Impacts of the COVID-19 Pandemic on the CODE ST-Segment Elevation Myocardial Infarction Program: A Quantitative and Qualitative Analysis.

BACKGROUND: The code ST-segment elevation myocardial infarction (STEMI) program is an operational standard of integrated service for STEMI patients carried out by Dr. Cipto Mangunkusumo Hospital. The emerging coronavirus disease 2019 (COVID-19) outbreak brought about many changes in the management of healthcare services, including the code STEMI program. This study aimed to evaluate the healthcare service quality of the Code STEMI program during the COVID-19 pandemic based on the Donabedian concept.  Methods: This was a mixed-methods study using quantitative and qualitative analyses. It was conducted at the Dr. Cipto Mangunkusumo Hospital, a national referral hospital in Indonesia. We compared the data of each patient, including response time, clinical outcomes, length of stay, and cost, from two years between 2018-2020 and 2020-2022 as the pre-COVID-19 code STEMI and COVID-19 Code STEMI periods, respectively. Interviews were conducted to determine the quality of services from the perspectives of stakeholders. RESULTS: A total of 195 patients participated in the study: 120 patients in pre-COVID-19 code STEMI and 75 patients in COVID-19 code STEMI. Our results showed that there was a significant increase in patient's length of stay during the COVID-19 pandemic (4 days vs. 6 days, p < 0.001). Meanwhile, MACE (13% vs. 11%, p = 0.581), the in-hospital mortality rate (8% vs. 5%, p = 0.706), door-to-wire crossing time (161 min vs. 173 min, p = 0.065), door-to-needle time (151 min vs. 143 min p = 0.953), and hospitalization cost (3,490 USD vs. 3,700 USD, p = 0.945) showed no significant changes. In terms of patient satisfaction, patients found code STEMI during COVID-19 to be responsive and excellent. CONCLUSION: The implementation of the code STEMI program during the COVID-19 pandemic revealed that modified pathways were required because of the COVID-19 screening process. According to the Donabedian model, during the pandemic, the code STEMI program's healthcare service quality decreased because of a reduction in efficacy, effectiveness, efficiency, and optimality. Despite these limitations attributed to the pandemic, the code STEMI program was able to provide good services for STEMI patients.

Association Between the Emergency Department Length of Stay and in-Hospital Mortality: A Retrospective Cohort Study.

Purpose: The number of emergency department (ED) visits and prolonged ED length of stay (LOS) are increasing worldwide. Prolonged ED LOS may be associated with a higher risk of in-hospital mortality. Here, we analysed the association between of ED LOS and the risk of in-hospital mortality in a hospital in Jakarta, Indonesia. Patients and methods: This was a single-centre retrospective cohort study performed in a referral academic hospital in Jakarta, Indonesia. Data on ED visits in 2019 were obtained from the electronic medical records. ED patient was used as the unit of the analysis. The dependent variable was all-cause in-hospital mortality during one's visit. The main independent variable was ED LOS with respect to approval (<8 h) and prolonged (≥8 h). Potential confounders were sex, age, triage categories, trauma-related case, malignancy-related case, labour-related case, and referral patients from other healthcare facilities. Multivariate logistic regression analysis was performed to evaluate the association of ED LOS and in-hospital mortality after adjusting for other confounders. Results: There were 18,553 participants included in the analysis. The in-hospital mortality was 13.5% among all participants, and 63.5% participants had an ED LOS ≥8 h. Multivariate analysis showed that a prolonged ED LOS was associated with an increased risk of in-hospital mortality (adjusted relative risk, 2.69; 95% confidence interval, 2.40-3.03; P<0.001). Conclusion: Prolonged ED LOS was associated with risk an increased of in-hospital mortality after adjusting for several confounders. In future, hospital service plans should aim to reduce ED LOS and increase patient flow from the ED to in-patient wards.

Plasmodium Ovale Malaria: Endemic Areas in Indonesia.

Plasmodium ovale consists of two subspecies - P. ovale wallikeri and P. ovale curtisi. Increased reports of imported malaria ovale in non-endemic regions and mixed infection of P. ovale with other Plasmodium species suggest that P. ovale might be under-detected during routine surveillance. Areas endemic with P. ovale have mostly been reported in African and Western Pacific countries. A recent case report in Indonesia indicated that regions with P. ovale endemicity are not only distributed in Lesser Sunda and Papua, but also in North Sumatra.

