Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study.

BACKGROUND: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. METHOD: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. RESULTS: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). CONCLUSION: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

A ruptured bronchial artery aneurysm presenting with neurological symptoms: A case report.

A 72-year-old man visited the emergency department with chief complaints of dizziness and dysarthria. Initially, a stroke was strongly suspected and brain computed tomography (CT) and neck CT angiography were performed; however, a ruptured bronchial artery aneurysm (BAA) was observed. BAA is a rare disease and usually asymptomatic but can be life-threatening. Patients with a ruptured BAA may present with hypovolemic shock, causing symptoms such as suspected cerebrovascular disease due to decreased cerebral blood flow.

Coronavirus disease pandemic impact on emergency department visits for cardiovascular disease in Korea: A review.

The coronavirus disease (COVID-19) pandemic has affected patient visits to the hospital, including visits to the emergency department (ED). This study aimed to analyze the impact of the COVID-19 pandemic on the patterns of ED visits and treatment in hospitals for diseases requiring urgent diagnosis and treatment. We analyzed entries from the South Korea National Emergency Department Information System claims database between January 1, 2018 and December 31, 2020. We analyzed data of patients who visited the ED with acute myocardial infarction (AMI), acute ischemic stroke (AIS), and acute hemorrhagic stroke (AHS). We found that the COVID-19 pandemic had impacted ED utilization and fatality in patients with AMI, AIS, and AHS.

High prevalence of depression and sleep-wake disorders among female emergency medicine residents in South Korea.

BACKGROUND: Depression and sleep-wake disorders are recognized as one of the major problems among emergency physicians. While depression is more common in females than in males, the associated factors linking depression and sleep-wake disorders in emergency physicians, particularly females, remain unknown. OBJECTIVE: To analyze the prevalence of depression and sleep-wake problems among emergency medicine (EM) residents in South Korea and to identify the gender differences and situations that adversely predispose female residents to mental health problems. METHODS: We conducted a cross-sectional analysis using the data collected from the 2019 National EM Residents Wellness Survey targeting all of 630 EM residents in South Korea. The survey included variables potentially influencing depression and sleep-wake problems, such as personal characteristics, work-related stress, and extrinsic environment. Information regarding medical conditions, depression, job stress, and sleep deprivation was obtained using the self-administered Patient Health Questionnaire (PHQ-9), the Apgar Wellness Score (AWS), and the Epworth Sleepiness Scale (ESS). We analyzed the data using IBM SPSS Statistics version 25 and MedCalc version 17. RESULTS: A total of 384 residents participated in the survey. Overall, 27.5% of the EM residents met the criteria for at least moderate depression and 36.9% of the EM residents had sleep-related problems. We found that difficulty in trading the shift schedule and frequent night shifts was associated with depression (p = .001, p = .005; respectively). Female residents demonstrated an increased risk of depression and sleepiness compared to their male counterparts (odds ratio [OR] 1.95, OR 1.81; respectively). In addition, logistic regression analysis revealed significant differences by gender in depression with regards to flexibility of trading shifts (p = .005), level of training in the emergency medical centre (p = .035), and frequent night shifts (p = .010). CONCLUSIONS: Approximately, one-third of EM residents report depression and sleep-wake problems, with female residents showing a higher risk than male residents. Several risk factors were identified, and future strategies should be aimed to address these issues to improve the training environment and overall wellbeing of EM residents.KEY MESSAGESThe prevalence of depression and sleep-related problems were, respectively, 1.95 and 1.81 times higher in female residents compared to their male colleagues.The associated risk factors for depression were flexibility of shift trade, level of training in the emergency medical centre, and frequency of night shifts.Improving the training environment and facilities, as well as offering more flexible duty trading options can provide potential opportunities to reduce the risk.

Collateral Effect of the Coronavirus Disease 2019 Pandemic on Emergency Department Visits in Korea.

