Factors associated with the worsening of COVID-19 symptoms among cohorts in community- or home-isolation care in southern Thailand.

Introduction: This study aimed to investigate factors associated with time-to-referral due to worsening symptoms in patients with laboratory-confirmed COVID-19 in southern Thailand. While underlying diseases have been evaluated to assess COVID-19 severity, the influence of vaccinations and treatments is also crucial. Methods: A cohort of 8,638 patients quarantined in home or community isolation with laboratory-confirmed COVID-19 was analyzed. Survival analysis and the Cox proportional hazard ratio were employed to assess factors influencing time-toreferral. Results: Age ≥ 60 years, neurologic disorders, cardiovascular disease, and human immunodeficiency virus infection were identified as significant risk factors for severe COVID-19 referral. Patients who received full- or booster-dose vaccinations had a lower risk of experiencing severe symptoms compared to unvaccinated patients. Notably, individuals vaccinated during the Omicron-dominant period had a substantially lower time-to-referral than those unvaccinated during the Delta-dominant period. Moreover, patients vaccinated between 1 and 6 months prior to infection had a significantly lower risk of time-to-referral than the reference group. Discussion: These findings demonstrate early intervention in high-risk COVID-19 patients and the importance of vaccination efficacy to reduce symptom severity. The study provides valuable insights for guiding future epidemic management strategies and optimising patient care during infectious disease outbreaks.

How the ARCH Project Could Contribute to Strengthening ASEAN Regional Capacities on Disaster Health Management (DHM).

OBJECTIVE: The Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) developed Regional Collaboration Drills (RCDs) and is proposing an ASEAN Academic Network to strengthen capacity in disaster health management (DHM) in ASEAN Member States (AMS), as well as developing a standard training curriculum in DHM. This study aims to clarify the impacts and sustainability of the ARCH Project. METHODS: The four previous RCDs and the enhancement of academic activities were reviewed. RESULTS: The ARCH Project developed the RCDs with simulation exercises based on possible disaster scenarios in each host country to test and validate the capacity of AMS International Emergency Medical Teams (I-EMTs), the Standard Operating Procedure (SOP) for I-EMT coordination, and regional tools, as well as the relevant domestic SOPs of the host countries for receiving international assistance. Following the RCD in Thailand, three AMS: Viet Nam, Philippines, and Indonesia, all of which are considered disaster-prone, successfully hosted RCDs with significant improvements. The project also established a sub-working group (SWG) to develop a standard curriculum in DHM. Two curricula developments, the Basic Course on DHM and In-Country Course for Coordination on EMTs, are on-going as part of the project activity. The establishment of the ASEAN Academic Network and the ASEAN Institute for DHM (AIDHM) are currently in the endorsement process of the ASEAN health sector. CONCLUSION: The RCDs are very effective to test and to validate the SOP and regional tools developed, providing opportunities for AMS I-EMT to familiarize the tools, as well as for host countries to assess their coordination capacity for receiving international assistance and identifying the country's specific challenges, and verifying ASEAN regional coordination mechanism. The development of the standard curriculum can enhance regional capacity both in supporting disaster-affected countries and in receiving international assistance. A sustainable capacity development mechanism in DHM is envisaged through the establishment of the ASEAN Academic Network and AIDHM toward the goal of One ASEAN One Response.

How the ARCH Project has Contributed to the Development of the ASEAN Regional Collaboration Mechanism on Disaster Health Management.

