2020 Guideline for Prehospital Management, Emergency Evaluation and Treatment of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the Taiwan Society of Emergency Medicine and Taiwan Stroke Society.

To improve the clinical outcomes of patients with acute ischemic stroke, the public, pre-hospital care system, and hospitals should cooperate to achieve quick assessment and management for such patients and to start treatment as soon as possible. To reach the goal, the Consensus Group, including emergency physicians and neurologists in the Taiwan Society of Emergency Medicine and Taiwan Stroke Society, performed an updated review and discussion for the local guidelines. The guidelines consist of 12 parts, including public education program, evaluation and management in the emergency medical system, emergency medical system, assessment of stroke care capability of the hospital by independent parties, stroke team of the hospital, telemedicine, organization, and multifaceted integration, improvement of quality of care process of stroke system, initial clinical and imaging evaluations after arriving at the hospital, imaging evaluation for indications of intravenous thrombolysis, imaging evaluation for indications of endovascular thrombectomy, and other diagnostics. For detailed contents in Chinese, please refer to the Taiwan Stroke Society Guideline and Taiwan Emergency Medicine Bulletin.

Traditional versus blended CPR training program: A randomized controlled non-inferiority study.

Cardiopulmonary resuscitation (CPR) training and its quality are critical in improving the survival rate of cardiac arrest. This randomized controlled study investigated the efficacy of a newly developed CPR training program for the public in a Taiwanese setting. A total of 832 adults were randomized to either a traditional or blended (18-minute e-learning plus 30-minute hands-on) compression-only CPR training program. The primary outcome was compression depth. Secondary outcomes included CPR knowledge test, practical test, quality of CPR performance, and skill retention. The mean compression depth was 5.21 cm and 5.24 cm in the blended and traditional groups, respectively. The mean difference in compression depth between groups was -0.04 (95% confidence interval -0.13 to infinity), demonstrating that the blended CPR training program was non-inferior to the traditional CPR training program in compression depth after initial training. Secondary outcome results were comparable between groups. Although the mean compression depth and rate were guideline-compliant, only half of the compressions were delivered with adequate depth and rate in both groups. CPR knowledge and skill retained similarly in both groups at 6 and 12 months after training. The blended CPR training program was non-inferior to the traditional CPR training program. However, there is still room for improvement in optimizing initial skill performance as well as skill retention. Clinical Trial Registration: NCT03586752; www.clinicaltrial.gov.

Association between risk factors of metabolic syndrome with lung function.

BACKGROUND/OBJECTIVES: Increased evidence suggests that metabolic syndrome (MetS) is correlated with lung function impairment. This study aimed to explore the associations between MetS risk factors and the lung function. SUBJECTS/METHODS: The cross-sectional study included 6945 participants attending health examination between 2010 and 2012 in Taiwan. MetS was assessed according to the criteria of National Cholesterol Education Program III. Spirometric parameters were measured to define lung function. The relationships were tested using multiple linear regression and logistic regression analyses. RESULTS: The prevalence of MetS was significantly higher in males (16.2%) than females (3.8%). Although the prevalence of restrictive lung disease (RLD) was comparable between genders (20.7 and 21.0%), males with co-existent MetS had a higher prevalence of RLD than females (27.4 vs. 18.0%). Abdominal obesity, indicated by waist circumference (WC) and weight-to-height ratio (WHtR), was the most significant factor associated with lung function decline. Other components of MetS also showed statistically significant relationships, but very weak, with lung function. There was a trend toward an increased prevalence of RLD with the increasing number of MetS scores in males, independent of age, smoking, and body mass index. CONCLUSIONS: Abdominal obesity was the key component of MetS associated with mechanical effect on lung function impairment in a prime-age adult population. Although RLD was not associated with increased probability of having MetS, the participants with more MetS scores were at a higher risk of losing lung function.

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.

The effectiveness of teaching chest compression first in a standardized public cardiopulmonary resuscitation training program.

Effectiveness of bystander cardiopulmonary resuscitation (CPR) is known to provide emergency medical services which reduce the number of deaths in patients with out-of-hospital cardiac arrest. The survival at these patients is affected by the training level of the bystander, but the best format of CPR training is unclear. In this pilot study, we aimed to examine whether the sequence of CPR instruction improves learning retention on the course materials.A total of 95 participants were recruited and divided into 2 groups; Group 1: 49 participants were taught firstly how to recognize a cardiac arrest and activate the emergency response system, and Group 2: 46 participants were taught chest compression first. The performance of participants was observed and evaluated, the results from 1 pre-test and 2 post-tests between 2 groups were then compared.There was a significantly better improvement of participants in Group 2 regarding the recognition of a cardiac arrest and the activation of the emergency response system than of those in Group 1. At the post-test, participants in Group 2 had an improvement in chest compression compared to those in Group 1, but the difference was not statistically significant.Our study had revealed that teaching CPR first in a standardized public education program had improved the ability of participants to recognize cardiac arrest and to activate the emergency response system.