Background and Objectives: The ongoing coronavirus disease 2019 (COVID-19) pandemic represents a global public health crisis that has had a serious impact on emergency department (ED) utilization trends. The aim of this study was to investigate the collateral effects of the COVID-19 pandemic on ED utilization trends by patients with mild and severe conditions as well as on 7-day fatality rates. Materials and Methods: We analyzed entries in the Korean National Health Insurance claims database between 1 January 2018 and 31 December 2020. Six target patient groups were identified using the main diagnosis codes in the 10th revision of the International Classification of Diseases. Numbers of patients visiting the ED, their age, regional differences, 7-day fatality rate, and rate of emergency procedures were compared between 2018 and 2019 as the control period and 2020, when the COVID-19 pandemic was in full force. Results: During the 2020 COVID-19 pandemic, the number of patients who visited the ED with low-acuity diseases and severe acute respiratory infection diseases sharply decreased to −46.22% and −56.05%, respectively. However, the 7-day fatality rate after ED visits for low-acuity diseases and severe acute respiratory infection diseases increased to 0.04% (p < 0.01), and 1.65% (p < 0.01), respectively, in 2020 compared to that in the control period. Conclusions: During the 2020 COVID-19 pandemic, ED utilization impacted and 7-day fatality rate after ED visit increased. Health authorities and health care providers must strive to ensure prompt delivery of optimal care in EDs for patients with severe or serious symptoms and time-dependent diseases, even during the ongoing COVID-19 or potential future pandemics.

A comparative analysis of gallbladder torsion and acute gallbladder disease without torsion: a single-center retrospective case series study.

BACKGROUND: Acute gallbladder disease (AGD) is frequent in the emergency department (ED), and usually requires surgical intervention. Gallbladder torsion (GT) is a rare entity among patients with AGD. There are sparse reviews of GT's clinical characteristics, and there is no comparative study between them in the same patient cohort. Therefore, we report the case series of GT, and compare the statistical differences between GT and non-GT with AGD. METHODS: We collected retrospective data from patients who visited ED with AGD and underwent emergency cholecystectomy between January 2005 and December 2020. We combined consecutive case series of GT and compared them with non-GT gallbladder disease. RESULTS: Six GT cases were diagnosed over the study duration. Five were female (83%) and the average age was 77.8 years. All patients presented with abdominal pain, and the median duration of pain was two days. Only two cases were suspected for GT pre-operatively (33%). One patient underwent laparotomy, and the others underwent laparoscopic cholecystectomy with a mean operation time of 59 min. The torsion direction was of the same proportion in both directions; five (83%) were rotated completely. The mean length of hospital stay was 9.3 d and outcomes were favorable in most GT cases. In the comparative study between GT and non-GT, age was higher in the GT group (P=0.048), and duration or severity of pain showed no statistical difference (P=0.528; P=0.637, respectively). Body temperature was higher in the non-GT group without statistical significance (P=0.074). Gallstones were present in 68.8% of the non-GT group, which is significantly higher than that of the GT group (P=0.036). CONCLUSIONS: Six exceptional GT cases were managed successfully. The overall characteristics of each GT case demonstrated similar with previous reviews. Our comparative analysis showed that age, pulse rate, serum creatinine level, and gallstone presence showed statistical differences. Contrary to the traditional knowledge of GT, some distinct features like sex, duration or severity of pain, and fever showed no significant differences within AGD in our research.

Impact of the COVID-19 Pandemic on Emergency Department Workload and Emergency Care Workers' Psychosocial Stress in the Outbreak Area.

Background and Objectives: Due to the unexpected spread of coronavirus disease 2019 (COVID-19), there was a serious crisis of emergency medical system collapse. Healthcare workers working in the emergency department were faced with psychosocial stress and workload changes. Materials and Methods: This was a cross-sectional survey of healthcare workers in the emergency department in Daegu and Gyeongbuk, Korea, from November 16 to 25, 2020. In the survey, we assessed the general characteristics of the respondents; changes in the working conditions before and after the COVID-19 pandemic; and resulting post-traumatic stress disorder, depression and anxiety statuses using 49 questions. Results: A total of 529 responses were collected, and 520 responses were included for the final analyses. Changes in working conditions and other factors due to COVID-19 varied by emergency department level, region and disease group. Working hours, intensity, role changes, depression and anxiety scores were higher in the higher level emergency department. Isolation ward insufficiency and the risk of infection felt by healthcare workers tended to increase in the lower level emergency department. Treatment and transfer delay were higher in the fever and respiratory disease groups (M = 3.58, SD = 1.18; M = 4.08, SD = 0.95), respectively. In all the disease groups, both treatment and transfer were delayed more in Gyeongbuk than in Daegu. Conclusions: Different goals should be pursued by the levels and region of the emergency department to overcome the effects of the COVID-19 pandemic and promote optimal care.

Public awareness and willingness to use automated external defibrillators in a metropolitan city.