OBJECTIVE: This paper aims to clarify how the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) strengthened regional collaboration mechanisms on disaster health management (DHM) in ASEAN. METHODS: The political process and the relevant documents of the ARCH Project were reviewed. RESULTS: The ARCH Project established the Regional Coordination Committee as a coordination platform for providing strategic direction to the project and strengthening the regional coordination of DHM. Also, the Project Working Groups and Sub-Working Groups were set up as implementation bodies for the project activities with representatives of ASEAN Member States (AMS). With support from DHM experts of Japan and Thailand, a series of discussions were conducted for the development of a Standard Operating Procedure (SOP) for the Coordination of International Emergency Medical Teams (I-EMTs), regional tools, and collective measures supporting AMS to overcome challenges, and thereby meeting the minimum requirements set by the WHO EMT Initiative. The progress and outputs of the ARCH Project are subsequently elevated to the ASEAN Health Sector for endorsement, the updates are further shared to the Joint Task Force to Promote Synergy with Other Relevant ASEAN Bodies on Humanitarian Assistance and Disaster Relief (JTF-HADR) for the implementation of the ASEAN Declaration on One ASEAN One Response. The initiation of the ARCH Project in July 2016 has resulted in the development of the ASEAN regional collaboration framework, including the establishment of the Regional Coordination Committee on Disaster Health Management (RCCDHM), the SOP for ASEAN I-EMT coordination, and regional tools, such as forms for Medical Record for Emergency and Disaster and Health Needs Assessment. Moreover, further discussions on ASEAN Collective Measures that aim to support AMS to meet the WHO EMT minimum standards and strengthening I-EMT coordination capacity were also conducted. As adopted by the ASEAN Health Ministers Meeting (AHMM) in 2019, the RCCDHM was established as one of the mechanisms to operationalize the Plan of Action to implement the ASEAN Leaders' Declaration on DHM. CONCLUSION: The contribution of the ARCH Project to strengthen the ASEAN regional capacity in DHM has enhanced the regional coordination platform, with a formalization of RCCDHM as ASEAN's official regional mechanism, and of the on-going integration process of the SOP for EMT coordination into the ASEAN SASOP.

Development and Validation of a Scoring Assessment Tool for Hospital Safety: A Pilot Study Comparing Hospital Preparedness in Thailand.

INTRODUCTION: Safe hospitals are crucial in the management of major incidents and disasters. A hospital self-assessment tool was developed for Thailand to identify gaps and shortcomings in hospital preparedness. However, this tool lacks the ability to determine the level of preparedness and cannot be used to standardize hospital readiness and enable continuous quality control. OBJECTIVE: The aim of this study was to test a developed scoring hospital assessment tool to evaluate the level of hospital preparedness and enable quality control and compare the results of various hospitals. MATERIAL AND METHODS: Using the nominal group technique, three experts evaluated all sections of the previously developed hospital self-assessment tool and recognized that each element could be answered by one of the three options: Yes, Not Known, and No. A pilot study was conducted in 11 hospitals to evaluate the feasibility of the tool. The number of Yes responses was divided by the total number of elements to represent the level of hospital preparedness and reported as either low (0‒59), average (60‒79), or good (80‒100). The results identified areas for improvement. RESULTS: Eleven out of 13 hospitals (85% response rate) in two provinces were enrolled in the study. The results showed various levels of preparedness in all the investigated hospitals. Two hospitals had low preparedness and needed great improvements. The remaining nine hospitals in the two provinces had average preparedness levels and needed improvements. One of the nine hospitals had a score very close to achieving good preparedness. No significant parameters were associated with the preparedness level. CONCLUSION: The developed scoring assessment tool for hospital safety demonstrated high utilization feasibility and indicated preparedness levels. The scoring tool also provided assessment levels that could enable continuous quality evaluation and improvements.

Development of Hospital MCI and Disaster Preparedness Assessment Tool for Thailand.

INTRODUCTION: Hospital preparedness is a key component to mitigate the effects of mass casualty incidents (MCIs) and disasters. Improving hospital preparedness requires an assessment of the country's current health system capacity, readiness, and preparedness. Although a variety of assessment tools exist, none are entirely suitable for Thailand's healthcare system. OBJECTIVE: To develop an assessment tool to evaluate hospital preparedness for MCI and disaster in Thailand. METHODS: A cross-sectional study was conducted from 1 March 2015 to December 2016. The contents of the first drafted tool were prepared based on evidence from a systematic search of electronic databases published up to 31 December 2014. Key elements identification, extraction, and further organization were based on the World Health Organization health system framework. Validity was tested by experts and emergency management personnel in four domains using a 5-point scale evaluation form. The feasibility of using this assessment tool was carried out in 41 hospitals on a voluntary basis. The tool was considered valid if the item-objective congruence (IOC) index results were at least 0.6 and feasible for median values of at least 4. RESULTS: Seventy-six full texts and guidelines out of 5869 titles and abstracts from a systematic search were enrolled in the study. A constructive literature review was performed to develop a hospital assessment tool. The IOC index results of the assessment tool components were 1.0, 0.9, 0.7, and 1.0 in framework appropriateness, relevance of items, clearness, and usefulness, respectively. The median (interquartile range) values of framework appropriateness, relevance of items, clearness, and usefulness were 4.0 (4.0‒5.0), 4.3 (4.3‒4.5), 4.0 (4.0‒4.0), and 5.0 (4.0‒5.0), respectively. CONCLUSION: An assessment tool to evaluate hospital MCI and disaster preparedness based on the WHO health system framework was valid and feasible at the national level of Thailand.

