Changes in Emergency Department Case Severity and Length of Stay before and after COVID-19 Outbreak in Korea.

Severe patients visited regional emergency centers more frequently during the COVID-19 period, and disposition status warranting admission to the intensive care unit or resulting in death was more common during the COVID-19 period. This study was conducted to compare the characteristics and severity of patients, and emergency department length of stay before and after the COVID-19 outbreak. Subjects were 75,409 patients who visited the regional emergency medical center from 1 February 2019 to 19 January 2020 and from 1 February 2020 to 19 January 2021. Data was analyzed using the SPSS/WIN 22.0 program. The significance level was p < 0.05. The chi-square test and t-test were used for variables, and Cramer V was used for correlation. We found that the total number of patients visiting the emergency room decreased by 37.6% after COVID-19, but emergency department length of stay among severely ill patients increased by 203.7%. Additionally, the utilization rate of 119 ambulances and relatively more severe patients increased by 9.0% and by 2.1%. More studies about emergency department designs and operational programs should be conducted for better action not only during regular periods but also during periods of pandemic.

Analysis of Disaster Medical Response: The Sejong Hospital Fire.

This paper provides a field report on a fire that broke out on January 26, 2018 at Sejong Hospital in Miryang, South Korea, engendering the establishment of a committee to investigate the hospital fire response. This field report analyzes the disaster medical response. The official records of the disaster response from each institution were examined. On-site surveys were conducted through interviews with government officials and other health care workers regarding communication during the disaster response without using a separate questionnaire. All medical records were abstracted from hospital charts. There were 192 casualties: 47 victims died, seven were seriously injured, and 121 suffered minor injuries. Emergency Medical Services (EMS) arrived three minutes after the fire started, while news of the fire reached the National Emergency Medicine Operation Center based in Seoul in 12 minutes. The first disaster medical assistance team (DMAT) was dispatched 63 minutes after the National Emergency Medicine Operation Center was notified. The disaster response was generally conducted in accordance with disaster medical support manuals; however, these response manuals need to be improved. Close cooperation among various institutions, including nearby community public health centers, hospitals, fire departments, and DMATs, is necessary. The response manuals should be revised for back-up institutions, as the relevant information is currently incomplete.

A study on the disaster medical response during the Mauna Ocean Resort gymnasium collapse.

OBJECTIVE: To investigate and document the disaster medical response during the Gyeongju Mauna Ocean Resort gymnasium collapse on February 17, 2014. METHODS: Official records of each institution were verified to select the study population. All the medical records and emergency medical service run sheets were reviewed by an emergency physician. Personal or telephonic interviews were conducted, without a separate questionnaire, if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. RESULTS: One hundred fifty-five accident victims treated at 12 hospitals, mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of collapse was disseminated in 4 minutes, dispatch of 4 disaster medical assistance teams took at least 69 minutes to take the decision of dispatch. Four point five percent were treated at the accident site, 56.7% were transferred to 2 hospitals that were nearest to the collapse site, and 42.6% were transferred to hospitals that were poorly prepared to handle disaster victims. CONCLUSION: In the Gyeongju Mauna Ocean Resort gymnasium collapse, the initial triage and distribution of patients was inefficient and medical assistance arrived late. These problems had also been noted in prior mass casualty incidents.

Red cell distribution width and early mortality in elderly patients with severe sepsis and septic shock.

OBJECTIVE: To investigate the association of red cell distribution width (RDW) with 30-day mortality in elderly patients with severe sepsis and septic shock. METHODS: Patients were recruited from a single tertiary emergency department. Patients with age over 65 years were selected. The main outcome was 30-day mortality. Potential confounders as Acute Physiologic and Chronic Health Evaluation (APACHE) II score and Sequential Organ Failure Assessment (SOFA) score along with initial vital signs were collected. Multivariate Cox proportional hazards analysis was performed to identify independent predictors of 30-day mortality. The discriminative ability of RDW for 30-day mortality was evaluated using receiver operating characteristic curve analysis. RESULTS: Overall, 458 patients were included. Univariate analysis showed that patients' survival was significantly associated with sites of infection, comorbidities, and severity scores. In the multivariate Cox proportional hazard model, the RDW was an independent predictor of 30-day mortality (hazards ratio, 1.10; 95% confidence interval, 1.04 to 1.17; P<0.001). CONCLUSION: In this study, initial RDW values were significantly associated with 30-day mortality in older patients hospitalized with severe sepsis and septic shock.

