The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study.

BACKGROUND: During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS: We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS: Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS: Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Best Practices in End of Life and Palliative Care in the Emergency Department.

Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.

Thirty-day mortality among patients with acute delirium in the emergency department.

Purpose: The number of visits to the emergency department (ED) is growing among older patients. Older people are at risk of acute delirium, which is associated with mortality. Our primary objective was to determine the 30-day mortality outcome between older patients with and without acute delirium. Methods: From August 2018 to October 2019, we conducted a prospective cohort study in the ED of a tertiary care and university hospital. Patients over the age of 65 years who presented to the ED were included in the study. Within the first 12 h after the ED visit, delirium was assessed by using the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected data on 30-day mortality, ED LOS, hospital length of stay (LOS), and the 30-day ED revisit rate. Results: We enrolled 173 patients in this study; 49 (28%) patients had acute delirium according to the CAM-ICU. The overall 30-day mortality was 4% (7/173). Delirium had no effect on 30-day mortality (adjusted odds ratio [OR], 2.15; 95% confidence interval [CI], 0.37-12.55; P = 0.40). Delirium was not associated with hospital LOS (adjusted mean difference -18.83 h; 95% CI, -71.94-34.28; P = 0.49) and the 30-day ED revisit rate (adjusted OR, 1.55; 95% CI, 0.59-4.11; P = 0.37). However, an increasing trend in ED LOS was observed (adjusted mean difference 16.39 h; 95% CI, -0.160-32.96; P = 0.05). Conclusions: We found insufficient evidence to establish an association between delirium and 30-day mortality, hospital LOS, or 30-day emergency department revisits. Trial registration: The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR2021082700 on August 27, 2021.

Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians.

CONTEXT: During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training. OBJECTIVES: To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training. METHODS: A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals. RESULTS: Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups. CONCLUSION: Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.

The Accuracy of Sepsis Screening Score for Mortality Prediction at Emergency Department Triage.

INTRODUCTION: Sepsis has a mortality rate of 10-40% worldwide. Many screening tools for sepsis prediction and for emergency department (ED) triage are controversial. This study compared the accuracy of the scores for predicting 28-day mortality in adult patients with sepsis in the triage area of the ED. METHODS: Adult patients who presented to the ED of a tertiary-care university hospital from January-December 2019 with an initial diagnosis of sepsis or other infection-related conditions were enrolled. We calculated predictive scores using information collected in the ED triage area. Prognostic accuracy was measured by the area under the receiver operating characteristic curve (AUROC) for predicting 28-day mortality as a primary outcome. The secondary outcomes included mechanical ventilation usage and vasopressor usage for 28 days. RESULTS: We analyzed a total of 550 patients. The 28-day mortality rate was 12.4% (n = 68). The 28-day mortality rate was best detected by the National Early Warning Score (NEWS) (AUROC = 0.770; 95% confidence interval [CI]: 0.705-0.835), followed by the quick Sequential Organ Failure Assessment (qSOFA) score (AUROC = 0.7473; 95% CI: 0.688-0.806), Search Out Severity (SOS) score (AUROC = 0.749; 95% CI: 0.685-0.815), Emergency Severity Index (ESI) triage (AUROC = 0.599; 95% CI: 0.542-0.656, and the Systemic Inflammatory Response System (SIRS) criteria (AUROC = 0.588; 95% CI: 0.522-0.654]). The NEWS also provided a higher AUROC and outperformed for 28-day mechanical ventilator usage and 28-day vasopressor usage. CONCLUSION: The NEWS outperforms qSOFA, SOS, SIRS, and ESI triage in predicting 28-day mortality, mechanical ventilator, and vasopressor usage of a patient with sepsis who is seen at ED triage.

Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial.

BACKGROUND: Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. METHODS: This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL. DISCUSSION: In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients' self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05209880.

Effect of appropriate dose, spectrum, and timing of antibiotics on 28-day mortality in patients with sepsis in the emergency department.

