water spray method may be considered as the priority treatment for thirst alleviation by healthcare providers in the clinical management of patients with tracheal intubation.

Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study.

BACKGROUND: This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients. METHODS: We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS. RESULTS: Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7-13.4) and CFS score (OR, 5.8; 95% CI, 1.9-17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS. CONCLUSIONS: The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.

SARS-CoV-2 rapid antigen testing positive rate in community testing stations as an indicator for COVID-19 epidemic trend, Taipei, Taiwan, May to August 2021.

BACKGROUND: Real-time surveillance of COVID-19 in large-scale community outbreaks presents challenges. Simple counts of the daily confirmed cases can be misleading due to constraints from bottlenecks in access to care or laboratory testing. This study aimed to investigate the role of the SARS-CoV-2 antigen rapid diagnostic test (Ag-RDT) in addressing these challenges for real-time COVID-19 surveillance. METHODS: This study included the results of 86,994 SARS-CoV-2 Ag-RDT and real-time reverse transcription polymerase chain reaction (RT-PCR) tests. These were conducted at four community testing stations within the Taipei metropolitan area during a community COVID-19 outbreak spanning from May 17, 2021, to August 9, 2021. We examined the correlation between the positive rates of Ag-RDT tests and the epidemic curve of laboratory-confirmed COVID-19 cases by onset date to examine its role in real-time surveillance. RESULTS: During the 85-day study period, the trend of Ag-RDT test positive rates paralleled that of the epidemic curve. The correlation between the Ag-RDT positive rate and the number of cases (Pearson correlation coefficient: 0.968) is comparable to that of the RT-PCR positive rate (Pearson correlation coefficient: 0.964). The Ag-RDT positive rate exhibited a more advanced leading trend, with Ag-RDT leading by 3 days in comparison to the 2-day lead for RT-PCR. CONCLUSION: The positive rate of SARS-CoV-2 Ag-RDT tests at community testing stations serves as a good surrogate for assessing virus activity within the community and a useful tool for real-time COVID-19 surveillance. It is a robust indicator of the outbreak trend and near-term numbers of cases. This finding may facilitate the management of subsequent outbreaks of emerging infectious diseases.

Comparison of the diagnostic accuracy of monocyte distribution width and procalcitonin in sepsis cases in the emergency department: a prospective cohort study.

BACKGROUND: Early diagnosis and treatment of patients with sepsis reduce mortality significantly. In terms of exploring new diagnostic tools of sepsis, monocyte distribution width (MDW), as part of the white blood cell (WBC) differential count, was first reported in 2017. MDW greater than 20 and abnormal WBC count together provided a satisfactory accuracy and was proposed as a novel diagnostic tool of sepsis. This study aimed to compare MDW and procalcitonin (PCT)'s diagnostic accuracy on sepsis in the emergency department. METHODS: This was a single-center prospective cohort study. Laboratory examinations including complete blood cell and differentiation count (CBC/DC), MDW, PCT were obtained while arriving at the ED. We divided patients into non-infection, infection without systemic inflammatory response syndrome (SIRS), infection with SIRS, and sepsis-3 groups. This study's primary outcome is the sensitivity and specificity of MDW, PCT, and MDW + WBC in differentiating septic and non-septic patients. In addition, the cut-off value for MDW was established to maximize sensitivity at an optimal level of specificity. RESULTS: From May 2019 to September 2020, 402 patients were enrolled for data analysis. Patient number in each group was: non-infection 64 (15.9%), infection without SIRS 82 (20.4%), infection with SIRS 202 (50.2%), sepsis-3 15 (7.6%). The AUC of MDW, PCT, and MDW + WBC to predict infection with SIRS was 0.753, 0.704, and 0.784, respectively (p < 0.01). The sensitivity, specificity, PPV, and NPV of MDW using 20 as the cutoff were 86.4%, 54.2%, 76.4%, and 70%, compared to 32.9%, 88%, 82.5%, and 43.4% using 0.5 ng/mL as the PCT cutoff value. On combing MDW and WBC count, the sensitivity and NPV further increased to 93.4% and 80.3%, respectively. In terms of predicting sepsis-3, the AUC of MDW, PCT, and MDW + WBC was 0.72, 0.73, and 0.70, respectively. MDW, using 20 as cutoff, exhibited sensitivity, specificity, PPV, and NPV of 90.6%, 37.1%, 18.7%, and 96.1%, respectively, compared to 49.1%, 78.6%, 26.8%, and 90.6% when 0.5 ng/mL PCT was used as cutoff. CONCLUSIONS: In conclusion, MDW is a more sensitive biomarker than PCT in predicting infection-related SIRS and sepsis-3 in the ED. MDW < 20 shows a higher NPV to exclude sepsis-3. Combining MDW and WBC count further improves the accuracy in predicting infection with SIRS but not sepsis-3. Trial registration The study was retrospectively registered to the ClinicalTrial.gov (NCT04322942) on March 26th, 2020.