OBJECTIVE: Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys. METHODS: Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs. RESULTS: Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10-1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43-2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13-1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26-5.93). CONCLUSION: To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

Factors affecting successful esophageal foreign body removal using a Foley catheter in pediatric patients.

OBJECTIVE: This study aimed to determine the factors that affect successful esophageal foreign body (FB) removal using a Foley catheter and to identify methods to increase the success rate. METHODS: In this retrospective, cross-sectional study, we included pediatric patients who presented with esophageal FB impaction that was removed using a Foley catheter in the emergency departments of tertiary care and academic hospitals. We analyzed the effect of the patients' age, sex, and symptoms; FB type, size, and location; Foley catheter size; complications during FB removal; duration between FB ingestion and removal; operator's years of training; sedation; success rate of FB removal; endoscopy; and patient's posture during FB removal on the success of Foley catheter-based FB removal. RESULTS: Of the 43 patients we enrolled, Foley catheter-based FB removal was successful in 81.4% (35/43) but failed in 18.6% (8/43) of patients; no FB-removal-related complications were reported. There was no significant association between the success rate of Foley catheter-based FB removal and any study variable. A higher number of years in training tended to increase the success rate of Foley catheter-based FB removal, although statistical significance was not achieved. CONCLUSION: Children's esophageal FB removal is a practical challenge in the emergency rooms, and using a Foley catheter is associated with a high success rate of the removal and low occurrence of complications. In this study, no single variable was found correlated with the success rate of Foley catheter-based esophageal FB removal in pediatric patients, which may indicate multiple variables interacting with one another to affect the success rate.

Clinical usefulness of deep learning-based automated segmentation in intracranial hemorrhage.

BACKGROUND: Doctors with various specializations and experience order brain computed tomography (CT) to rule out intracranial hemorrhage (ICH). Advanced artificial intelligence (AI) can discriminate subtypes of ICH with high accuracy. OBJECTIVE: The purpose of this study was to investigate the clinical usefulness of AI in ICH detection for doctors across a variety of specialties and backgrounds. METHODS: A total of 5702 patients' brain CTs were used to develop a cascaded deep-learning-based automated segmentation algorithm (CDLA). A total of 38 doctors were recruited for testing and categorized into nine groups. Diagnostic time and accuracy were evaluated for doctors with and without assistance from the CDLA. RESULTS: The CDLA in the validation set for differential diagnoses among a negative finding and five subtypes of ICH revealed an AUC of 0.966 (95% CI, 0.955-0.977). Specific doctor groups, such as interns, internal medicine, pediatrics, and emergency junior residents, showed significant improvement with assistance from the CDLA (p= 0.029). However, the CDLA did not show a reduction in the mean diagnostic time. CONCLUSIONS: Even though the CDLA may not reduce diagnostic time for ICH detection, unlike our expectation, it can play a role in improving diagnostic accuracy in specific doctor groups.

How to keep patients and staff safe from accidental SARS-CoV-2 exposure in the emergency room: Lessons from South Korea's explosive COVID-19 outbreak.

OBJECTIVES: We report our experience with an emergency room (ER) shutdown related to an accidental exposure to a patient with coronavirus disease 2019 (COVID-19) who had not been isolated. SETTING: A 635-bed, tertiary-care hospital in Daegu, South Korea. METHODS: To prevent nosocomial transmission of the disease, we subsequently isolated patients with suspected symptoms, relevant radiographic findings, or epidemiology. Severe acute respiratory coronavirus 2 (SARS-CoV-2) reverse-transcriptase polymerase chain reaction assays (RT-PCR) were performed for most patients requiring hospitalization. A universal mask policy and comprehensive use of personal protective equipment (PPE) were implemented. We analyzed effects of these interventions. RESULTS: From the pre-shutdown period (February 10-25, 2020) to the post-shutdown period (February 28 to March 16, 2020), the mean hourly turnaround time decreased from 23:31 ±6:43 hours to 9:27 ±3:41 hours (P < .001). As a result, the proportion of the patients tested increased from 5.8% (N=1,037) to 64.6% (N=690) (P < .001) and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (P < .001). All 23 patients with COVID-19 in the post-shutdown period were isolated in the ER without any problematic accidental exposure or nosocomial transmission. After the shutdown, several metrics increased. The median duration of stay in the ER among hospitalized patients increased from 4:30 hours (interquartile range [IQR], 2:17-9:48) to 14:33 hours (IQR, 6:55-24:50) (P < .001). Rates of intensive care unit admissions increased from 1.4% to 2.9% (P = .023), and mortality increased from 0.9% to 3.0% (P = .001). CONCLUSIONS: Problematic accidental exposure and nosocomial transmission of COVID-19 can be successfully prevented through active isolation and surveillance policies and comprehensive PPE use despite longer ER stays and the presence of more severely ill patients during a severe COVID-19 outbreak.