Segmented regression analysis of emergency departments patient visits from Septicemia in Taiwan.

BACKGROUND: The protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan. OBJECTIVES: To assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits. METHODS: Segmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues. RESULTS: The EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented. CONCLUSIONS: The EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.

Association of In-Hospital Mortality and Dysglycemia in Septic Patients.

BACKGROUND: The associations between dysglycemia and mortality in septic patients with and without diabetes are yet to be confirmed. Our aim was to analyze the association of diabetes and sepsis mortality, and to examine how dysglycemia (hyperglycemia, hypoglycemia and glucose variability) affects in-hospital mortality of patients with suspected sepsis in emergency department (ED) and intensive care units. METHODS: Clinically suspected septic patients admitted to ED were included, and stratified into subgroups according to in-hospital mortality and the presence of diabetes. We analyzed patients' demographics, comorbidities, clinical and laboratory parameters, admission glucose levels and severity of sepsis. Odds ratio of mortality was assessed after adjusting for possible confounders. The correlations of admission glucose and CoV (blood glucose coefficients of variation) and mortality in diabetes and non-diabetes were also tested. RESULTS: Diabetes was present in 58.3% of the patients. Diabetic patients were older, more likely to have end-stage renal disease and undergoing hemodialysis, but had fewer malignancies, less sepsis severity (lower Mortality in Emergency Department Sepsis Score), less steroid usage in emergency department, and lower in-hospital mortality rate (aOR:0.83, 95% CI 0.65-0.99, p = 0.044). Hyperglycemia at admission (glucose≥200 mg/dL) was associated with higher risks of in-hospital mortality among the non-diabetes patients (OR:1.83 vs. diabetes, 95% CI 1.20-2.80, p = 0.005) with the same elevated glucose levels at admission. In addition, CoV>30% resulted in higher risk of death as well (aOR:1.88 vs. CoV between 10 and 30, 95%CI 1.24-2.86 p = 0.003). CONCLUSIONS: This study indicates that while diabetes mellitus seems to be a protective factor in sepsis patients, hyper- or hypoglycemia status on admission, and increased blood glucose variation during hospital stays, were independently associated with increased odds ratio of mortality.

Pneumocystis Pneumonia Infection in a Survivor of Paraquat Intoxication.

Patients who survived recent paraquat intoxication might be treated with glucocorticoid andcyclophosphamide to avoid further lung fi brosis. Such patients might be susceptible to opportunistic infections. Pneumocystis pneumonia (PCP) is an important opportunistic lung infection in hematologic malignancy patients on chemotherapy. We report a patient who recently survived paraquat intoxication and presented with acute respiratory insuffi ciency post glucocorticoid and cyclosporine treatment. A fulminant clinical course, and a clear medical history of immunocompromised state draw physician's attention to the possible opportunistic lung infection. PCP infection was confi rmed by a PCP deoxyribonucleic acid test. The symptoms improved markedly after appropriate antibiotics treatment. This report suggests that clinicians should consider PCP infection in patients who develop secondary pneumonia after paraquat intoxication. PCP treatment as part of empirical antibiotics should be added, especially in such patients presented with rapidly progressive course.

Exploring the influence of gender, seniority and specialty on paper and computer-based feedback provision during mini-CEX assessments in a busy emergency department.