Does medical disparity exist while treating severe mental illness patients with acute appendicitis in emergency departments? A real-world database study.

BACKGROUND: Patients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group. As the causes for this mortality gap are complex, clarification regarding the contributing factors is crucial to improving the health care of SMI patients. Acute appendicitis is one of the most common indications for emergency surgery worldwide. A higher perforation rate has been found among psychiatric patients. This study aims to evaluate the differences in appendiceal perforation rate, emergency department (ED) management, in-hospital outcomes, and in-hospital expenditure among acute appendicitis patients with or without SMI via the use of a multi-centre database. METHODS: Relying on Chang Gung Research Database (CGRD) for data, we selectively used its data from January 1st, 2007 to December 31st, 2017. The diagnoses of acute appendicitis and SMI were confirmed by combining ICD codes with relevant medical records. A non-SMI patient group was matched at the ratio of 1:3 by using the Greedy algorithm. The outcomes were appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure. RESULTS: A total of 25,766 patients from seven hospitals over a span of 11 years were recruited; among them, 11,513 were excluded by criteria, with 14,253 patients left for analysis. SMI group was older (50.5 vs. 44.4 years, p < 0.01) and had a higher percentage of females (56.5 vs. 44.4%, p = 0.01) and Charlson Comorbidity Index. An analysis of the matched group has revealed that the SMI group has a higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). There was no significant difference in appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure. CONCLUSIONS: Our study demonstrated no obvious differences in appendiceal perforation rate, ED management, in-hospital outcomes, and in-hospital expenditure among SMI and non-SMI patients with acute appendicitis. A higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group was found. ED health providers need to be cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints.

Effect of national curriculum reform on medical students' preparedness for practice: a prospective cohort study from undergraduate to postgraduate periods.

BACKGROUND: In recent years, a national curriculum reform was implemented in undergraduate medical education in Taiwan to reduce clinical rotation training from 3 years to 2 years. The last generation of the old curriculum and the first generation of the new curriculum both graduated in 2019. This study aimed to compare the learning outcomes of the medical students in these two curriculum groups in terms of preparedness for practice during the transition from undergraduate to postgraduate study. METHODS: This was a 3-year prospective, longitudinal, comparative cohort study between 2017 and 2020. Medical students from both the 7-year and 6-year curriculum groups received biannual questionnaire surveys starting 18 months before graduation and running until 11 months after graduation. The measurement tools were the Preparedness for Hospital Practice Questionnaire (PHPQ) and Copenhagen Burnout Inventory (CBI). Personal demographic information was also collected. Linear mixed models were used to determine the effect of curriculum change on learners' preparedness and burnout levels. RESULTS: A total of 130 medical students from the two cohorts provided 563 measurements during the study period. Compared to their counterparts following the old curriculum, the participants following the new curriculum showed a lower level of preparedness when first entering clinical rotation (p = 0.027) and just after graduating (p = 0.049), especially in the domains of clinical confidence (p = 0.021) and patient management p = 0.015). The multivariate linear mixed model revealed gradual increases in preparedness and burnout in serial measurements in both curriculum groups. Students following the new curriculum, which involved a shortened clinical rotation, showed a slightly lower overall preparedness (p = 0.035) and the same level of burnout (p = 0.692) after adjustment. The factor of year of change did not show a significant effect on either preparedness (p = 0.258) or burnout (p = 0.457). CONCLUSION: Shortened clinical rotation training for medical undergraduates is associated with a decrease in preparedness for practice during the transition from undergraduate to postgraduate study. Clinical confidence and patient management are the main domains affected.

Using mobility status as a frailty indicator to improve the accuracy of a computerised five-level triage system among older patients in the emergency department.