Status epilepticus as an initial presentation of aortic dissection: A case report.

BACKGROUND: Status epilepticus (SE) as the initial presentation of aortic dissection in the absence of chest pain is very rare. We report a case of aortic dissection (AD), which presented as SE with markedly elevated levels of D-dimer, a reliable and sensitive index of fibrin deposition and stabilization. CASE REPORT: A 74-year-old Asian woman presented to the emergency department (ED) with an altered mental state following three consecutive generalized tonic-clonic seizures at home. Her initial vital signs were normal, and the head CT scan was non-informative. Most of the laboratory results were normal, but the D-dimer levels were markedly elevated. About 90 minutes after arriving at the ED, the patient developed another tonic-clonic seizure for about three-four minutes. Emergent chest CT revealed type A AD with hemopericardium. During preparation for the emergency operation, the patient suffered a cardiac arrest. Despite performing cardiopulmonary resuscitation (CPR) for 35 minutes, the patient died. CONCLUSIONS: The goal of this case report is to make clinicians aware of the possibility that new-onset SE with elevated D-dimer levels can be an indication of acute AD type A in the absence of typical symptoms.

Obstruction of the Hepatic Venous Flow Caused by Intravenous Leiomyomatosis.

Budd-Chiari syndrome (BCS) is a rare intrahepatic vascular disease that is characterized by a hepatic venous outflow obstruction. Intravenous leiomyomatosis (ILs) is a rare complication of a myoma. Here, we report a case of BCS that was caused by intracaval ILs. A woman presented to the emergency department (ED) with abdominal distension that had gradually progressed over a period of 3 years. Bedside ultrasonography and contrast-enhanced computed tomography (CECT) showed a large ascites and pelvic mass. The mass continued to the inferior vena cava and the right atrium. The intracaval mass was obstructing the left and middle hepatic veins. We established a tentative diagnosis of BCS caused by intracaval ILs and attempted surgical resection. Complete resection of the intracaval mass failed because of adhesion; however, she was discharged from the hospital without any postoperative complications. After 3 months, a pelvic ultrasonography showed a recurrence of a 4 × 3 cm pelvic mass. The mass size increased to 6 cm after 30 months. ILs can cause secondary BCS and can lead to life-threatening conditions. Owing to its extreme rarity, early detection in the ED is challenging. Bedside ultrasonography and CECT can enable the early recognition of BCS by ILs.

Confirmation of COVID-19 in Out-of-Hospital Cardiac Arrest Patients and Postmortem Management in the Emergency Department during the COVID-19 Outbreak.

BACKGROUND: There is currently a lack of evidence-based postresuscitation or postmortem guidelines for patients with out-of-hospital cardiac arrest (OHCA) in the setting of an emerging infectious disease. This study aimed to develop and validate a multimodal screening tool that aids in predicting the disease confirmation in emergency situations and patients with OHCA during a coronavirus disease 2019 (COVID-19) outbreak. MATERIALS AND METHODS: We conducted a retrospective, multicenter observational study of adult patients with OHCA in Daegu, Korea. To identify the potential predictors that could be used in screening tools in the emergency department, we applied logistic regression to data collected from March 1 to March 14. The prediction performance of the screening variables was then assessed and validated on the data of patients with OHCA who were treated between February 19 and March 31, 2020. General patient characteristics and hematological findings of the COVID-19-negative and COVID-19-positive groups were compared. We also evaluated confirmation test criteria as predictors for COVID-19 positivity in patients with OHCA. RESULTS: Advanced age, body temperature, and abnormal chest X-ray (CXR) revealed significant predictive ability in the derivation cohort. Of the 184 adult patients with OHCA identified in the validation cohort, 80 patients were included in the analysis. Notably, 9 patients were positive and 71 were negative on the COVID-19 reverse transcription polymerase chain reaction test. Five patients (55.6%) in the COVID-19-positive group had a fever before OHCA, and 12 (16.9%) of the COVID-19-negative group had a fever before OHCA (P = 0.018). Eight patients (88.9%) in the COVID-19-positive group had a CXR indicating pneumonic infiltration. Of the criteria for predicting COVID-19, fever or an abnormal CXR had a sensitivity of 100% (95% confidence interval [CI]: 65.4 - 100) and a specificity of 22.5% (95% CI: 13.5 - 34.0). CONCLUSION: The screening tools that combined fever or abnormal CXR had a good discriminatory ability for COVID-19 infection in adult patients with OHCA. Therefore, during the COVID-19 outbreak period, it is recommended to suspect COVID-19 infection and perform COVID-19 test if patients present with a history of fever or show abnormal findings in postmortem CXR.

