Design and evaluation of collaborative decision-making application for patient care in the emergency department.

Background and Aims: Collaboration has become a crucial element of effective healthcare delivery in the emergency department (ED). In high-pressure environments, healthcare providers can prioritize patients by consulting with other specialists to gain diverse perspectives and arrive at a shared understanding of the best course of action. It was conducted for the purpose of designing and evaluating the collaborative decision-making application for patient care in the ED. Methods: The present applied research study was conducted between April 1, 2021 and May 31, 2023 at Imam Reza Hospital of Tabriz University of Medical Sciences. The study was conducted in three phases: exploration, development, and evaluation, utilizing modern technologies such as Flutter and Node.js to design and program the application. The effectiveness of the system was evaluated using established measures, including the think-aloud protocol, user experience questionnaire, and Likert-scale questionnaires developed by Ghadri et al. Results: The average scale for attractiveness was 2.03, perspicuity was 2.90, efficiency was 2.40, dependability was 1.93, stimulation was 2.48, and novelty was 2.78. Additionally, 71% of physicians gave a very good rating to the accessibility of necessary information at any time, motivation to use the system for accessing information, usefulness of the system compared to the time spent using it throughout the day. Furthermore, 57% of physicians gave a very positive rating to sharing information and knowledge, ease of using the search function and accessing the system, user control and monitoring, free access to the system, and support from colleagues and system users. Conclusion: The study suggests that introducing Information and Communication Technology such as medical apps can improve healthcare delivery by streamlining patient care, promoting effective teamwork, and reducing medical errors and treatment delays.

The Accuracy of Rapid Emergency Medicine Score in Predicting Mortality in Non-Surgical Patients: A Systematic Review and Meta-Analysis.

Background: Emergency department (ED) physicians often need to quickly assess patients and determine vital signs to prioritize them by the severity of their condition and make optimal treatment decisions. Effective triage requires optimal scoring systems to accelerate and positively influence the treatment of trauma cases. To this end, a variety of scoring systems have been developed to enable rapid assessment of ED patients. The present systematic review and meta-analysis aimed to investigate the accuracy of the rapid emergency medicine score (REMS) system in predicting the mortality rate in non-surgical ED patients. Methods: A systematic search of articles published between 1990 and 2020 was conducted using various scientific databases (Medline, Embase, Scopus, Web of Science, ProQuest, Cochrane Library, IranDOC, Magiran, and Scientific Information Database). Both cross-sectional and cohort studies assessing the REMS system to predict mortality in ED settings were considered. Two reviewers appraised the selected articles independently using the National Institutes of Health (NIH) quality assessment tool. The random-effects model was used for meta-analysis. I2 index and Q statistic were used to examine heterogeneity between the articles. Results: The search resulted in 1,310 hits from which, 29 articles were eventually selected. Out of these, for 25 articles, the area under the curve value of REMS ranged from 0.52 to 0.986. The predictive power of REMS for the in-hospital mortality rate was high in 19 articles (67.85%) and low in nine articles (32.15%). Conclusion: The results showed that the REMS system is an effective tool to predict mortality in non-surgical patients presented to the ED. However, further evidence using high-quality design studies is required to substantiate our findings.

Complete Blood Count Parameters as Prognostic Factor of Stroke: A Systematic Review.

Introduction: Stroke is known as a common cause of disability all over the world. Stroke prognosis estimation has always been a topic of interest. In this study, it was tried to investigate the prognostic value of laboratory findings of complete blood count in a systematic review. Methods: In this systematic review, literature from Medline via (PubMed, Ovid) Embase, Scopus, Cochrane Library, and ProQuest between 1988 and 2020 were included. A combination of Mesh and free terms were included in the search strategy: "Stroke", "Red Cell Distribution Width", "Blood Cell Count", "Mean corpuscular hemoglobin", and "Mean Corpuscular Volume" and with the abbreviation, in all fields. Data synthesis was achieved using content analysis. Results: Elevated red blood cell distribution width was associated with stroke, cardiovascular events, and all-cause deaths among patients with prior stroke. Mean platelet volume has not any prognostic significance in ischemic stroke. There was a poor association between mean corpuscular volume (MCV) and stroke prognosis. Globulin and hemoglobin level predicted short-term mortality following acute ischemic stroke. Conclusion: Complete blood count as a routine and efficient test performed in health care centers can be used to estimate the prognosis of stroke.