BACKGROUND: Appropriate antibiotics prescribing is key to treatment and to preventing mortality in patients with sepsis. The aim of this study was to determine the effect of the appropriate timing, spectrum, and dose of antibiotics on 28-day mortality in patients with sepsis. METHODS: We performed a retrospective cohort observational study. We enrolled patients with sepsis in the emergency department of a tertiary care hospital between 1 March and 31 July 2019. Patients were coded into an appropriate antibiotics group (time, spectrum, dose) and an inappropriate antibiotics group. We collected information of patient characteristics, comorbidities, vital signs, laboratory test results, and initial treatment. We followed patient outcomes, 28-day mortality, hospital deaths, 28-day ventilator-free days, and 28-day hospital-free days. RESULTS: A total of 593 patients were enrolled, with 323 (54.46%) in the appropriate antibiotics group. We used multivariate logistic analyses to assess factors for mortality. Primary outcomes of appropriate antibiotics (administration within 60 min of triage, appropriate spectrum and dose) did not affect 28-day mortality (adjusted odds ratio [OR], 0.57; 95% confidence interval [CI] 0.22-1.144; P=0.23). Subgroup analysis showed that appropriate spectrum alone influenced 28-day mortality (adjusted OR, 0.38; 95% CI, 0.15-0.99; P=0.047). Appropriate antibiotics was not associated with in-hospital mortality (adjusted OR, 0.62; 95% CI, 0.29-1.30; P=0.21). CONCLUSION: Appropriate antibiotics included timing less than 60 min, spectrum and the dose was not significantly affected in 28-day mortality in emergency sepsis patients. TRIAL REGISTRATION: The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR20211216003 .

The 28-Day Mortality Outcome of the Complete Hour-1 Sepsis Bundle in the Emergency Department.

INTRODUCTION: The Surviving Sepsis Campaign published the Hour-1 Sepsis Bundle in 2018. The first-hour management of patients with sepsis in the emergency department (ED) is important, as suggested in the Hour-1 Sepsis Bundle. The objectives of the present study were to evaluate 28-day mortality and delayed septic shock with use of a complete and incomplete Hour-1 Sepsis Bundle in the ED. METHODS: This prospective cohort study included adult patients with sepsis from March to July 2019. We followed the sepsis protocol used in the ED of a tertiary care hospital. RESULTS: We enrolled 593 patients, with 55.9% in the complete Hour-1 Sepsis Bundle group. The 28-day mortality was 3.9% overall and no significant difference between the complete and incomplete Hour-1 Sepsis Bundle groups (3.6% vs. 4.2%, P = 0.707). Complete Hour-1 Sepsis Bundle treatment was not associated with 28-day mortality (adjusted OR = 2.04, 95% confidence interval [CI] = 0.72-5.74, P = 0.176) or delayed septic shock (adjusted OR = 0.74, 95% CI = 0.30-1.78, P = 0.499). Completion of each bundle did not affect outcomes of 28-day mortality and delayed septic shock. CONCLUSIONS: The complete Hour-1 Sepsis Bundle treatment in the ED was not significantly associated with 28-day mortality and delayed septic shock. TRIAL REGISTRATION: The trial was registered in the Thai Clinical Trial Registry, TCTR 20200526013.

Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study.

OBJECTIVE: Palliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients' needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work. METHODS: This questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills. RESULTS: Among 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006). CONCLUSION: Our findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.

Clinical Prediction Score for Ruptured Appendicitis in ED.

BACKGROUND: Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population. METHODS: This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis. RESULT: During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times. CONCLUSION: Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Prognostic Accuracy of VqSOFA for Predicting 28-day Mortality in Patients with Suspected Sepsis in the Emergency Department.

BACKGROUND: Sepsis screening in the emergency department (ED) is challenging. The quick Sequential Organ Failure Assessment (qSOFA) score had poor accuracy for predicting mortality in both the intensive care unit and ED. High lactate levels were associated with an increased mortality. However, a previous study using lactate levels in combination with the qSOFA score did not observe a meaningful improvement in predictive accuracy. This study assessed the prognostic accuracy of venous lactate levels plus the qSOFA (VqSOFA) score for predicting 28-day mortality. METHODS: Patients who visited the Ramathibodi ED with suspected sepsis were enrolled. The VqSOFA, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores were calculated using the initial vital signs and laboratory values. Prognostic accuracy was measured using the area under the receiver operating characteristic (AUROC) curve of the VqSOFA score and Sepsis-3 criteria for predicting 28-day mortality. RESULTS: In total, 1,139 patients were enrolled, 118 of whom died within 28 days of admission. The AUROCs of the VqSOFA, qSOFA, and SOFA scores were 0.851 (95% CI 0.813-0.889), 0.813 (95% CI 0.772-0.854), and 0.728 (95% CI 0.671-0.784), respectively. Using VqSOFA score ≥ 3 as the cutoff, the sensitivity, specificity, and positive likelihood ratio were 74.6%, 82.5%, and 4.25%, respectively. VqSOFA ≥ 3 was linked to a low probability of 28-day survival and higher odds of vasopressor and ventilator use within 24 h. CONCLUSIONS: VqSOFA was more predictive of 28-day mortality and vasopressor and mechanical ventilator use than the qSOFA and SOFA scores.

Correlation between optic nerve sheath diameter measured on imaging with acute pathologies found on computed tomography of trauma patients.