The relationship between hypophosphataemia and outcomes during low-intensity and high-intensity continuous renal replacement therapy.

AIM: To identify risk factors for development of hypophosphataemia in patients treated with two different intensities of continuous renal replacement therapy (CRRT) and to assess the independent association of hypophosphataemia with major clinical outcomes. MATERIALS AND METHODS: We performed secondary analysis of data collected from 1441 patients during a large, multicentre randomised controlled trial of CRRT intensity. We allocated patients to two different intensities of CRRT (25mL/kg/hour vs 40 mL/kg/hour of effluent generation) and obtained daily measurement of serum phosphate levels. RESULTS: We obtained 14 115 phosphate measurements and identified 462 patients (32.1%) with hypophosphataemia, with peak incidence on Day 2 and Day 3. With lower intensity CRRT, there were 58 episodes of hypophosphataemia/1000 patient days, compared with 112 episodes/1000 patient days with higher intensity CRRT (P < 0.001). On multivariable logistic regression analysis, higher intensity CRRT, female sex, higher Acute Physiology and Chronic Health Evaluation score and hypokalaemia were independently associated with an increased odds ratio (OR) for hypophosphataemia. On multivariable models, hypophosphataemia was associated with better clinical outcomes, but when analysis was confined to patients alive at 96 hours, hypophosphataemia was not independently associated with clinical outcomes. CONCLUSIONS: Hypophosphataemia is common during CRRT and its incidence increases with greater CRRT intensity. Hypophosphataemia is not a robust independent predictor of mortality. Its greater incidence in the higher intensity CRRT arm of the Randomised Evaluation of Normal vs Augmented Level trial does not explain the lack of improved outcomes with such treatment.

A comparison of the Niagara and Medcomp catheters for continuous renal replacement therapy.

PURPOSE: The choice of vascular access catheter may affect filter life during continuous renal replacement therapy (CRRT). In particular, differences in catheter design might affect the incidence of circuit clotting related to catheter malfunction. DESIGN AND SETTING: Sequential controlled study in a tertiary, adult intensive care unit (ICU). AIM: To compare circuit life when CRRT was performed with a Niagara catheter or a Medcomp catheter. PATIENTS AND MEASUREMENTS: We studied 46 patients with acute kidney injury requiring CRRT, all delivered with catheters in the femoral position. We obtained information on age, gender, disease severity score [acute physiology and chronic health evaluation (APACHE II) and APACHE III], filter life, heparin dose per hour, daily systemic hemoglobin concentration, platelet count, international normalized ratio (INR), and activated partial thromboplastin time (APTT) during CRRT. RESULTS: We studied 254 circuits in 46 patients. Of these, 26 patients (140 circuits) used the Niagara catheter and 20 patients (114 circuits) used the Medcomp catheter. Median circuit life in the two groups were 11 h and 7.3 h, respectively (p < 0.01). Patients using Medcomp catheters had a lower platelet count (p = 0.04) and a lower hemoglobin concentration (p = 0.01), but INR (p = 0.16), APTT (p = 0.46), anticoagulant treatment (p = 0.89), and heparin dose per hour (p = 0.24) were similar. After correcting for confounding variables by multivariable linear regression analysis, it was found that the choice of catheter is not an independent predictor of circuit life. On Kaplan-Meier survival analysis, circuit life was not significantly different between the two catheters (p = 0.87). CONCLUSION: The choice of either the Niagara or Medcomp catheter does not appear to be a significant independent determinant of circuit life during CRRT.

Bubble chamber clotting during continuous renal replacement therapy: vertical versus horizontal blood flow entry.