Neurological manifestations of COVID-19 infection: an umbrella review.

BACKGROUND: Neurological involvements of COVID-19 are one of the most reported manifestations of this infection. This study aims to systematically review the previous systematic reviews which addressed the neurological manifestations of the COVID-19 infection. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a comprehensive search was conducted in PubMed, Embase, Scopus, Web of Science databases and Google Scholar from December 2019 to December 2020. Articles were critically screened by two independent reviewers and if met the inclusion criteria, entered the study. Assessment of methodological quality was conducted by Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool. Statistical analysis was not applicable. From a total of 1302 studies, 308 studies were removed due to their irrelevant title and abstract. After screening the full texts, a total of 66 found to be eligible. Twenty-one studies reported general manifestations of the COVID-19, 13 studies reported cerebrovascular events, 19 olfactory and oral dysfunctions, 5 systematic reviews on Guillen-Barré syndrome (GBS) and 8 articles on the sporadic manifestations like ocular signs and symptoms. The majority of the studies were classified as critically low or low in terms of quality. CONCLUSION: Despite great heterogeneity in the current literature, neurological involvements are an important extra-pulmonary aspect of the COVID-19; most commonly in the form of general manifestations like headache and olfactory disturbances. Long-term effects of this virus on the nervous system must be a research priority for future references. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41983-021-00366-5.

A Comparative Study of the Registry System effect on Patients Satisfaction Rate in Two Emergency Department Settings.

OBJECTIVE: To assess the patient's satisfaction rate during two distinct registry procedures in the emergency department. METHODS: A cross-sectional study was conducted in educational hospitals with a high volume of patient's admission in Tabriz-Iran and Erzurum-Turkey. In this study, we used a Press Ganey questionnaire as a data collection tool that was filled out with patients or their companions before discharging or referred to other areas (wards). Finally, data were analyzed by using SPSS software version 16. RESULTS: The included patients were from three-admission time courses includes morning, evening, and night shifts. The present study results indicated that the total satisfaction score was two scores higher than the classic one (p<0.001) in the model registry system. Furthermore, the findings of the current study interestingly showed a correlation between satisfaction rate and education level as well as patient's location. Thus, patients with moderate education levels had a higher satisfaction rate in urban regions when compared with rural regions and higher/lower education levels (p=0.03). CONCLUSION: Patients' satisfaction rate with multiple variables can be improved by designing an appropriate registry procedure.

An intelligent system for improving adherence to guidelines on acute stroke.

OBJECTIVES: A timely, accurate assessment and decision-making process is essential for the diagnosis and treatment of the acute stroke, which is the world's third leading cause of death. This process is often performed using the traditional method that increases the complexity, duration, and medical errors. The present study aimed to design and evaluate an intelligent system for improving adherence to the guidelines on the assessment and treatment of acute stroke patients. METHODS: Decision-making rules and data elements were used to predict the severity and to treat patients according to the specialists' opinions and guidelines. A system was then developed based on the intelligent decision-making algorithms. The system was finally evaluated by measuring the accuracy, sensitivity, specificity, applicability, performance, esthetics, information quality, and completeness and rates of medical errors. The segmented regression model was used to evaluate the effect of systems on the level and the trend of guideline adherence for the assessment and treatment of acute stroke. RESULTS: Fifty-three data elements were identified and used in the data collection and comprehensive decision-making rules. The rules were organized in a decision tree. In our analysis, 150 patients were included. The system accuracy was 98.30%. Evaluation results indicated an error rate of 1.69% by traditional methods. Documentation quality (completeness) increased from 78.66% to 100%. The average score of system quality was 4.60 indicating an acceptable range. After the system intervention, the mean of the adherence to the guideline significantly increased from 65% to 99.5% (P < 0.0008). CONCLUSION: The designed system was accurate and can improve adherence to the guideline for the severity assessment and the determination of a therapeutic trend for acute stroke patients. It leads to physicians' empowerment, significantly reduces medical errors, and improves the documentation quality.