Non-randomized comparative study on the efficacy of a trauma protocol in the emergency department.

PURPOSE: Trauma is a major health problem in developing countries and worldwide which requires many resources and much time in an emergency department (ED). Although Advanced Trauma Life Support (ATLS) is the gold standard, operator dependence can affect the quality of care. The objective was to identify differences in numbers and time to lifesaving interventions, investigation, ED length of stay, and mortality between an in-house protocol and conventional practice. METHODS: This was a single-center prospective non-randomized study for adult trauma patients in the ED. The trauma protocol was developed from the recent ATLS guideline. RESULTS: Thirty-two and 41 cases were in the in-house protocol group and conventional practice group, respectively. Endotracheal intubation was done more frequently in the in-house protocol group (84% vs. 59%, p = 0.03). Intercostal drainage tube insertion was done faster (6-26 min, median 11 min vs. 15-84 min, median 35 min, p = 0.02) and pre-arrival notification by emergency medical service increased in the in-house protocol group (66% vs. 30%, p = 0.01). Hypothermia in the operating room was found only in the conventional practice group (62% vs. 0, p = 0.007) and a warm blanket was used significantly more often in the in-house protocol group (25% vs. 0, p < 0.001). A directed acyclic graph with multivariate analysis was used to identify confounders. Time to Focused Assessment Sonography in Trauma was significantly shorter in the in-house protocol group (6.5-15.6 min, median 11 min, p = 0.019). CONCLUSION: In addition to the ATLS guideline, the trauma protocol could improve trauma care by reduced time to investigation, early notification of the trauma team in pre-hospital situations, reduced incidence of hypothermia in the operating room, and increased use of a warm blanket.

Septic shock in the ER: diagnostic and management challenges.

Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.

Appropriateness of Broad Spectrum Antibiotics for Severe Sepsis and Septic Shock in the Emergency Department.

OBJECTIVE: Determine the appropriateness of broad-spectrum antibiotics applied in severe sepsis and septic shock in an emergency room and its impact on the survival rate. MATERIAL AND METHOD: This was a prospective observational study in an emergency room setting at a tertiary care facility where early goal-directed therapy (EGDT) was applied for resuscitation of severe septic and septic shock patients. The data recorded were the initial vital signs, SAP II score, time of EGDT goals achieved (ScvO2> 70), time of antibiotics initiated, type of antibiotics used, organisms that were identified, source of infection, initial and final diagnosis, and outcome of treatment. The student's t-test and Mann Whitney U test were used to compare survival rates between appropriate and inappropriate antibiotics used. RESULTS: Seventy-eight newly diagnosed severe septic and septic shock cases were treated per the EGDT protocol. There were 41 (52.6%) male and 37 (47.4) female patients. The organisms were identified by hemoculture in 28 cases, 18 (64.3%) cases were gram-negative, seven (25.0%) cases were gram-positive, and three (10.7%) were mixed organisms. The five most common sites of infection were 30 (38.5%) cases of lung infection, 18 (23.1%) cases of bacteremia, 16 (20.5%) of gastrointestinal tract infection, 15 (19.2%) cases were genito-urinary tract infection, and six (7.7%) were skin and soft tissue infection. The mean SAP II score was 44.2 ± 15.4 and the mean time to initiate antibiotics was 59 ± 50 minute. Fifty-five cases (70.5%) were classified as appropriate antibiotics group, 31 (56.4%) of the 55 cases survived, while only nine (39.1%) of the 23 cases in the inappropriate group survived. This was not statistically significant. CONCLUSION: The most common sources of infection of septic patients were lung infection, bacteremia, gastrointestinal tract infection, genito-urinary tract infection, and skin and soft tissue infection. The hemocultures were positive in 58.9% of the cases and the common organisms were E. coli, K. pneumonia, S. aureus, and S. pneumoniae. The immunocompromised, multiple co-morbid and prolonged intubated patients should receive antibiotics to cover ESBL-producing E. coli, P. aeruginosa, and A. baumannii.