BACKGROUND: The continuous renal replacement therapy (CRRT) bubble trap chamber is a frequent site of clotting. AIMS: To assess clot formation when comparing our standard 'vertical' blood entry chamber (BEC) with a new 'horizontal' BEC. METHODS: Adult ICU patients requiring CRRT were treated with the vertical BEC and then a similar subsequent cohort with the horizontal BEC in continuous veno-venous haemofiltration mode. RESULTS: 40 chambers were assessed for each design. Circuit life was 13.9 ± 9.5 h for the vertical and 17.7 ± 15.9 h for the horizontal BEC (p = 0.33). APTT, however, was higher for the horizontal BEC (55.7 ± 34.7 vs. 37.4 ± 9.0, p < 0.002) and no difference in circuit life was found after multivariable analysis. A clotting score ≥3 was observed in 85% of all chambers. There was no difference in chamber clotting score (vertical 3.6 ± 1.03 vs. horizontal 3.8 ± 1.0, p = 0.5). In addition, no difference was found when scores were divided into two groups using a 'likelihood' to clot analysis (p = 1.0). CONCLUSION: CRRT horizontal BEC were not associated with less clotting compared to our standard vertical BEC.

A comparison of the Niagara™ and Dolphin® catheters for continuous renal replacement therapy.

PURPOSE: The choice of vascular access catheter may affect filter life during continuous renal replacement therapy (CRRT); specifically, a new surface-modified catheter has been reported to possibly prevent thrombosis and catheter malfunction. DESIGN AND SETTING: A sequential, controlled study in a tertiary ICU. AIMS: To compare circuit life when CRRT was performed with a Bard®Niagara™ catheter or the surface-modified GamCath™ Dolphin® Protect 1320 catheter. PATIENTS AND MEASUREMENTS: We studied 50 patients with acute kidney injury requiring CRRT, all delivered with catheters in the femoral position. We obtained information on age, gender, disease severity score (APACHE II and APACHE III), filter life, total heparin dose, hemoglobin concentration, platelet count, INR, and aPTT during CRRT. RESULTS: We studied 341 circuits in 50 patients; 30 patients (140 circuits) used the Niagara and 20 patients (201 circuits) used the Dolphin catheter. Mean of circuit life in two groups was 14.9 hours and 13.1 hours, respectively (p=0.22). Patients using Niagara catheters had a more prolonged APTT (p<0.01) and lower platelet count (p=0.05), while heparin dose (p=0.22), and other anticoagulant treatment (p=0.73) were not significantly different. On Kaplan-Meier survival analysis, circuit life was not significant different between the two catheters (p=0.15). CONCLUSIONS: The Niagara and Dolphin catheters appear to be broadly equivalent in terms of their impact on circuit life.

Ionized calcium concentration and outcome in critical illness.

OBJECTIVE: To assess the association of abnormalities of ionized calcium levels with mortality in a heterogeneous cohort of critically ill patients. DESIGN: Retrospective, combined clinical and biochemical study. SETTING: Four combined medical/surgical intensive care units. PATIENTS: Cohort of 7,024 adult critically ill patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied 177,578 ionized calcium measurements, from 7024 patients, with a mean value of 1.11 mmol/L (ionized calcium measured every 4.5 hrs on average). The unadjusted lowest and highest ionized calcium reported during intensive care unit stay were significantly different between intensive care unit survivors and nonsurvivors (p < .001). If hypocalcemia occurred at least once during the intensive care unit stay, the probability of intensive care unit mortality increased by 46%, 108%, and 150% for ionized calcium levels <1.15, 0.90, and 0.80 mmol/L, respectively. If hypercalcemia occurred at least once during the intensive care unit stay, the probability of intensive care unit mortality increased by 100%, 162%, and 190% for ionized calcium levels >1.25, 1.35, and 1.45 mmol/L, respectively. Similar trends were seen for hospital mortality. However, from multivariate logistic regression analysis, only an ionized calcium <0.8 mmol/L or an ionized calcium >1.4 mmol/L were independently associated with intensive care unit and hospital mortality. CONCLUSIONS: Within a broad range of values, ionized calcium concentration has no independent association with hospital or intensive care unit mortality. Only extreme abnormalities of ionized calcium concentrations are independent predictors of mortality.