The mini-clinical evaluation exercise (mini-CEX) is a well-established method of assessing trainees' clinical competence in the workplace. In order to improve the quality of clinical learning, factors that influence the provision of feedback are worthy of further investigation. A retrospective data analysis of documented feedback provided by assessors using the mini-CEX in a busy emergency department (ED) was conducted. The assessors comprised emergency physicians (EPs) and trauma surgeons. The trainees were all postgraduate year one (PGY1) residents. The completion rate and word count for each of three feedback components (positive feedback, suggestions for development, and an agreed action plan) were recorded. Other variables included observation time, feedback time, the format used (paper versus computer-based), the seniority of the assessor, the gender of the assessor and the specialty of the assessor. The components of feedback provided by the assessors and the influence of these contextual and demographic factors were also analyzed. During a 26-month study period, 1101 mini-CEX assessments (from 273 PGY1 residents and 67 assessors) were collected. The overall completion rate for the feedback components was 85.3 % (positive feedback), 54.8 % (suggestions for development), and 29.5 % (agreed action plan). In only 22.9 % of the total mini-CEX assessments were all three aspects of feedback completed, and 7.4 % contained no feedback. In the univariate analysis, the mini-CEX format, the seniority of the assessor and the specialty of the assessor were identified as influencing the completion of all three components of feedback. In the multivariate analysis, only the mini-CEX format and the seniority of the assessor were statistically significant. In a subgroup analysis, the feedback-facilitating effect of the computer-based format was uneven across junior and senior EPs. In addition, feedback provision showed a primacy effect: assessors tended to provide only the first or second feedback components in a busy ED setting. In summary, the authors explored the influence of gender, seniority and specialty on paper and computer-based feedback provision during mini-CEX assessments for PGY1 residency training in a busy ED. It was shown that junior assessors were more likely to provide all three aspects of written feedback in the mini-CEX than were senior assessors. The computer-based format facilitated the completion of feedback among EPs.

Predicting emergency departments visit rates from septicemia in Taiwan using an age-period-cohort model, 1998 to 2012.

The aim of this study was to determine the age-period-cohort (APC) effects on the rate of infection-related emergency department (ED) visits from septicemia for predicting the same in recent periods.In our study, we investigated the longitudinal trends in septicemia-related visit rates. Using an APC model to decompose the septicemia visit rates into the effects of age, time period, and cohort, and examine whether their effects varied by sex.The septicemia ED visit rate was classified as the International Classification of Disease Code 038 by primary and secondary diagnosis between 1998 and 2012.In both males and females, the visit rate of septicemia showed an increase from 2003 through 2012. An increase in septicemia visit rate after 2003 was observed in all age groups. An APC model indicated a reversal increasing period effect, which increased prominently from 2003 to 2012 in both males and females. The age effect showed an increasing trend. The cohort effect tended to show a slight oscillation from 1913 to 1988. With reference to the prediction of the logarithms of the age-specific 5-year visit rates, we observed that the younger cohorts exhibited a slightly increasing trend, as compared to the older cohorts.The period effect can explain the increase in septicemia visit rates, suggesting the role of screening for septicemia. Furthermore, it is well known that aging is a relevant risk variable for infectious diseases. The present study concludes that the aged population exhibited a strong increasing future trend for septicemia-related ED visit rates.

Impact of performance grading on annual numbers of acute myocardial infarction-associated emergency department visits in Taiwan: Results of segmented regression analysis.

To reduce patient boarding time at the emergency department (ED) and to improve the overall quality of the emergent care system in Taiwan, the Minister of Health and Welfare of Taiwan (MOHW) piloted the Grading Responsible Hospitals for Acute Care (GRHAC) audit program in 2007-2009.The aim of the study was to evaluate the impact of the GRHAC audit program on the identification and management of acute myocardial infarction (AMI)-associated ED visits by describing and comparing the incidence of AMI-associated ED visits before (2003-2007), during (2007-2009), and after (2009-2012) the initial audit program implementation.Using aggregated data from the MOHW of Taiwan, we estimated the annual incidence of AMI-associated ED visits by Poisson regression models. We used segmented regression techniques to evaluate differences in the annual rates and in the year-to-year changes in AMI-associated ED visits between 2003 and 2012. Medical comorbidities such as diabetes mellitus, hyperlipidemia, and hypertensive disease were considered as potential confounders.Overall, the number of AMI-associated patient visits increased from 8130 visits in 2003 to 12,695 visits in 2012 (P-value for trend < 0.001), corresponding to an average annual growth rate of 5.3% (95%confidence interval [CI]: 0.5-10%). Although age was a major risk factor for AMI-associated ED visits, the statistical association was observed in middle-to-old (aged 40-64; P-value < 0.001) and older aged individuals (aged ≥65; P-value <0.001). As compared to 2003-2007, AMI-associated ED visits increased slightly during the intervention roll-in period (2007-2009, slope = 394.5, P-value = 0.117) followed by a dramatic uptake in the early post-intervention period (2010-2012, slope = 1037, P-value = 0.083).There was evidence suggesting for a significant intervention effect of the GRHAC program on identifying critically ill patients with AMI-associated diagnosis at the ED. As the program evaluation is still ongoing, we expect to observe a sustained program effect on hospitals' capacity for timely and correctly diagnosing and managing patients presenting with AMI-associated symptoms or signs at the ED.