Success of applying early goal-directed therapy for septic shock patients in the emergency department.

BACKGROUND: Since early goal-directed therapy (EGDT) became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room. OBJECTIVE: We aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate. METHODS: This was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, SAP II (Simplified Acute Physiology II) score, SOFA (Sequential Organ Failure Assessment) score, time at which EGDT goals were achieved (central venous oxygen saturation [ScvO2] >70%), initial and final diagnosis, and outcome of treatment. The t-test and Mann-Whitney U-test were used to compare between the achieved goal and nonachieved goal groups. RESULTS: There were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9%) cases were male. Thirty-nine (70.9%) patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097). Thirty of the 39 patients (70.9%) survived in the achieved goal group, which was a statistically significant improvement of the survival rate when compared with only one of 16 patients (6.3%) surviving in the nonachieved goal group (P<0.001).

Serum Lactate Levels as a Prognostic Predictor of Septic Shock in Emergency Department Patients with Systemic Inflammatory Response Syndrome (SIRS) at Songklanagarind Hospital.

Objective: To determine whether serum venous lactate is associated with an increased risk of septic shock and risk of death in emergency department patients with systemic inflammatory response syndrome (SIRS). Material and Method: This was a prospective observational study at the Songklanagarind Hospital Emergency Department. Between April 1 and October 31, 2009, 131 consecutive patients met the enrollment criteria of age older than 18 years and fulfilled the SIRS criteria. Serum venous lactate was obtained in all enrolled patients. The main outcome measurements were development of septic shock, death within 24 hours, and in-hospital mortality at 3- and 28-day of presentation. Results: Of the 131 patients enrolled, 50 (38.1%) developed septic shock. A lactate level greater than 36 mg/dL was associated with death (odds ratio [OR] = 4.29, 95% confidence interval [CI] = 1.19-15.55) to predict 28-day hospitalization mortality. It was also statistically significant to the progression to septic shock (p = 0.013) with 50.0% sensitivity and 73.2% specificity (OR = 2.73, 95% CI = 1.22-6.13). Conclusion: For patients presenting to the emergency department with clinical symptoms of SIRS, a single serum venous lactate level measurement of greater than 36 mg/dL provides valuable prognostic predictor information concerning the high-risk group likely to progress to septic shock, more serious disease severity, and death.

Sustainable Effectiveness of Applying Trauma Team Activation in Managing Trauma Patients in the Emergency Department.

OBJECTIVE: To determine long term effectiveness of trauma team activation criteria by measuring emergency department length of stay (EDLOS) and 28-day mortality. MATERIAL AND METHOD: A 3-year retrospective cohort study conducted in adult trauma patients who met one of the trauma team activation criteria (shock, penetrating torso injury, post traumatic arrest, respiratory rate of less than 12 or more than 30, and pulse rate of more than 120). Specific demographic data, physiologic parameters, EDLOS, injury severity score (ISS), and 28-day mortality were prospectively recorded into the Trauma Registry database. Multiple logistic regression analysis was used to determine factors affecting mortality. The Institutional Review Board approval was obtained prior to undertaking the project. RESULTS: Two hundred eighty two patients with a mean age of35.1 years old were eligible. The median ISS was 25 (range, 13-30). The median EDLOS was 85 minutes (range, 50-135) and the 28-day mortality rate was 46.5%. The mean age was 31.7 years in the survival group and 38.7 years in the fatal group (p = 0.001). The median ISS was 17 in the survival group and 26 in the fatal group (p = 0.000) and the median EDLOS was 110 minutes in the survival group and 82 minutes in the fatal group (p = 0.034). When compared to data prior to the TTA application, the median time of EDLOS improvedsustainably from 184 to 85 minutes (p = 0.000) and the mortality rate decreased from 66.7% to 46.5% (p = 0.057). The parameters affecting patient mortality were older age, high ISS, and shorter EDLOS. CONCLUSION: Trauma team activation criteria significantly improved acute trauma care in the emergency department and decreased mortality.