The association of the COVID-19 outbreak with in-hospital mortality: A single-centre study from Indonesia.

Objective: The early outbreak period of Coronavirus Disease (COVID-19) has affected the emergency department (ED) and hospital services in many countries. This study aimed to investigate the association between COVID-19 outbreak and in-hospital mortality in Jakarta, Indonesia. Methods: This retrospective cohort study was conducted in a single-centre referral hospital in Jakarta, Indonesia. Data were collected between May and October 2020. All patients who visited the ED and required inpatient care during the early COVID-19 outbreak period at the study location (March to April 2020) were included in the exposure group. All patients who visited the ED and required inpatient care during the non-outbreak period (March to April 2019) were included in the non-exposure group. In-hospital mortality was the primary outcome, whereas other variables, such as sex, age, triage categories, trauma cases, referral cases, and ED length of stay (LOS), were measured to identify confounding and effect modifications. Multivariate logistic regression analysis was performed to assess this association. Results: A total of 2,808 patients during the outbreak period and 2,423 patients during the non-outbreak period participated in the study. The odds of in-hospital mortality increased during the outbreak period compared to that during the non-outbreak period (odds ratio [OR], 1.41; 95%CI 1.04-1.91; p = 0.01) after adjusting for age, sex, triage categories, trauma case, ED LOS, and interaction between the outbreak period and ED LOS. Conclusion: COVID-19 outbreaks have been associated with an increased risk of in-hospital mortality in referral hospitals in Jakarta, Indonesia.

Post COVID-19 Syndrome Monitoring in Confirmed COVID-19 Patients with Telemedicine at Cipto Mangunkusumo Hospital.

BACKGROUND: The incidence of post-covid-19 syndrome is quite high and requires further monitoring after the patient is discharged from treatment. So we need a proper monitoring method and description of the Covid-19 syndrome in Indonesia.  Methods: This retrospective cohort study with total sampling method uses data from medical records and telemedicine observations of confirmed COVID-19 patients who received treatment in the Kiara room at Cipto Mangunkusumo. The data were then analyzed using chi-squared and multinomial logistic regression techniques. RESULTS: A total of 133 samples were used, including 44.4% male and 55.6% female, with an average age Standard Deviation (SD) of 40.36 (17.94). The severity levels of Covid-19 were mild (66.9%). The most common post-Covid-19 symptom manifestations was cough expressed at the first follow-up (first week after recovery) and second follow-up (the fourth week after recovery). Furthermore, the significant relationship between severity levels and post-Covid-19 symptomatic syndrome outcomes is the critical headache or vertigo symptoms with an RR of 8.70 (95% CI, 1.10-68.69,). In comparison, the telemedicine quality assessment was declared good, as shown by 98.7% of an examined sample. CONCLUSION: The most manifestation shown in the first and fourth week of follow-up is cough. Other symptoms tend to decrease in the second follow-up. The severity level associated with post-Covid-19 manifestations are severe-critical with headache or vertigo as a risk factor and mild with symptoms of headache or vertigo as a preventative. Meanwhile, the quality of telemedicine services was recognized as good by the majority of the sample.

Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study.

OBJECTIVE: Intubation is an important competency for emergency doctors. Emergency patients are often unstable, with undifferentiated conditions. There is little time to prepare these patients prior to intubation and so ED intubation may differ from intubation in intensive care units and operating theatres. The present study aims to describe the characteristics of emergency intubation after an administrative policy change within a tertiary teaching hospital in Jakarta, allowing non-anaesthetists to perform intubation in the ED. METHODS: Prospective data were collected regarding patients of all age groups who were intubated at the ED of Cipto Mangunkusumo General Hospital, Jakarta, from February 2018 to January 2019. Patient characteristics, intubation attempts, medications used, complications, and disposition were recorded in a self-reported airway registry based on the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) form. RESULTS: During the 12-month study period, 231 patients, or 41.5% of ED intubated patients were enrolled in the study, and there were 268 intubation attempts on these enrolled patients. The first-pass success rate was 207 out of 231 patients, or 89.6%, with anaesthetist (88.9%), better than emergency doctors (55.4%). Complications were reported in 51 patients, or 22.0%, with desaturation and hypotension being the most common. Thirty-three patients, or 14.3%, died in the ED before being transferred to another unit. CONCLUSIONS: The first-pass success rate is comparable with international data. Non-anaesthetic physicians must improve their experience to achieve a favourable success rate. The data on complications highlight the need for improvement in Indonesian ED intubation practices.