Deep-learning algorithms for the interpretation of chest radiographs to aid in the triage of COVID-19 patients: A multicenter retrospective study.

The recent medical applications of deep-learning (DL) algorithms have demonstrated their clinical efficacy in improving speed and accuracy of image interpretation. If the DL algorithm achieves a performance equivalent to that achieved by physicians in chest radiography (CR) diagnoses with Coronavirus disease 2019 (COVID-19) pneumonia, the automatic interpretation of the CR with DL algorithms can significantly reduce the burden on clinicians and radiologists in sudden surges of suspected COVID-19 patients. The aim of this study was to evaluate the efficacy of the DL algorithm for detecting COVID-19 pneumonia on CR compared with formal radiology reports. This is a retrospective study of adult patients that were diagnosed as positive COVID-19 cases based on the reverse transcription polymerase chain reaction among all the patients who were admitted to five emergency departments and one community treatment center in Korea from February 18, 2020 to May 1, 2020. The CR images were evaluated with a publicly available DL algorithm. For reference, CR images without chest computed tomography (CT) scans classified as positive for COVID-19 pneumonia were used given that the radiologist identified ground-glass opacity, consolidation, or other infiltration in retrospectively reviewed CR images. Patients with evidence of pneumonia on chest CT scans were also classified as COVID-19 pneumonia positive outcomes. The overall sensitivity and specificity of the DL algorithm for detecting COVID-19 pneumonia on CR were 95.6%, and 88.7%, respectively. The area under the curve value of the DL algorithm for the detection of COVID-19 with pneumonia was 0.921. The DL algorithm demonstrated a satisfactory diagnostic performance comparable with that of formal radiology reports in the CR-based diagnosis of pneumonia in COVID-19 patients. The DL algorithm may offer fast and reliable examinations that can facilitate patient screening and isolation decisions, which can reduce the medical staff workload during COVID-19 pandemic situations.

Transtracheal ultrasonographic confirmation of endotracheal intubation using I-gel and an endotracheal tube introducer.

BACKGROUND: This study aimed to investigate the efficacy of transtracheal ultrasonography in confirming the placement of an endotracheal tube introducer during endotracheal intubation using the I-gel supraglottic airway as a guide. METHODS: In this prospective study, endotracheal intubation using an endotracheal tube introducer through the I-gel was performed in patients with return of spontaneous circulation after I-gel insertion for out-of-hospital cardiac arrest. The introducer placement was assessed by the occurrence of hyperechoic artifacts within the trachea or esophagus in transtracheal ultrasonography. Results of ultrasonography were confirmed by waveform capnography in the case of tracheal artifacts and direct visualization by laryngoscopy in the case of esophageal artifacts. RESULTS: One hundred and six patients were enrolled in this study. In transtracheal ultrasonography, artifacts of introducer in the trachea and esophagus were observed in 80 (75.5%) and 26 (24.5%) patients, respectively. Transtracheal ultrasonography in identifying the placement of introducers revealed a sensitivity of 100% (95% CI 95.4 to 100), specificity of 96.3% (95% CI 81.0 to 99.9), a PPV of 98.7% (95% CI 92.0 to 99.8), and a NPV of 100% (95% CI 94.8 to 99.9). CONCLUSION: Transtracheal ultrasonography is an accurate method for identifying introducer placement during endotracheal intubation using an endotracheal tube introducer through the I-gel.

Appendectomy in patient with suspected COVID-19 with negative COVID-19 results: A case report.