Predictive factors for hospitalization of nonurgent patients in the emergency department.

Nonurgent emergency department (ED) patients are a controversial issue in the era of ED overcrowding. However, a substantial number of post-ED hospitalizations were found, which prompted for investigation and strategy management. The objective of this study is to identify risk factors for predicting the subsequent hospitalization of nonurgent emergency patients. This was a retrospective study of a database of adult nontrauma ED visits in a medical center for a period of 12 months from January 2013 to December 2013. Patient triages as either Taiwan Triage and Acuity Scale (TTAS) level 4 or 5 were considered "nonurgent." Basic demographic data, primary and secondary diagnoses, clinical parameters including blood pressure, heart rate, body temperature, and chief complaint category in TTAS were analyzed to determine if correlation exists between potential predictors and hospitalization in nonurgent patients.A total of 16,499 nonurgent patients were included for study. The overall hospitalization rate was 12.47 % (2058/16,499). In the multiple logistic regression model, patients with characteristics of males (odds ratio, OR = 1.37), age more than 65 years old (OR = 1.56), arrival by ambulance (OR = 2.40), heart rate more than 100/min (OR = 1.47), fever (OR = 2.73), and presented with skin swelling/redness (OR = 4.64) were predictors for hospitalization. The area under receiver-operator calibration curve (AUROC) for the prediction model was 0.70. Nonurgent patients might still be admitted for further care especially in male, the elderly, with more secondary diagnoses, abnormal vital signs, and presented with dermatologic complaints. Using the TTAS acuity level to identify patients for diversion away from the ED is unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.

All Components of Metabolic Syndrome Are Associated with Microalbuminuria in a Chinese Population.

BACKGROUND AND AIM: Albuminuria is a well-known predictor of poor renal and cardiovascular outcomes and associated with increased risk of all-cause mortality. The study aimed to evaluate the associations between metabolic characteristics and the presence of albuminuria. METHODS: This cross-sectional study included 18,384 adult Chinese who participated in health examinations during 2013-2014. Differences in clinical characteristics were compared for microalbuminuria (MAU) and albuminuria, and between genders. Potential risk factors associated with the risk of developing MAU and albuminuria were analyzed using univariate logistic regression. Multiple logistic regression was applied to further identify the independent associations between different levels of risk factors and the presence of MAU and albuminuria. The area under the ROC curve (AUC) was used to determine the discriminatory ability of metabolic risk factors in detecting albuminuria. RESULTS: There were significant gender differences in clinical characteristics according to albuminuria status. Risk for the presence of albuminuria was significantly associated with age, male gender, waist circumference (WC), waist-to-height ratio (WHtR), hypertension, fasting plasma glucose (FPG), and triglycerides to high-density lipoprotein cholesterol ratio (TG/HDL-C) in univariate logistic regression. Multiple logistic regression analysis indicated that the factors significantly associated with the presence of MAU were WC > 90cm, WHtR at 0.6-0.7, hypertension, FPG > 6.1 mmole/L, and TG/HDL-C ratio > 1.6. The optimal cutoffs for risk factors of metabolic syndrome (MetS) to predict albuminuria in males and females were: WC, 90.8 vs. 80.0 cm; WHtR, 0.53 vs. 0.52; MAP, 97.9 vs. 91.9 mmHg; FPG, 5.40 vs. 5.28 mmole/L; and TG/HDL-C, 1.13 vs. 1.08. CONCLUSION: MetS and all its components were associated with the presence of MAU in a health check-up population in China. Gender specific and optimal cutoffs for MetS components associated with the presence of MAU were determined.

Factors associated with ED length of stay during a mass casualty incident.