BACKGROUND: Owing to societal ageing, the number of older individuals visiting emergency departments (EDs) has increased in recent years. For this patient population, accurate triage systems are required. This retrospective cohort study assessed the accuracy of a computerised five-level triage system, the Taiwan Triage and Acuity System (TTAS), by determining its ability to predict in-hospital mortality in older adult patients and compare it with the corresponding rate in younger adult patients presenting to EDs. The association between frailty, which the current triage system does not consider, was also investigated. METHODS: The medical records of adult patients admitted to a single ED between 2016 and 2017 were reviewed. Data collected included information on demographics, triage level, frailty status, in-hospital mortality, and medical resource utilisation. The patients were divided into four age groups: two older adult groups (older: 65-84 years and very old: ≥85 years) and two younger adult groups (young: 18-39 and middle-aged: 40-64 years). RESULTS: Our study included 265,219 ED adult patients, of whom 64,104 and 16,009 were in the older and very old groups, respectively. The in-hospital mortality rate at each triage level increased with age. The ability of the TTAS to predict in-hospital mortality decreased with age (area under the receiver operating characteristic curve [AUROC]: young: 0.86; middle-aged, 0.84; and older and very old: 0.79). Frailty was associated with in-hospital mortality (odds ratio, 2.20; 95% confidence interval, 2.03-2.38). Adding mobility status as a frailty indicator to TTAS only slightly improved its ability to predict in-hospital mortality (AUROC: 0.74-0.77) in patients ≥65 years of age. CONCLUSIONS: The ability of the current triage system to predict in-hospital mortality decreases with age. Although frailty as mobility was associated with in-hospital mortality, its addition to the TTAS only slightly improved the accuracy with which in-hospital mortality in older patients presenting to EDs was predicted.

In-Hospital and Long-Term Outcomes in Patients with Head and Neck Cancer Bleeding.

Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox's proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81-59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29-14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07-32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16-3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20-8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21-4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.

A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department.

BACKGROUND: Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM: We developed a screening model for predicting 1-year mortality. DESIGN: A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS: Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS: We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS: A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.

Prediction of emergency department volume and severity during a novel virus pandemic: Experience from the COVID-19 pandemic.

BACKGROUND: During a novel virus pandemic, predicting emergency department (ED) volume is crucial for arranging the limited medical resources of hospitals for balancing the daily patient- and epidemic-related tasks in EDs. The goal of the current study was to detect specific patterns of change in ED volume and severity during a pandemic which would help to arrange medical staff and utilize facilities and resources in EDs in advance in the event of a future pandemic. METHODS: This was a retrospective study of the patients who visited our ED between November 1, 2019 and April 30, 2020. We evaluated the change in ED patient volume and complexity of patients in our medical record system. Patient volume and severity during various periods were identified and compared with data from the past 3 years and the period that SARS occurred. RESULTS: A reduction in ED volume was evident. The reduction began during the early epidemic period and increased rapidly during the peak period of the epidemic with the reduction continuing during the late epidemic period. No significant difference existed in the percentages of triage levels 1 and 2 between the periods. The admission rate, length of stay in the ED, and average number of patients with out-of-hospital cardiac arrest increased during the epidemic periods. CONCLUSION: A significant reduction in ED volume during the COVID-19 pandemic was noted and a predictable pattern was found. This specific change in pattern in the ED volume may be useful for performing adjustments in EDs in the future during a novel virus pandemic. The severity of patients visiting the ED during epidemic periods was inconclusive.

The evolution of medical students' preparedness for clinical practice during the transition of graduation: a longitudinal study from the undergraduate to postgraduate periods.