BACKGROUND: Even at present, we are in the middle of the novel coronavirus disease 2019 (COVID-19) pandemic and are facing challenges in trial and error. Presently, emergency surgery for patients with suspected COVID-19 is burdensome not only for patients but also for healthcare workers. Therefore, we established a surveillance system in the emergency room and established principles for managing patients suspected of COVID-19 who require emergency surgery. CASE SUMMARY: A 67-year-old man was diagnosed with appendicitis in March 2020. His wife was diagnosed with COVID-19 10 d earlier, and the patient was in close contact with her. The patient tested negative twice on an upper respiratory COVID-19 reverse transcription-polymerase chain reaction screening test, but chest X-ray and chest computed tomography revealed patchy ground-glass opacity in both upper lobes of the patient's lungs. The same emergency surgery procedure for patients with confirmed COVID-19 was applied to this patient suspected of having the disease to ensure that surgery was not delayed while waiting for the reverse transcription-polymerase chain reaction results. A few hours after surgery, the upper respiratory tract specimen taken in the emergency room was negative for COVID-19 but the lower respiratory tract specimen was found to be positive for the disease. CONCLUSION: When COVID-19 is suspected, emergency surgery should be performed as for confirmed COVID-19 without delay.

Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City.

BACKGROUND: When an emergency-care patient is diagnosed with an emerging infectious disease, hospitals in Korea may temporarily close their emergency departments (EDs) to prevent nosocomial transmission. Since February 2020, multiple, consecutive ED closures have occurred due to the coronavirus disease 2019 (COVID-19) crisis in Daegu. However, sudden ED closures are in contravention of laws for the provision of emergency medical care that enable the public to avail prompt, appropriate, and 24-hour emergency medical care. Therefore, this study ascertained the vulnerability of the ED at tertiary hospitals in Daegu with regard to the current standards. A revised triage and surveillance protocol has been proposed to tackle the current crisis. METHODS: This study was retrospectively conducted at 6 level 1 or 2 EDs in a metropolitan city where ED closure due to COVID-19 occurred from February 18 to March 26, 2020. The present status of ED closure and patient characteristics and findings from chest radiography and laboratory investigations were assessed. Based on the experience from repeated ED closures and the modified systems that are currently used in EDs, revised triage and surveillance protocols have been developed and proposed. RESULTS: During the study period, 6 level 1 or 2 emergency rooms included in the study were shut down 27 times for 769 hours. Thirty-one confirmed COVID-19 cases, of whom 7 died, were associated with the incidence of ED closure. Typical patient presentation with respiratory symptoms of COVID-19 was seen in less than 50% of patients, whereas abnormal findings on chest imaging investigations were detected in 93.5% of the study population. The chest radiography facility, resuscitation rooms, and triage area were moved to locations outside the ED, and a new surveillance protocol was applied to determine the factors warranting quarantine, including symptoms, chest radiographic findings, and exposure to a source of infection. The incidence of ED closures decreased after the implementation of the revised triage and surveillance protocols. CONCLUSION: Triage screening by emergency physicians and surveillance protocols with an externally located chest imaging facility were effective in the early isolation of COVID-19 patients. In future outbreaks of emerging infectious diseases, efforts should be focused toward the provision of continued ED treatment with the implementation of revised triage and surveillance protocols.

Comparing the neurologic outcomes of patients with out-of-hospital cardiac arrest according to prehospital advanced airway management method and transport time interval.

OBJECTIVE: The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database. METHODS: We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome. RESULTS: Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65-2.87 for SGAs; OR, 1.31; CI, 0.30-5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31-1.07 for SGAs; OR, 0.63; CI, 0.12-3.26 for ETI). CONCLUSION: Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.

A simple blood preparation method for nucleic acid amplification tests using membranes.

BACKGROUND: To detect most of bloodborne pathogens, serum must be separated from whole blood for efficient nucleic acid amplification. Centrifugation is the most commonly used preparation step for whole blood, but it is not easy to use a centrifuge in rural areas where electricity is not accessible. OBJECTIVE: This study aimed to develop a simple method for obtaining serum suitable for nucleic acid amplification without the use of any instruments. METHODS: Whole blood spiked with Escherichia coli (E. coli) was separated into serum and cellular fraction using 2 closely attached membranes with different characteristics. After brief heating, bacterial DNA in the serum was used for polymerase chain reaction (PCR). RESULTS: Serum was successfully separated from cellular fraction after filtration of one membrane sheet. Membrane sheet containing serum was heated and bacterial DNA in the serum was used for PCR. The quality and concentration of DNA in the heated serum was sufficient for PCR and amplified E. coli gene products were observed. CONCLUSIONS: Separation of bacteria-containing serum was feasible using two membrane sheets and the DNA isolated from serum can be used for PCR after brief heating.