Severe complications of tramadol overdose in Iran.

OBJECTIVES: Severe complications of tramadol overdose have been reported; however, few large-scale studies have investigated this issue. Therefore, this study aimed to explore the presentation and complications of tramadol overdose in patients admitted to an intoxication referral center in northwestern Iran. METHODS: Patients with tramadol overdose admitted to Sina Teaching Hospital in Tabriz, Iran during 2013-2017 were included. For each patient, the following data were collected: demographics, previous drug or medication overdose, whether the patient was in the process of quitting drug use, ingested dose of tramadol and co-ingestants, Glasgow Coma Scale (GCS) score, clinical symptoms at the time of admission, and admission characteristics. Serotonin toxicity was diagnosed in patients who fit the Hunter criteria. Multiple logistic regression was performed to identify variables associated with the incidence of severe complications of tramadol overdose. RESULTS: In total, 512 cases of tramadol overdose were evaluated, of which 359 patients were included, with a median age of 41 years (range, 16-69) and a median tramadol dose of 1,500 mg (range, 500-4,000). The most frequent complications associated with tramadol overdose were hypertension (38.4%), tachycardia (24.8%), and seizure (14.5%). No serotonin toxicity was detected in patients. Having a GCS score <15, having taken a tramadol dose of >1,000 mg, being in the process of quitting drug use, being 30-49 years old, and male sex were significantly related to the incidence of severe complications of tramadol overdose. CONCLUSIONS: Although seizure was prevalent among Iranian patients with tramadol poisoning, serotonin toxicity and cardiogenic shock were rare findings.

National emergency X-radiography utilization study guidelines versus Canadian C-Spine guidelines on trauma patients, a prospective analytical study.

INTRODUCTION: The most common cause of hospital emergency department visits is trauma resulting from a variety of underlying mechanisms. Unknown neck and spinal cord injuries and a lack of early diagnosis can have catastrophic consequences, such as paralysis of some or all limbs. The use of imaging techniques reduces the number of patients suffering from severe injuries. OBJECTIVE: To assess and compare the effectiveness and ease of utilizing two different sets of guidelines, the National Emergency X-Radiography Utilization Study guidelines (NEXUS) and the Canadian C-Spine guidelines (CCR), on trauma patients. METHODS: This study was approved by the Ethics Committee of Tabriz University of Medical Sciences. Of all the patients presenting to the hospital, 200 trauma patients were randomly included in the study. NEXUS and CCR were surveyed for each patient, and subsequent radiographies were also requested. The specificity and sensitivity of each of the methods was calculated, and the two methods were compared using Kendall's W test. RESULTS: A total of 200 trauma patients who met the inclusion criteria were included in the study. A total of 69.5% of the patients were male, and 30.5% were female. According to NEXUS guidelines, 47.5% of the patients were required to undergo neck radiography. According to CCR guidelines, 57.5% of the patients were required to undergo neck radiography. The sensitivity was found to be 90% for neck radiography by both NEXUS and CCR guidelines, while specificities were found to be 54.73% and 44.2% for NEXUS and CCR guidelines, respectively. CONCLUSION: This study showed that the two guidelines have the same sensitivity for evaluating which trauma patients need to undergo radiography. It seems that the NEXUS guidelines have the same effectiveness as CCR for determining which trauma patients need to undergo radiography. They also perform better than CCR guidelines in terms of ruling out which cases need no further radiologic investigation.

Association Between the Subtypes of Stroke and the Various Risk Factors of Cerebrovascular Accidents: A Cross-Sectional Study.