BACKGROUND: Graduating from medical school and beginning independent practice appears to be a major transition for medical students across the world. It is often reported that medical graduates are underprepared for independent practice. Most previous studies on undergraduates' preparedness are cross-sectional. This study aimed to characterize the development and trend of medical students' preparedness and its association with other objective and subjective indicators from the undergraduate to postgraduate periods. METHODS: This was a prospective cohort study. The participants were recruited and followed from two years before graduation to the postgraduate period. The preparedness for independent practice, professional identity, and teamwork experience were biannually measured using previously validated questionnaires. The participants' basic demographic information, clinical learning marks from the last two years, and national board exam scores were also collected. RESULTS: A total of 85 participants completed 403 measurements in the 5 sequential surveys. The mean age at recruitment was 23.6, and 58 % of participants were male. The overall total preparedness score gradually increased from 157.3 (SD=21.2) at the first measurement to 175.5 (SD=25.6) at the fifth measurement. The serial individual preparedness scores revealed both temporal differences within the same learner and individual differences across learners. Despite the variations, a clear, steady increase in the overall average score was observed. Participants were least prepared in the domain of patient management at first, but the score increased in the subsequent measurements. The participants with better final preparedness had better professional identity (p<0.01), better teamwork experience (p < 0.01), and higher average clinical rotation marks (p<0.05). CONCLUSIONS: The preparedness for practice of medical students from the undergraduate to postgraduate periods is associated with their professional identity, teamwork experience, and objective clinical rotation endpoint. Although preparedness generally increases over time, educators must understand that there are temporal fluctuations and individual differences in learners' preparedness.

Clinical teachers' motivations for feedback provision in busy emergency departments: a multicentre qualitative study.

BACKGROUND: Feedback is an effective pedagogical tool in clinical teaching and learning, but the actual perception by learners of clinical feedback is often described as unsatisfactory. Unlike assessment feedback or teaching sessions, which often happen within protected time and space, clinical feedback is influenced by numerous clinical factors. Little is known about clinical teachers' motivations to provide feedback in busy clinical settings. We aimed to investigate the motivations behind feedback being given in emergency departments (EDs). METHODS: A qualitative analysis of semi-structured interview data was conducted between August 2015 and June 2016. Eighteen attending physicians were purposively sampled from three teaching hospital EDs in Taiwan. Data were thematically analysed, both inductively (from the data) and deductively (using self-determination theory (SDT)). Themes were mapped to the different motivation types identified by the SDT. RESULTS AND DISCUSSION: Despite working in busy clinical settings, Taiwanese ED clinical teachers reported being motivated to provide feedback when they felt responsible for their learners, when they understood the importance of feedback (patient safety and partner building), or simply because they were committed to following a tradition of passing on their clinical knowledge to their juniors. Suggestions to facilitate the internalisation of external motivations are proposed. CONCLUSIONS: In this qualitative study, motivations for clinical feedback were identified. Although the motivations are mostly extrinsic, the elicitation of internal motivation is possible once true satisfaction is fostered during the feedback-giving process. This understanding can be used to develop interventions to enable clinical feedback to be provided in a sustained manner.

Prognostic accuracy of SIRS criteria and qSOFA score for in-hospital mortality among influenza patients in the emergency department.

BACKGROUND: The seasonal influenza epidemic is an important public health issue worldwide. Early predictive identification of patients with potentially worse outcome is important in the emergency department (ED). Similarly as with bacterial infection, influenza can cause sepsis. This study was conducted to investigate the effectiveness of the Systemic Inflammatory Response Syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) score as prognostic predictors for ED patients with influenza. METHODS: This single-center, retrospective cohort study investigated data that was retrieved from a hospital-based research database. Adult ED patients (age ≥ 18 at admission) with laboratory-proven influenza from 2010 to 2016 were included for data analysis. The initial SIRS and qSOFA scores were both collected. The primary outcome was the utility of each score in the prediction of in-hospital mortality. RESULTS: For the study period, 3561 patients met the study inclusion criteria. The overall in-hospital mortality was 2.7% (95 patients). When the qSOFA scores were 0, 1, 2, and 3, the percentages of in-hospital mortality were 0.6, 7.2, 15.9, and 25%, respectively. Accordingly, the odds ratios (ORs) were 7.72, 11.92, and 22.46, respectively. The sensitivity and specificity was 24 and 96.2%, respectively, when the qSOFA score was ≥2. However, the SIRS criteria showed no significant associations with the primary outcome. The area under the receiver operating characteristic curve (AUC) was 0.864, which is significantly higher than that with SIRS, where the AUC was 0.786 (P < 0.01). CONCLUSIONS: The qSOFA score potentially is a useful prognostic predictor for influenza and could be applied in the ED as a risk stratification tool. However, qSOFA may not be a good screening tool for triage because of its poor sensitivity. The SIRS criteria showed poor predictive performance in influenza for mortality as an outcome. Further research is needed to determine the role of these predictive tools in influenza and in other viral infections.