PURPOSE: To evaluate the correlation between optic nerve sheath diameter (ONSD) measurement with signs of increased intracranial pressure (ICP) found on computed tomography (CT) in trauma patients. MATERIALS AND METHODS: 271 consecutive head CT trauma scans performed at our trauma center were retrospectively reviewed for ONSD and CT findings. Measurement of ONSD was made at CT and, when available, with ultrasonography (US). Imaging signs of increased ICP were assessed. Association between ONSD and signs of ICP were analyzed. RESULTS: The mean ONSD on axial CT images, optic-nerve axial plane and US was 4.70 ± 0.59 mm, 4.78 ± 0.59 mm, and 3.16 ± 0.50 mm, respectively. The ONSD measured at CT was significantly higher than that measured by US(p < 0.01). No difference of ONSD measured at CT between axial and optic-nerve axial planes. Patients with CT evidence of increased ICP had significantly higher ONSD than those without imaging abnormalities (p = 0.0001-0.0064). The ONSD cutoff points for suggesting increased ICP were 4.8 mm (60.5 % sensitivity, 61.2 % specificity, 20.4 % PPV, 90.4 % NPV) at CT and 3.15 mm (97.4 % sensitivity, 13.8 % specificity, 15.7 % PPV, 97 % NPV) at US. CONCLUSION: There was a significant association between ONSD and imaging signs of increased ICP in CT with a high NPV. No difference of ONSD measurement at CT between normal and optic-nerve axial planes was observed, whereas there was a significant difference between diameter obtained at CT and US.

Is a mechanical-assist device better than manual chest compression? A randomized controlled trial.

BACKGROUND: Chest compression quality is a determinant of survival from sudden cardiac arrest. The CPR RsQ Assist Device (CPR RAD) is a new cardiopulmonary resuscitation device for chest compression. It is operated manually but it does not pull up on the chest on the up stroke. The aim of this study was to compare the CPR RAD with standard manual compression in terms of chest compression quality in a manikin model. METHODS: Participants were randomly assigned to either the device or manual chest compression group. Each participant performed a maximum of 4 minutes of hands-only compression with or without the device. During chest compression, the following quality parameters from the manikin were recorded: compression rate, compression depth, and correctness of hand position. RESULTS: Duration of chest compression was significantly higher in device users compared with manual compression (223.93±36.53 vs 179.67±50.81 seconds; P<0.001). The mean compression depth did not differ in a statistically significant way between manual compression and device at 2 minutes (56.42±6.42 vs 54.25±5.32; P=0.052). During the first and second minutes, compression rate was higher in cases of standard compression (133.21±15.95 vs 108±9.45; P<0.001 and 127.41±27.77 vs 108.5±9.93; P<0.001). There was no statistically significant difference in the percentage of participants who employed compression that was too shallow or exhibited incorrect hand position. CONCLUSION: The CPR RAD is more effective in chest compression compared with manual chest compression, as using the device led to better results in terms of fatigue reduction and correct compression rate than standard manual compression.

Acute chest pain fast track at the emergency department: who was misdiagnosed for acute coronary syndrome?

BACKGROUND: Acute coronary syndrome (ACS) is a commonly treated disease in the emergency department (ED). Acute chest pain is a common presenting symptom of ACS. Acute chest pain fast track (ACPFT) is a triage to cover patients presenting with chest pain with the aims of early detection and treatment for ACS. This study aimed to assess the quality of the ACPFT with the aim of improving the quality of care for ACS patients. METHODS: This study was conducted at the ED in Mahidol University, Bangkok, Thailand. The inclusion criterion was patients presenting with acute chest pain at the ED. We retrospectively reviewed the medical records of all eligible patients. The primary outcomes of this study were to determine time from door to electrocardiogram and time from door to treatment (coronary angiogram with percutaneous coronary intervention or thrombolytic therapy in the case of ST elevation myocardial infarction). The outcome was compared between those who were in and not in the ACPFT. RESULTS: During the study period, there were 616 eligible patients who were divided into ACPFT (n=352 patients; 57.1%) and non-ACPFT (n=264 patients; 42.9%) groups. In the ACPFT group (n=352), 315 patients (89.5%) received an electrocardiogram within 10 minutes. The final diagnosis of ACS was made in 80 patients (22.7%) in the ACPFT group and 13 patients (4.9%) in the non-ACPFT group (P-value <0.01). After adjustment using multivariate logistic regression analysis, only epigastric pain was independently associated with being in the ACPFT group (adjusted odds ratio of 0.11; 95% confidence interval of 0.02, 0.56). CONCLUSION: The ACPFT at the ED facilitated the prompt work-ups and intervention for ACS.