OBJECTIVE: Stroke is a common heterogeneous disease classified into two subtypes: ischemic and hemorrhagic. Many risk factors have been associated with stroke, and the most well-known is hypertension. Although the relation between stroke and these risk factors has been emphasized before, there is inconclusive evidence about the relation between the different risk factors and the subtypes of stroke. The present study aims to fill this gap. MATERIALS AND METHODS: In the present retrospective, cross-sectional study, 827 patients with diagnosed stroke were included. Demographic data and the acquired risk factors were determined using pre-designed questionnaires. Statistical analysis was conducted using chi-square test, Student t-test, and Pearson correlation coefficient. RESULTS: Among the included 827 patients, 432 (52.2%) were men and 395 (47.8%) were women. The mean±standard deviation of age was 68.41±12.46 y in men and 67.89±11.85 y in women, respectively, and the difference was not significant. Of all the patients, 672 had ischemic strokes and 155 had hemorrhagic strokes. The most common risk factor in the patients was hypertension with a prevalence of 66.7%. Of all the risk factors, only hypertension, atrial fibrillation (AF), age, and a positive family history were significantly related to a subtype of stroke. CONCLUSION: Knowing that the prevalence of hypertension, AF, age, and positive family history are significantly different between the two subtypes, the patients having these risk factors can be entered into more specified public health measures, which puts more emphasis on the subtype that they are more prone to.

Decision support system for triage management: A hybrid approach using rule-based reasoning and fuzzy logic.

OBJECTIVES: Fast and accurate patient triage for the response process is a critical first step in emergency situations. This process is often performed using a paper-based mode, which intensifies workload and difficulty, wastes time, and is at risk of human errors. This study aims to design and evaluate a decision support system (DSS) to determine the triage level. METHODS: A combination of the Rule-Based Reasoning (RBR) and Fuzzy Logic Classifier (FLC) approaches were used to predict the triage level of patients according to the triage specialist's opinions and Emergency Severity Index (ESI) guidelines. RBR was applied for modeling the first to fourth decision points of the ESI algorithm. The data relating to vital signs were used as input variables and modeled using fuzzy logic. Narrative knowledge was converted to If-Then rules using XML. The extracted rules were then used to create the rule-based engine and predict the triage levels. RESULTS: Fourteen RBR and 27 fuzzy rules were extracted and used in the rule-based engine. The performance of the system was evaluated using three methods with real triage data. The accuracy of the clinical decision support systems (CDSSs; in the test data) was 99.44%. The evaluation of the error rate revealed that, when using the traditional method, 13.4% of the patients were miss-triaged, which is statically significant. The completeness of the documentation also improved from 76.72% to 98.5%. CONCLUSIONS: Designed system was effective in determining the triage level of patients and it proved helpful for nurses as they made decisions, generated nursing diagnoses based on triage guidelines. The hybrid approach can reduce triage misdiagnosis in a highly accurate manner and improve the triage outcomes.

Comparison of granisetron and metoclopramide in the treatment of pain and emesis in migraine patients: A randomized controlled trial study.

OBJECTIVES: One of the irritating features of migraine is emesis that can compromise taking oral medications. We designed this study to compare the effectiveness of granisetron and metoclopramide in reducing pain and treating emesis in migraine patients. METHODS: We included a total of 148 patients with migraine headache presenting to two referral hospitals in a prospective, double-blinded randomized controlled trial. We compared the effect of granisetron (2 mg intravenous) with metoclopramide (10 mg intravenous). Pain intensity and emesis episodes were recorded before drug administration, one, two and four 4 h after drug administration. RESULTS: Of the 148 patients, 47 were male and 101 were female. 75 patients received granisetron and 73 metoclopramide. Mean pain intensity before the administration of the medications was 7.67 ± 1.30 in granisetron group and 7.68 ± 1.13 in metoclopramide group with an insignificant difference. Mean pain intensity at one, two, and 4 h after drug administration was 3.20 ± 1.37, 2.39 ± 1.28, and 1.31 ± 0.52 in granisetron group and 5.04 ± 1.77, 4.1 ± 1.8, and 1.56 ± 0.68 in metoclopramide group (P = 0.03). Mean emesis episodes before drug administration were 1.85 ± 0.81 and 1.80 ± 0.77 in granisetron and metoclopramide groups, respectively. These episodes were 1.33 ± 0.66, 0.25 ± 0.49, and 0.04 ± 0.19 in granisetron group and 1.38 ± 0.73, 0.21 ± 0.47, and 0.41 ± 0.19 in metoclopramide group at one, two, and 4 h after the drug administration (P = 0.7). CONCLUSION: To came in conclusion, compared to metoclopramide, granisetron is a better choice in acute migraine ATTACK because it decreases the patients' pain as well as their emesis.

Does the normal four steps weight-bearing rule predict the need for radiography in cases of blunt ankle trauma?