Effects of the COVID-19 pandemic on the management of ST-Segment elevation myocardial infarction in Indonesia: a cohort study.

Background: ST-segment elevation myocardial infarction (STEMI) is a form of acute coronary syndrome with high mortality rate. Management of STEMI should be performed as soon as possible to prevent further damage. With the emergence of coronavirus disease 2019 (COVID-19), it may face obstacles. To overcome those problems, some changes in policy focusing on fibrinolytic therapy in STEMI patients have been applied. This study aimed to identify the effects of COVID-19 in management of STEMI patients in Indonesia. Methods: This retrospective study was conducted in Dr. Cipto Mangunkusumo Hospital (CMH), the national referral center in Indonesia. We compared data between 2018 to 2019 and 2020 to 2021 as before and during COVID-19 pandemic period, respectively. We analyzed the effects of COVID-19 on STEMI patients' visits to hospital i.e., monthly hospital admission and symptoms-to-hospital, management of STEMI i.e., the strategies and time of reperfusion, and clinical outcomes of STEMI patients i.e., major adverse coronary event and mortality. Results: There was a significant statistically reduced mean of monthly hospital admissions from 11 to 7 (p = 0.002) and prolonged duration of symptoms-to-hospital during COVID-19 from 8 to 12 hours (p = 0.005). There was also a decrease in primary percutaneous coronary intervention (PPCI) procedures during COVID-19 (65.2% vs. 27.8%, p<0.001), which was accompanied by an increased number of fibrinolytic (1.5% vs. 9.5%, p<0.001) and conservative therapy (28.5% vs. 55.6%, p <0.01). Moreover, there was also a prolonged duration of diagnosis-to-wire-crossing time (160 vs. 186 minutes, p = 0.005), meanwhile, percentage of urgent PCI, door-to-needle time, and clinical outcomes were not statistically significant. Conclusions: During COVID-19 pandemic, the number STEMI patients declined in monthly hospital admission, delays in symptoms-to-hospital time, changes in type of reperfusion strategy, and delays in PPCI procedures in CMH. Meanwhile, fibrinolytic time and clinical outcomes were not affected.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia.

INTRODUCTION: Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19. PRESENTATION OF CASE: This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination. CONCLUSIONS: We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

Triage in the Time of Diphtheria.

INTRODUCTION: A diphtheria outbreak occurred in 2017 in Jakarta, Indonesia, during which our hospital was appointed as a referral hospital where patients with upper respiratory tract symptoms were sent for confirmation of the diagnosis and medical intervention. In this study we review the implementation of the emergency department (ED) triage process and patient flow management during the diphtheria outbreak. No previous study in Indonesia has provided a detailed report on the triage process during infectious disease outbreaks. METHOD: We modified our pre-existing hospital triage method according to the "identify, isolate, and inform" principle. We developed novel criteria for triage to identify triage-suspected cases and also a diphtheria package to simplify the diagnostic process. Four separate rooms were modified to isolation spaces to enable medical staff to observe these patients. We obtained data from the ED outbreak registry and electronic health records. RESULTS: Of 60 cases of triage-suspected diphtheria, six were classified as suspected diphtheria. The mean time from "identify" to "isolate" was 3.5 minutes, and from "isolate" to "inform" was 10 minutes. Mean ED length of stay for probable diphtheria was 24.46 hours. No medical personnel in the ED showed any signs of diphtheria 30 days after the outbreak had abated. CONCLUSION: The modified criteria can help triage officers detect suspected diphtheria cases and measure the triage response time. Use of the diphtheria package and four separate rooms in the ED could act as an infection control procedure and facilitate the improvement of the diagnostic process.

Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia.

PURPOSE: A national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method. METHODS: This cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality. RESULTS: There were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5-99.9) and 96.9% (95% CI, 95.7-97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259-1.429) and a RR for mortality of 4.294 (95% CI, 3.180-5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11-4.54). CONCLUSION: CTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

ST-Elevation Myocardial Infarction: A Simulation Case for Evaluation of Interprofessional Performance in a Hospital.