BACKGROUND: The aim of this study was to examine the factors associated with emergency department (ED) length of stay (LOS) using the patient registry data from a medical burns center during a burn injury mass casualty incident (MCI) after a dust explosion in New Taipei City, Taiwan. METHODS: This was a retrospective cohort study conducted at an urban, tertiary care teaching hospital during an MCI event that occurred on June 27, 2015. A celebratory party was held at the Formosa Fun Water Park in New Taipei City, Taiwan. At 20:32, the was an explosion caused by an overheated spotlight accidentally igniting colored cornstarch powder that had been sprayed on the stage. Factors associated with ED LOS were compared. RESULTS: In total, 48 burn injury patients were enrolled for study analysis. The median total body surface area of second- to third-degree burns was 35.0% (interquartile range [IQR], 15.8%-55.0%). The median ED LOS was 121.5 minutes (IQR, 38.3-209.8 minutes). The output time interval accounted for the longest interval with a median time of 56.0 minutes (IQR, 15.3-117.3 minutes). In multivariate analysis of the variables, triage level (level III; hazard ratio, 0.06; 95% confidence interval, 0.01-0.52) and output time (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98) were significant influential factors. CONCLUSIONS: The triage level and output time intervals were significantly associated with ED LOS in a burn-related MCI. Time effectiveness analyses, using a patient flow model, might serve as an important indicator during a hospital MCI response.

Rescuer factors predict high-quality CPR--a manikin-based study of health care providers.

BACKGROUND: In the provision of high-quality cardiopulmonary resuscitation (CPR) by health care providers, factors associated with high-quality CPR should be explored. METHODS: This is a post hoc analysis using data from a manikin-based survey of CPR quality among volunteer emergency medical technicians (EMTs) from 2 county fire departments in northern Taiwan. RESULTS: Among the 95 enrolled EMTs, 36 (37.9%) performed high-quality CPR on a manikin. The baseline characteristics that differed significantly between groups were board-certified EMT levels (P = .010), body mass index (BMI, P = .029), average exercise frequency (P = .001), and average exercise duration (P = .005). Average total exercise time per week, which uses frequency times exercise duration, was independently associated with high-quality CPR performance after adjusting for variables via logistic regression analysis (odds ratio, 1.004; P = .044). An index was developed (BMI × ExeTime) based on the product of BMI and average total exercise time per week. A comparison of the area under curve for the different indices showed that BMI × ExeTime was a significant predictor of high-quality CPR, with an area under curve of 0.718 (95% confidence interval, 0.613-0.824; P < .001; Fig. 2) and a cutoff value of 4136.7 kg·min/m(2) (sensitivity, 0.722; specificity, 0.678). CONCLUSIONS: This study identified factors associated with the performance by health care providers of high-quality CPR, including BMI and exercise habits. To optimize CPR quality, a program of exercise frequency and duration adjusted according to individual's BMI should be considered in such populations.

Excessive adiposity, metabolic health, and risks for genital human papillomavirus infection in adult women: a population-based cross-sectional study.

BACKGROUND: The role of excessive adiposity or its metabolic consequences in persistent HPV infection among general adult women remains unknown. METHODS: Using data from the National Health and Nutrition Examination Survey (NHANES) in 2003-2010, we compared adult women's likelihood for any- or high-risk (HR) type HPV infection by degrees of excessive adiposity and metabolic health status. RESULTS: Any-type (41.1 % vs. 44.9 %, P = 0.045) or HR-type HPV prevalence (21.9 % vs. 25.4 %, P = 0.055) was comparable in women aged 20-59 years with or without central obesity. After adjusting for age, socioeconomic indicators, and lifetime sexual risks, centrally-obese women barely showed a different likelihood for any-type (aPR [adjusted prevalence ratio] = 0.91, P = 0.03) or HR-HPV infection (aPR = 0.92, P = 0.279). However, obesity (aPR = 0.76, P = 0.017) or centrally-obesity (aPR = 0.72, P = 0.003) was negatively correlated with HR-HPV infection in women reporting an early sex debut (<16 years; P for interaction <0.05). In the fasting subpopulation, obesity (aPR = 0.77, P = 0.016) or metabolically unhealthy obesity (aPR = 0.69, P = 0.018) was significantly correlated with a 23 % or 31 % reduced prevalence of HR-HPV infection. DISCUSSION: In contrary to findings for the general population, HR-HPV prevalence was decreased in a subgroup of women with obesity or central obesity. Possible explanations for such heterogeneity included less risky sexual behaviors, an altered immune milieu that promoted viral clearance, and increased access to healthcare resources due to other obesity-related co-morbidities in this subpopulation. CONCLUSIONS: Obesity or central obesity was not significantly associated with prevalent any-type or HR-type HPV infection among adult women in general. However, in certain subpopulations, excessive adiposity or its relevant metabolic dysfunction was negatively associated with HR-HPV infection.

Outcomes of an emergency department intensive care unit in a tertiary medical center in Taiwan: An observational study.