What is the impact of the COVID-19 pandemic on emergency medicine residency training: an observational study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has engendered difficulties for health systems globally; however, the effect of the pandemic on emergency medicine (EM) residency training programs is unknown. The pandemic has caused reduced volumes of emergency department (ED) patients, except for those with COVID-19 infections, and this may reduce the case exposure of EM residents. The primary objective of this study was to compare the clinical exposure of EM residents between the prepandemic and pandemic periods. METHODS: This was a retrospective study of EM resident physicians' training in a tertiary teaching hospital with two branch regional hospitals in Taiwan. We retrieved data regarding patients seen by EM residents in the ED between September 1, 2019, and April 30, 2020. The first confirmed COVID-19 case in Taiwan was reported on January 11, so the pandemic period in our study was defined as spanning from February 1, 2020, to April 30, 2020. The number and characteristics of patients seen by residents were recorded. We compared the data between the prepandemic and pandemic periods. RESULTS: The mean number of patients per hour (PPH) seen by EM residents in the adult ED decreased in all three hospitals during the pandemic. The average PPH of critical area of medical ED was 1.68 in the pre-epidemic period and decreased to 1.33 in the epidemic period (p value < 0.001). The average number of patients managed by residents decreased from 1.24 to 0.82 in the trauma ED (p value = 0.01) and 1.56 to 0.51 in the pediatric ED (p value = 0.003) during the pandemic, respectively. The severity of patient illness did not change significantly between the periods. CONCLUSIONS: The COVID-19 pandemic engendered a reduced ED volume and decreased EM residents' clinical exposure. All portion of EM residency training were affected by the pandemic, with pediatric EM being the most affected. The patient volume reduction may persist and in turn reduce patients' case exposure until the pandemic subsides. Adjustment of the training programs may be necessary and ancillary methods of learning should be used to ensure adequate EM residency training.

Brain Computed Tomography in Stimulant Poisoning with Altered Consciousness.

BACKGROUND: Stimulant poisoning frequently causes altered mental status (AMS) and can result in severe cerebral vascular complications. The role of noncontrast brain computed tomography (CT) in acute stimulant-poisoned patients presenting with AMS remains unclear. OBJECTIVES: We examined the results and impacts of brain CT in acute stimulant-poisoned patients with AMS. METHODS: We performed a retrospective single-center study that included all adult patients who presented to the emergency department with stimulant poisoning and AMS (Glasgow coma scale [GCS] score <15) between January 1, 2010 and December 31, 2017. Patients who had concomitant head trauma or who presented with focal neurologic symptoms were excluded. The primary outcome was the rate of acute abnormalities on brain CT. The secondary outcomes were to identify factors that affected the decision to perform brain CT in stimulant-poisoned patients with AMS and whether obtaining the brain CT scan itself affected the patients' prognoses. RESULTS: The analysis included 66 patients, of whom 6 died from the poisoning. Noncontrast brain CT was performed in 31 patients and none had acute abnormalities. Patients who underwent brain CT were found to have worse GCS scores, higher body temperatures, higher intubation rates, higher admission rates, longer admission periods and intensive care unit stays, and a higher mortality rate. After adjusting for the propensity score, performing brain CT itself did not independently affect the patients' clinical outcomes. CONCLUSIONS: Nontrauma stimulant-poisoned patients presenting with AMS and without focal neurologic symptoms were unlikely to have acute abnormalities on brain CT. Patients who underwent brain CT scans had worse consciousness and greater disease severity.

Examining the association of career stage and medical specialty with personality preferences - a cross-sectional survey of junior doctors and attending physicians from various specialties.