Background: Ankle injuries are one of the most common complaints of patients presenting to emergency departments (ED). The Ottawa ankle rules (OAR) was introduced to help physicians to decide who may require x-ray for blunt injuries. The present study aimed at validating the four steps weight-bearing rule of OAR as a sole criterion. Methods: This prospective observational study was conducted on 214 patients with acute ankle injury who referred to 3 emergency departments over a 7-months period in 2008. Main outcome measures of this survey included the sensitivity, specificity, positive and negative predictive values, and the likelihood ratios (positive and negative) of the four steps weight-bearing rule. Results: In this study, 34 fractures were found among the patients. The decision rule had a sensitivity of 0.88 and specificity of 0.61 in detecting all midfoot and ankle fractures. Application of this rule by emergency medicine residents resulted in a 47% reduction in the use of midfoot and ankle radiography. Conclusion: Applying a four steps weight-bearing rule as a sole criterion to detect ankle fractures is not as accurate and sensitive as OAR. Solitary application of this rule may lead to an increasing number of missed fractures compared with OAR.

Fireworks-Related Injuries in Iran: A Survey Following the 2014 New Year's Festival in Tabriz.

BACKGROUND: Iranian people celebrate the last Wednesday eve of the year as Chaharshanbe Suri and use explosives and firecrackers as part of this festival. OBJECTIVES: This study concerned fireworks injuries related to the Chaharshanbe Suri festival in Tabriz, a provincial capital in East Azerbaijan, Iran, to evaluate the epidemiology and provide data to prevent and manage these accidents. PATIENTS AND METHODS: This study was comprised of patients who were treated at the emergency department of Tabriz Sina hospital with burn injuries related to fireworks. The patients' demographics, time of the accidents, locations of the burns, and the type of explosive were recorded. Descriptive statistics were used to analyze the data. RESULTS: Forty-nine patients were seen in the emergency department. The mean age was 17.16 ± 9.1, ranged from 3 to 36. Forty patients were male (81.6%) and 9 were female (18.4%). Twenty-one patients had second degree burns (47.7%), 10 patients had first degree burns (22.7%), 9 patients had third degree burns (20.5%), and 4 patients had first and second degree burns (9.1%). CONCLUSIONS: The study shows that walking in the streets or driving with open windows can be dangerous in Iran during Charshanbe suri.

Bicycle-Related Injuries Presenting to Tabriz Imam Reza Hospital, Iran.

BACKGROUND: Rising fuel cost and subsequent increase in transportation prices encourage people to use cheap transportation such as a bicycle. This vehicle can also be used for sports and recreation. Bicycles are widely used in Iran, like other countries. There is not enough data about bicycle-related traumas in our country. OBJECTIVES: The aim of this study was to obtain the epidemiology of this type of injury in Tabriz Imam Reza Hospital as a referral center in northwest of Iran during 2009 to 2012. MATERIALS AND METHODS: One hundred bicycle-related patients during the three years were entered in this descriptive cross-sectional study. Patient's demographics, place and time of crash, mechanism of trauma, helmet and other safety device usage, and disposition information were gathered by a researcher-made checklist. Admission rate and ward as well as the site of injuries were also collected. The data were analyzed by SPSS 16 software using descriptive statistics. RESULTS: All the patients were males with a mean age of 31.3 ± 23.12. Seventy six bicycle-related injuries occurred during weekdays and 24 happened on holidays; 71 patients attended the emergency department in the morning and 29 at night. Only three of 100 cyclists had helmets during the accident. The rates of injuries were as follows: 65 head and face, 20 abdomen, 14 chest, 11 soft tissue, eight lower limb, eight cervical spine, six upper limb, four thoracic and lumbar spine, and three pelvis injuries. CONCLUSIONS: Head and face are the most common sites of injury and skull fracture is the most common one. Considering the preventable entity of trauma, the use of helmets seems to be beneficial to prevent most bicycle-related injuries.

Diagnostic Accuracy of Focused Assessment With Sonography for Trauma in the Emergency Department.

