Efficacy of endovascular therapy for stroke in developing country: A single-centre retrospective observational study in Indonesia from 2017 to 2021.

Background: Indonesia as a developing nation faces a plethora of challenges in applying endovascular therapy (EVT), mostly due to the lack of physicians specialized in neuro-intervention, high operational cost, and time limitation. The efficacy of EVT in improving functional outcomes of stroke in developing countries has not been previously studied. Methods: This retrospective cohort study was conducted at Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) from January 2017 to December 2021. Large vessel occlusion (LVO) diagnosis was established based on a combination of clinical and imaging characteristics. We assessed patients' functional independence on day-90 based on modified Rankin Scale (mRS) between the endovascular treatment group and the conservative group (those receiving intravascular thrombolysis or medical treatment only). Functional independence was defined as mRS ≤2. Results: Among 111 stroke patients with LVO, we included 32 patients in the EVT group and 50 patients in the conservative group for this study. Patients with younger age (p = 0.004), lower hypertension rate (p < 0.001), higher intubation rate (p = 0.014), and earlier onset of stroke were observed in the EVT group. The proportion of mRS ≤2 at day-90 in the EVT group was higher than the conservative group (28.1 % vs. 18.0 %; p = 0.280). Patients within mRS ≤2 group had earlier onset-to-puncture time (p = 0.198), onset-to-recanalization time (p = 0.341), lower NIHSS (p = 0.026) and higher ASPECTS (p = 0.001) on admission. In multivariate analysis, ASPECTS (aOR 2.43; 95%CI 1.26-4.70; p = 0.008) defined functional independence in the EVT group. Conclusion: The endovascular therapy group had a higher proportion of mRS ≤2 at day-90 than the conservative group despite its statistical insignificance.

The association of the COVID-19 outbreak with in-hospital mortality: A single-centre study from Indonesia.

Objective: The early outbreak period of Coronavirus Disease (COVID-19) has affected the emergency department (ED) and hospital services in many countries. This study aimed to investigate the association between COVID-19 outbreak and in-hospital mortality in Jakarta, Indonesia. Methods: This retrospective cohort study was conducted in a single-centre referral hospital in Jakarta, Indonesia. Data were collected between May and October 2020. All patients who visited the ED and required inpatient care during the early COVID-19 outbreak period at the study location (March to April 2020) were included in the exposure group. All patients who visited the ED and required inpatient care during the non-outbreak period (March to April 2019) were included in the non-exposure group. In-hospital mortality was the primary outcome, whereas other variables, such as sex, age, triage categories, trauma cases, referral cases, and ED length of stay (LOS), were measured to identify confounding and effect modifications. Multivariate logistic regression analysis was performed to assess this association. Results: A total of 2,808 patients during the outbreak period and 2,423 patients during the non-outbreak period participated in the study. The odds of in-hospital mortality increased during the outbreak period compared to that during the non-outbreak period (odds ratio [OR], 1.41; 95%CI 1.04-1.91; p = 0.01) after adjusting for age, sex, triage categories, trauma case, ED LOS, and interaction between the outbreak period and ED LOS. Conclusion: COVID-19 outbreaks have been associated with an increased risk of in-hospital mortality in referral hospitals in Jakarta, Indonesia.

Post COVID-19 Syndrome Monitoring in Confirmed COVID-19 Patients with Telemedicine at Cipto Mangunkusumo Hospital.

BACKGROUND: The incidence of post-covid-19 syndrome is quite high and requires further monitoring after the patient is discharged from treatment. So we need a proper monitoring method and description of the Covid-19 syndrome in Indonesia.  Methods: This retrospective cohort study with total sampling method uses data from medical records and telemedicine observations of confirmed COVID-19 patients who received treatment in the Kiara room at Cipto Mangunkusumo. The data were then analyzed using chi-squared and multinomial logistic regression techniques. RESULTS: A total of 133 samples were used, including 44.4% male and 55.6% female, with an average age Standard Deviation (SD) of 40.36 (17.94). The severity levels of Covid-19 were mild (66.9%). The most common post-Covid-19 symptom manifestations was cough expressed at the first follow-up (first week after recovery) and second follow-up (the fourth week after recovery). Furthermore, the significant relationship between severity levels and post-Covid-19 symptomatic syndrome outcomes is the critical headache or vertigo symptoms with an RR of 8.70 (95% CI, 1.10-68.69,). In comparison, the telemedicine quality assessment was declared good, as shown by 98.7% of an examined sample. CONCLUSION: The most manifestation shown in the first and fourth week of follow-up is cough. Other symptoms tend to decrease in the second follow-up. The severity level associated with post-Covid-19 manifestations are severe-critical with headache or vertigo as a risk factor and mild with symptoms of headache or vertigo as a preventative. Meanwhile, the quality of telemedicine services was recognized as good by the majority of the sample.

Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study.

OBJECTIVE: Intubation is an important competency for emergency doctors. Emergency patients are often unstable, with undifferentiated conditions. There is little time to prepare these patients prior to intubation and so ED intubation may differ from intubation in intensive care units and operating theatres. The present study aims to describe the characteristics of emergency intubation after an administrative policy change within a tertiary teaching hospital in Jakarta, allowing non-anaesthetists to perform intubation in the ED. METHODS: Prospective data were collected regarding patients of all age groups who were intubated at the ED of Cipto Mangunkusumo General Hospital, Jakarta, from February 2018 to January 2019. Patient characteristics, intubation attempts, medications used, complications, and disposition were recorded in a self-reported airway registry based on the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) form. RESULTS: During the 12-month study period, 231 patients, or 41.5% of ED intubated patients were enrolled in the study, and there were 268 intubation attempts on these enrolled patients. The first-pass success rate was 207 out of 231 patients, or 89.6%, with anaesthetist (88.9%), better than emergency doctors (55.4%). Complications were reported in 51 patients, or 22.0%, with desaturation and hypotension being the most common. Thirty-three patients, or 14.3%, died in the ED before being transferred to another unit. CONCLUSIONS: The first-pass success rate is comparable with international data. Non-anaesthetic physicians must improve their experience to achieve a favourable success rate. The data on complications highlight the need for improvement in Indonesian ED intubation practices.

Snapshot of emergency departments in Jakarta, Indonesia.

OBJECTIVE: EDs in Indonesia face an unprecedented increase in patient influx after the expansion of national health insurance system coverage. The present study aims to describe EDs' characteristics and capabilities utilisation in Jakarta. METHODS: An ED inventory was created from the Jakarta Provincial Health Office and the Indonesian Hospital Association registries. The EDs that were accessible to the general public 24/7 were surveyed about their characteristics during the calendar year 2017. For further ED analysis, we stratified the hospitals into four types (A, B, C and D) based on their size and capabilities, with type A being the largest. RESULTS: From the 118 (81%) out of 146 EDs that responded, there were 2 million ED visits or 202 per 1000 people. The median annual visit volume was 11 200 (interquartile range 4233-18 000). Further stratification highlights the annual visit difference among hospital types where type A hospitals reported the most with 32 000 (interquartile range 13 459-38 873). Almost half of the EDs (47%) answered that ≥60% of the inpatient census came from the ED. Less than half of the EDs (44%) can manage psychiatry, oral-maxillofacial and plastic surgery cases. Consultant coverage varied across hospitals and by hospital type (P < 0.05), except for general surgery and obstetrics and gynaecology consultants who were available in most hospitals (74%). CONCLUSION: Physicians with limited experience and EDs with heterogeneous emergency care capabilities likely threatened the consistency of quality emergency care, particularly for time-sensitive conditions. Our study provides a benchmark for future improvements in emergency care.

Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia.

PURPOSE: A national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method. METHODS: This cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality. RESULTS: There were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5-99.9) and 96.9% (95% CI, 95.7-97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259-1.429) and a RR for mortality of 4.294 (95% CI, 3.180-5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11-4.54). CONCLUSION: CTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

ST-Elevation Myocardial Infarction: A Simulation Case for Evaluation of Interprofessional Performance in a Hospital.

INTRODUCTION: Interprofessional collaboration between units in a hospital is essential in order to reach desired time for primary percutaneous intervention (PCI) in acute ST-Segment Elevation Myocardial Infarction (STEMI) cases. We developed a simulation to engage various medical and nonmedical staff in interprofessional and interunit team collaboration. METHOD: We used a scenario in this simulation. Beginning in the emergency department, it detailed a 50-year-old male presenting with progressive chest pain since 7 hours before admission. The emergency team directly examined the patient, and STEMI diagnosis was made, followed by sending the patient to the cardiac catheterization laboratory to undergo primary PCI. A resuscitation kit was required for the simulation. An evaluation sheet was prepared to evaluate every step of patient management. Three judges observed the simulation. At the end of the simulation, debriefing was done, and recommendation for the simulation was discussed. Besides medical activities during patient management, interprofessional communication, administration activities, consultations, and handover process were also evaluated. RESULTS: The team achieved the appropriate door-to-electrocardiogram (ECG) time in 8 minutes, but overall target was delayed since door-to-skin puncture time was reached in 110 minutes. Some factors that contributed to these conditions were long waiting time during patient admission, several attempts for telephone consultation to the cardiologist, and prolonged admission process in the cardiac catheterization laboratory. CONCLUSIONS: The simulation was well received by both participant and our institution, stating that it is a valuable resource for developing interdisciplinary learning program. This simulation also contributed to the development of the clinical pathway, STEMI protocol, in our institution.