BACKGROUND: Personality preference research on medical students and physicians demonstrates that personality preferences may affect one's choice of specialty and transform over the course of one's academic career as well as during one's time spent in the clinical setting. The literature offers valuable methods for evaluating medical curricula, understanding medical specialties, and rethinking communication techniques between educators and learners. In line with this encompassing body of work, this study examines the personality preferences of junior doctors and attending physicians from various specialties to investigate how career stage and medical specialty are associated with personality preferences. METHOD: The Myers-Briggs Type Indicator (MBTI) was applied to assess the personality preferences of junior doctors (postgraduates year 1-3) and attending physicians from six major medical specialties. Participants completed a self-administered 93-item questionnaire, while a certified MBTI practitioner explained the personality dichotomies as well as facilitated the self-evaluation process and the questionnaire's interpretation. Contrasted dichotomous scores and radar plots were employed to illustrate the distinction between junior doctors and attending physicians' personality preferences. All analyses were performed using the SAS statistical software, while a Wilcoxon rank-sum test was used to quantify the polarisation of personality preferences between junior doctors and attending physicians. RESULTS: In total, 98 participants were recruited, of whom 59 were attending physicians and 39 were junior doctors. The most common personality types among the junior doctors were ESTJ (15.4%), INTP (12.8%), and ESFJ (10.3%), while among the attending physicians, the most common types were ISTJ (23.7%) and ESTJ (18.6%). Both junior doctors and attending physicians expressed personality preferences for sensing, thinking, and judging. However, compared to the junior doctors, more polarised personality preferences were noted among the attending physicians for sensing (p = 0.038), thinking (p = 0.032), and judging (p = 0.024). Moreover, junior doctors exhibited less distinct personality preferences in this study. CONCLUSION: Attending physicians and junior doctors exhibited greater personality inclinations for sensing, thinking, and judging, although the former expressed these personality preferences more strongly than the latter. These findings highlight that, amongst physicians, career stage is strongly associated with the expression of personality preferences.

Clinical learning in the context of uncertainty: a multi-center survey of emergency department residents' and attending physicians' perceptions of clinical feedback.

BACKGROUND: Feedback is an essential part of clinical teaching and learning, yet it is often perceived as unsatisfactory in busy clinical settings. Clinical teachers need to balance the competing demands of clinical duty and feedback provision. The influence of the clinical environment and the mutual relationship between feedback giving and seeking has been inadequately investigated. This study therefore aimed to quantify the adequacy, perceptions, and influential factors of feedback provision during resident training in emergency departments (EDs). METHODS: A multicenter online questionnaire study was undertaken. The respondents comprised ED residents and clinical teachers from four teaching hospitals in Taiwan. The questionnaire was developed via an expert panel, and a pilot study ensured validity. Ninety clinical teachers and 54 residents participated. RESULTS: The respondents reported that the majority of feedback, which usually lasted 1-5 min, was initiated by the clinical teachers. Feedback satisfaction was significantly lower for the clinical teachers than for the residents (clinical teachers M = 13.8, SD = 1.83; residents M = 15.3, SD = 2.14; p < 0.0001), and positive feedback was provided infrequently in clinical settings (31.1%). Both groups of participants admitted hesitating between providing/seeking feedback and completing clinical work. Being busy, the teachers' clinical abilities, the learners' attitudes, and the relationship between both parties were reported as the most influential factors in feedback provision. CONCLUSION: ED clinical feedback provision is often short, circumstantial, and initiated by clinical teachers. Providing or seeking feedback appears to be an important part of clinical learning in the context of uncertainty. The importance of the relationship between the feedback seeker and the provider highlights the interactive, reciprocal nature of clinical feedback provision.

Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians.

OBJECTIVES: This study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption. METHODS: This was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale. RESULTS: After EMT's underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike's Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption. CONCLUSIONS: A five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

An interprofessional training program for intrahospital transport of critically ill patients: model build-up and assessment.

Intrahospital transport of critically ill patients for diagnostic or therapeutic procedures can be compromised by patient instability, equipment problems or inexperienced teamworking. This quasi-experimental study aimed to assess the effectiveness of an in-situ interprofessional simulation-based training (IIST) model for junior member transport teams. Newly registered postgraduate physicians, nurses and respiratory therapists underwent the IIST. The technical skills (TS) of each participant and non-technical skills (NTS) of each interprofessional team were assessed using well-validated checklists. Thirty-six participants enrolled and were randomly assigned to six experimental and six control teams. Most participants achieved a significantly higher level of both TS and NTS. Both the control and experimental teams overvalued their NTS in the pretest, while the posttest self-assessment scores among the experimental groups more closely matched the expert assessments. Despite challenges in scheduling and the setting, the IIST was successfully conducted in a crowded hospital, which enabled trainees to optimize their learning in a real-life environment. In conclusion, the IIST model can facilitate the development of both TS and NTS for transport team members. Transport teams made up of newly registered staff from different disciplines may lack insight into their NTS in critical patient transfer management, but simulation training may cause improvements.