BACKGROUND: Trauma is currently the fourth leading cause of death in developed countries. One of the main objectives in abdominal trauma patients is to develop a rapid and accurate diagnosis. There is a tendency to use emergency abdominal ultrasound with abdominal trauma, therefore, it is recommended in some centers as a diagnostic tool and as a primary choice in abdominal trauma. OBJECTIVES: The aim of this study was to determine the diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents. PATIENTS AND METHODS: This was a descriptive and analytical study performed on patients with abdominal blunt trauma who referred to the emergency ward. The diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents was evaluated. RESULTS: Of the 380 patients, 296 were males and 84 were females. The mean ages of male and female patients were 34.52 ± 16.38 years and 41.19 ± 21.38 years, respectively (P = 0.009). The sonographies performed by emergency residents were positive in 46 patients, with 22 of these confirmed by CT scans. The sensitivity and specificity of the sonography by emergency residents, as confirmed by CT scans, were 78.5% and 93.2%, respectively. The sonographies performed by radiology residents were positive in 38 patients, with 24 being confirmed by CT scans. CONCLUSIONS: The sensitivity and specificity of the sonography by radiology residents, as confirmed by CT scans, were 85.7% and 96%, respectively. Sonographies performed by emergency residents were positive in 46 patients with 34 of these being confirmed by sonographies by radiology residents. The sensitivity and specificity of the sonographies by emergency residents, as confirmed by sonographies by radiology residents, were 89.5% and 96.5%, respectively.

Independent Predictive Factors of Hospitalization in a North-West Burn Center of Iran; an Epidemiologic Study.

INTRODUCTION: A high-grade burn is one of the most devastating injuries with several medical, social, economic, and psychological effects. These injuries are the most common cause of accidental deaths after traffic injuries in both the developed and developing countries. Therefore, this research was aimed to determine demographic characteristics of patients with burn injury admitted to the emergency department and identify predictive factors of hospitalization. METHODS: This is a cross sectional descriptive study, which is done in 20 March up to 20 September 2011 in emergency department of Sina Hospital, Tabriz, Iran. Patients' information including demographic characteristic, cause of burn, place of accident, anatomical areas burned, grading and percent of burning and disposition were gathered and analyzed using SPSS version 18.0 statistical software. Stepwise multivariate regression analysis was used for recognition of independent predictive factors of hospitalization in burned patients. RESULTS: One hundred and sixty patients were enrolled (54.4% female). The average age of those was 20.47±13.5 years. The prevalence of burn was significantly higher in ages under 20 years (p<0.001). Lower limb (37.5%), head and neck (21.25%) and upper limb (17.5%) were three frequent site of burn. The most common cause of burns was boiling water scalding (34.4%). Home related burn was significantly higher than other place (p<0.001). The most frequent percent of burn was <5% (46.25%). Finally, 50 (31.25%) cases hospitalized. Univariate analysis demonstrated that age under 20 years old (p=0.02) female gender (p=0.02), burning site (p=0.002), cause (p=0.005), place (p<0.001), grade (p<0.001), and percent (p<0.001) was related to disposition of patients. Stepwise multiple logistic regression showed female gender (OR=3.52; 95% CI: 1.57-7.88; p=0.002), work related burning (OR=1.78; 95% CI: 1.26-2.52; p=0.001), and burning over 5 percent (OR=2.15; 95% CI: 1.35-3.41; p=0.001) as independent predictive factors of hospitalization. CONCLUSION: The results of present study showed that burns injury are most frequent in age under 20 year old, lower limbs, with boiling water, and at home. In addition, the most frequent type and percentage of burned area were second degree and <5% of total body surface area, respectively. Among age under 20 years old, female gender, burning site, cause, place, grade, and percent only female gender, work related burning, and burning over 5% were detected as independent predictive factors of hospitalization.

Periumbilical Pain with Radiation to Both Legs Following Tarantula Bite; a Case Report.

Tarantulas have recently become as pets in most parts of the world that increased the probability of encountering emergency physicians with patients hurt with these spiders. Their attacks usually do not cause general manifestation, however there are some case reports in this regard. Here, a 40-year-old man was reported who was referred to the emergency department with severe periumbilical pain that radiated to both legs and diagnosed as a victim of tarantula bite. Such symptoms usually are belonging to other spiders like Black Widow spider, but it seems that tarantula can mimic them in some cases, too.