Cancer Patients Are at High Risk of Mortality if Presenting with Sepsis at an Emergency Department.

BACKGROUND: Sepsis is an emergency condition with high mortality and morbidity rate. There are limited data on the association of cancer as a risk factor for mortality in sepsis patients in the emergency department (ED). MATERIALS AND METHODS: This retrospective study was conducted at the ED, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand. The study period was between January 1st and December 31st, 2014. The inclusion criteria were as follows: adult patients over 15 years of age who presented at the ED with suspicion of sepsis, received treatment at the ED, and whose blood culture was found to be positive. Clinical data were recorded from medical records including the Mortality in Emergency Department Sepsis score (MEDS score). The primary outcome of this study was mortality at one month. Multivariate logistic regression analysis was used to identify independent factors associated with death. RESULTS: During the study period, there were 775 eligible patients. The two most common pathogens identified from blood cultures were Staphylococcus aureus (193 patients; 24.9%) and Escherichia coli (158 patients; 20.4%). At one month after presenting at the ED, 110 patients (14.2%) had died. There were four significant factors for death, having cancer, being on an endotracheal tube, initial diagnosis of bacteremia, and high MED scores. Having cancer had an adjusted OR of 2.12 (95% CI of 1.29, 3.47). CONCLUSIONS: Cancer patients have double the risk of mortality if presenting with sepsis at the ED.

Trauma Ultrasound.

Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.

An emergency medical service system in Thailand: providers' perspectives.

BACKGROUND: Emergency medical services (EMS) in Thailand have been established for more than 20 years. However evaluation of EMS is limited The present study aimed to determine providers 'perspectives on EMS in Thailand MATERIAL AND METHOD: The present study was conducted at the tenth Academic Annual Meeting of Emergency Medicine between February 9 and 13, 2009 at Rajavithi Hospital, Bangkok. All participants at the meeting were eligible and randomly selected for the survey Subjects were physicians, nurses, or paramedics who worked in Emergency Department/Room at hospitals in Thailand. The survey was performed by self-rated questionnaire. RESULTS: Four hundred fifty questionnaires were distributed and 425 were returned completed (94.4%). Of those, 365 subjects (85.9%) were female, 359 (84.5%) were nurses, 103 (24.5%) worked at the ER for more than 10 years, and 284 (67.6%) worked at the community hospitals. The most three common issues of EMS system were insufficient medical personnel, insufficient medical devices, and lack of knowledge of medical personnel. At the ER, overcrowding was the most common issue, while problems with medical devices, collaborations with other organizations, and communication devices were main problems at the pre-hospital EMS. The average satisfactory score of EMS was 2.86 out of 5. CONCLUSION: EMS in Thailand requires improvement in terms of numbers ofmedical personnel, well-equipped ambulance, and collaborations among organizations.

A 6-year experience of CPR outcomes in an emergency department in Thailand.

PURPOSE: Sudden cardiac arrest is a common emergency condition found in the emergency department of the hospital. The survival rate of out-of-hospital cardiac arrest patients is 2.0%-10.0% and 7.4%-27.0% percent for in-hospital cardiac arrest patients. The factors for survival outcome are divided into three main groups: patient characteristics, pre-hospital factors, and resuscitated information. The objective of this study was to evaluate the related factors, outcome, and survival rate in patients with cardiac arrest who received cardiopulmonary resuscitation (CPR) at Ramathibodi Emergency Medicine Department. There are limited data for this issue in Thailand and other Asian countries. METHODS: This retrospective study included all patients who were older than 15 years with sudden cardiac arrest and who were resuscitated in the emergency room between January 2005 and December 2010. Descriptive analytic statistics and logistic regressions were used to analyze factors that related to the sustained return of spontaneous circulation (ROSC) and survival at discharge. RESULTS: There were 181 patients enrolled. The overall sustained ROSC rate was 34.8% and the survival rate at discharge was 11.1%. There were 145 out-of-hospital cardiac arrest patients, in whom the survival rate was 52.4% and the survival to discharge rate was 7.6%. For inhospital cardiac arrest, there were 36 patients with a survival rate of 86.1% and the survival to discharge rate was 25.0%. Statistically significant factors related to sustained ROSC were good and moderate cerebral performance, in-hospital cardiac arrest, beginning of CPR in less than 30 minutes, and cardiopulmonary cause of arrest. The factors influencing survival to discharge were cardiopulmonary causes of cardiac arrest. CONCLUSION: Factors associated with sustained ROSC were functional status before cardiac arrest, location of cardiac arrest, duration of CPR, and cause of cardiac arrest. Survival rate was related to the cause of cardiac arrest.