Wound management in disaster settings.

BACKGROUND: Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management. METHODS: We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy. RESULTS: We included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons. CONCLUSION: Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.

Knowledge and practices of Thai emergency physicians regarding the care of delirious elderly patients.

BACKGROUND: The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients. METHODS: We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand. RESULTS: We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium. CONCLUSIONS: Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.

Correlation of caval index, inferior vena cava diameter, and central venous pressure in shock patients in the emergency room.

OBJECTIVES: This study aims to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in patients with shock in the emergency room. MATERIALS AND METHODS: This is a prospective double-blind observational study conducted in the emergency room of a tertiary care center. All patients who presented with shock and had a central venous catheter insertion performed were enrolled. The caval index was calculated as a relative decrease in the IVC diameter during the normal respiratory cycle. The correlation of CVP and the caval index were calculated by Pearson's product-moment correlation coefficient. RESULTS: Among the 30 patients enrolled, the median age was 59.90±21.81 years and 17 (56.7%) patients were men. The summary statistics that were generated for the participants' characteristics were divided into CVP <10 cm H2O, 10-15 cm H2O, and >15 cm H2O. The correlation of the CVP measurement with the ultrasound IVC caval index was r=-0.721 (P=0.000) by two-dimensional mode ultrasound and r=-0.647 (P=0.001) by M-mode. The correlations of CVP with the end-expiratory IVC diameter were r=0.551 (P=0.002) by two-dimensional mode ultrasound and r=0.492 (P=0.008) by M-mode. The sensitivity and specificity of the caval index were calculated to predict the CVP. The results showed that the cut-off points of the caval index were 30, 20, and 10 at CVP levels <10 cm H2O, 10-15 cm H2O, and >15 cm H2O, respectively. CONCLUSION: The caval index calculated from the IVC diameter measured by bedside ultrasound in the emergency room has a good correlation with CVP.

Predictive factors for a FAST-positive and a therapeutic laparotomy in blunt abdominal injuries at the emergency room.

OBJECTIVE: Identify the various factors that predict a Focused Assessment with Sonography for Trauma (FAST) positive result and a subsequent therapeutic laparotomy. MATERIAL AND METHOD: The medical records of all patients, aged greater than fifteen-years-old, with blunt abdominal injuries that underwent a FAST examination in an emergency room at a university level I trauma center over a one-year period were reviewed retrospectively. Patient data (demographic, vital signs and revised trauma score) was analyzed to identify the factors that correlated with a FAST-positive result and the need to perform a therapeutic laparotomy. RESULTS: Four hundred sixty five patients were eligible, of which twenty-eight patients had a FAST-positive result, and thirty-one patients underwent a therapeutic laparotomy. In multivariate analysis, the significant factors correlating with a FAST-positive result were an initial O2 saturation of 95% or less (OR = 4.0, 95% CI 1.4-11.5) and an abnormal abdominal examination (OR = 9.8, 95% CI 3.1-31.1). The factors correlating with a therapeutic laparotomy were a time of injury of one hour or less (OR = 11.2, 95% CI 1.1-116.8) and a FAST-positive result (OR = 11.1, 95% CI 1.1-113.6). CONCLUSION: Patients with blunt abdominal injuries who present with decreased oxygen saturation and an abnormal abdominal examination have a high probability of FAST-positive result. Patients with the time of injury of less than one hour before reaching the emergency room, and a FAST-positive are important predictors of the need for therapeutic laparotomy.

Gastropleural fistula following a splenectomy for splenic abscess: a case report.

Gastropleural fistula is a rare condition that occurs as a consequence of various thoraco-abdominal surgical procedures and septic conditions. The diagnosis is difficult, it needs a high index of suspicion and appropriate investigations. There are no previous reports of a patient developing a fistula after a splenectomy procedure. The authors report a twelve-year old boy who developed gastropleural fistula following thoracoabdominal surgery, a splenectomy. The patient presented with the clinical condition of chronic empyema thoracis and responded well to medical and surgical treatment.