PURPOSE: The boarding of critically ill patients in the emergency department (ED) could reduce quality of care and increase mortality. An ED intensive care unit (ICU) was set up in a 3715-bed medical center to facilitate timely delivery of critical care. This study reports comparative outcomes of EDICU patients with specialty ICU patients. MATERIALS AND METHODS: Medical records of adult nontrauma ED patients admitted to nonsurgical ICUs (EDICU, medical, cardiac, alimentary, and neurological units) between January 2007 and July 2011 were retrospectively reviewed. The respective number of admissions, bed turnover rate, and length of stay were compared. Cox regression models were also applied to compare inhospital mortality risks among these patients. RESULTS: With only 13% (14/108) of all ICU beds, EDICU admitted 36% (3711/10449) of patients. Emergency department ICU patients had an unfavorable adjusted hazard ratio for inhospital mortality compared with medical ICU and cardiac ICU patients, but after excluding patients with an ICU length of stay of 2 days or less, the difference in hazard ratio became nonsignificant. CONCLUSIONS: Emergency department ICU has admitted a disproportionately higher proportion of patients without sacrificing quality of care. Specialty care could be secured through direct communication between EDICU and specialty physicians and forming close collaboration between departments and ICUs.

Pediatric overtriage as a consequence of the tachycardia responses of children upon ED admission.

BACKGROUND: Overtriage has been observed among pediatric patients in emergency departments (EDs) under 5-level acuity pediatric triage systems. This study aimed to investigate the causes of overtriage and to provide suggestions for future amendments to such systems. METHODS: This study has a retrospective follow-up design in which 42000 pediatric patients who were admitted to the ED of the largest medical center in Taiwan between January and December of 2010 were recruited. The study variables included patient demographics, chief concerns, individual vital signs (ie, blood pressure, heart rate, body temperature, respiratory rate, and O2 saturation), triage level, ED final disposition, ED expenses, and total medical expenses. A logistic regression model was applied to explore the causes of overtriage and the effectiveness of a modified acuity system. RESULTS: Approximately 13.6% of the pediatric ED visits were upgraded to acuity level 1 based on vital signs that included heart rate (97.3%). The strength of the trend association (odds ratio) between decreasing acuity urgency (from levels 1 to 5) and hospitalization increased from 0.73 (95% confidence interval, 0.72-0.75) with the Pediatric Triage and Acuity System (Ped-TTAS) to 0.57 (95% confidence interval, 0.55-0.59) with the modified Ped-TTAS, which downgraded acuity levels by excluding the weighting of vital signs. Further validation was accomplished by comparing the trend association between decreasing acuity urgency and total medical expenses (Ped-TTAS: ß = -0.13; modified Ped-TTAS: ß = -0.18). CONCLUSIONS: Heart rate is prone to be affected by emotional responses among pediatric patients in certain specific age groups. Appropriate revisions of the pediatric triage system are suggested.

Rate of ascent and acute mountain sickness at high altitude.

OBJECTIVE: To examine the effect of ascent rate on the induction of acute mountain sickness (AMS) in young adults during a climb to Jiaming Lake (3350 m) in Taiwan. DESIGN: Prospective, nonrandomized. SETTING: Climb from 2370 to 3350 m. PARTICIPANTS: Young adults (aged 18 to 26 years) (N = 91) chose to participate in either the fast ascent (3 days; n = 43) or slow ascent (4 days; n = 48) group (1 and 2). ASSESSMENT OF RISK FACTORS: Two criteria were used to define AMS. A Lake Louise score ≥3 and Lake Louise criteria [in the setting of a recent gain in altitude, the presence of headache and at least 1 of gastrointestinal discomfort (anorexia, nausea, or vomiting), fatigue or weakness, dizziness or lightheadedness, or difficulty sleeping]. MAIN OUTCOME MEASURES: Heart rate, blood oxygen saturation (SaO2), and symptoms of AMS were monitored each morning and evening. RESULTS: Baseline characteristics were similar between groups, except for significant differences in history of alcohol consumption (P = 0.009) and climbing experience above 3000 m (P < 0.001). The incidence of AMS was not associated with the rate of ascent. Acute mountain sickness was most prevalent in group 1 on day 2 in the evening and in group 2 on day 3 in the evening. In both groups, AMS correlated with the initial reduction in SaO2. Body mass index (BMI) >24 kg/m was identified as a significant risk factor for AMS. CONCLUSIONS: The development of AMS was closely associated with an initial reduction in SaO2. A BMI >24 kg/m also contributed to the occurrence of AMS. CLINICAL RELEVANCE: These findings indicate that factors other than ascent rate should be considered when trying to ameliorate the risk of AMS.