INTRODUCTION: Interprofessional collaboration between units in a hospital is essential in order to reach desired time for primary percutaneous intervention (PCI) in acute ST-Segment Elevation Myocardial Infarction (STEMI) cases. We developed a simulation to engage various medical and nonmedical staff in interprofessional and interunit team collaboration. METHOD: We used a scenario in this simulation. Beginning in the emergency department, it detailed a 50-year-old male presenting with progressive chest pain since 7 hours before admission. The emergency team directly examined the patient, and STEMI diagnosis was made, followed by sending the patient to the cardiac catheterization laboratory to undergo primary PCI. A resuscitation kit was required for the simulation. An evaluation sheet was prepared to evaluate every step of patient management. Three judges observed the simulation. At the end of the simulation, debriefing was done, and recommendation for the simulation was discussed. Besides medical activities during patient management, interprofessional communication, administration activities, consultations, and handover process were also evaluated. RESULTS: The team achieved the appropriate door-to-electrocardiogram (ECG) time in 8 minutes, but overall target was delayed since door-to-skin puncture time was reached in 110 minutes. Some factors that contributed to these conditions were long waiting time during patient admission, several attempts for telephone consultation to the cardiologist, and prolonged admission process in the cardiac catheterization laboratory. CONCLUSIONS: The simulation was well received by both participant and our institution, stating that it is a valuable resource for developing interdisciplinary learning program. This simulation also contributed to the development of the clinical pathway, STEMI protocol, in our institution.

Human Tapeworm from Simalungun, Indonesia.

A 46-years-old man from Indonesia, resides in Nagori Dolok Village, Silau Kahaean Subdistrict, Simalungun District, Sumatra Utara Province, had of spontaneous discharge of tapeworm segments (proglottids) from anus almost every day for ten years. There were 1-5 segments which can move actively discharge per day. Although he feels embarrassed about the condition, no significant symptoms were found, and physical examination was within normal limits. Clinical diagnosis of Taeniasis was made on October 20, 2017, and subsequently received oral Praziquantel 600 mg tablet single dose and 5 mg of oral Bisacodyl. Four hours later, the patient was defecated. The stool was collected in plastic and filtered with a filter device to collect any tapeworm segments.A full segment of tapeworm as long as 2.86 meters were found. Microscopic examination was done to identify the egg worms, proglottids, and scolex. Dye substance was injected into a mature gravid proglottid through the genital pore and pressed in two object-glasses to identify the reproductive organs. Microscopic examination (400x magnification) of this sample revealed that the number of uterine branches and testes in a proglottid were 16 pairs. The number of uterine branches in T. solium are 8-12 pairs and T. saginata are 18-32 pairs.The filtered stool was moved into a container and carefully observed. A soft yellowish-white material of 1.5 mm in diameter was found, which turned out to be the head of the tapeworm called Scolex. Microscopic examination of scolex revealed that the rostellum was absent. A segment called 'snout' was found at the apex. The functions were probably as a sense of smell and vacuum organ.The patient was lived in Simalungun, North Sumatera, some tribe in that area has a long tradition of culinary called 'Hinasumba', consist of raw pork liver and meat, and 'Naiholat' consist of poorly cooked pork.Even though pig was determined as an intermediate host, the type of tapeworm was not consistent with T.solium. The patient had the long history of infection but never had sign or symptoms of neurocystecercosis. Based on etno-geographical condition, the patient was infected by T.asiatica. Microscopic examination of the uterus and scolex indicate that the tapeworm had most similarity to T.asiatica.Amin et al.8 from Bangladesh in 2009 reported a case of T. asiatica in human with total strobila length was 1.5 meters. Macroscopic morphology (length:width) of gravid proglottid segment of T.saginata is 3:1, T. solium 1.5:1. The tapeworm that we discovered had 1-1.5:1 ratio (2.5 cm length and 2 cm width).Some features of the tapeworm (no rostellum, present of the snout, and fix number of theuterus in every proglottid) were not found in three existing type of Taenia species. Further microscopic and molecular study should be done to determined type or subtype of the tapeworm. A case of taeniasis asiatica who had completed treatment was reported. Macroscopic and microscopic was done to support the clinical diagnosis.

An HIV positive man with single erythema skin lesion: a case report of neglected tropical disease.

Skin lesion is common in person living with HIV. We reported a 42 years old HIV positive man with single erythema skin lesion on the right foot. Clinical examination, anamnesis and laboratory examination revealed that it was cutaneous larva migrant due to parasitic infection. The cutaneous larva migrant due to hookworms is one of neglected tropical disease that might occur in adult with immunocompromised. This neglected disease is discussed rarely and might not be found in developed country, but it is still a common disease in the tropical region. Patient was treated successfully with albendazole, cetirizine, chlorethyl spray and betamethasone cream.