Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study.

BACKGROUND: Due to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas. METHODS: A questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services. RESULTS: In total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics. CONCLUSIONS: The study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future.

Three-in-one protocol reduces mortality of patients with haemodynamically unstable pelvic fractures-a five year multi-centred review in Hong Kong.

PURPOSE: The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. Despite the new advances in trauma care which are in phase in trauma centres in Hong Kong, the management of haemodynamically unstable pelvic fracture is still heterogeneous. The aim of this study is to review the results of management of haemodynamically unstable pelvic fracture patients in Hong Kong over a five year period. METHODS: This is a retrospective multi-centred cohort study of patients with haemodynamic and mechanically unstable pelvic fractures from 1 January 2010 to 31 December 2014. The primary outcome investigated is mortality of patients (including overall, 30-day, 7-day and 24-hour mortalities). RESULTS: Implementation of three-in-one pelvic damage control protocol was identified to be a significant independent predictive factor for overall, 30-day, seven-day and 24-hour mortalities. The overall in-hospital and 30-day mortality rates for patients managed with three-in-one protocol was 12.5%, while it was 11% for seven day mortality and 6% for 24 hour mortality. There were no significant differences in demographic characteristics, physiological measurements, types of pelvic fracture, severity and mechanism of injury between patients managed with or without three-in-one protocol. CONCLUSIONS: Implementation of the multidisciplinary three-in-one pelvic damage control protocol reduces mortality and therefore should be highly recommended. The results are convincing as it has eliminated the limitations of our previous single-centred trial.

Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures.

BACKGROUND: The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. In recent years, angioembolisation and pelvic packing have been introduced as part of a multimodality treatment for these patients. Protocol-driven management has been shown to improve outcomes. PATIENTS AND METHODS: This is a Level III retrospective cohort study of patients suffering from unstable pelvic fractures from 1 January 1996 to 30 September 2011. The aim of the study was to review our results, particularly in terms of mortality through the evolution of three phases of treatment protocols: preangiography, angiography and pelvic packing. RESULTS: The overall 30-day mortality rate for all patients was 47.2%, with a rate of 63.5% in the preangiography phase, 42.1% in the angiography phase and 30.6% in the pelvic packing phase. Multivariate logistic regression analysis identified the use of retroperitoneal packing as a significant independent predictive factor for 24 h mortality. CONCLUSIONS: Our results showed an improvement in patient survival with sequential protocols over the study period, during which we incorporated a multidisciplinary approach to managing these complicated pelvic fractures. The results strongly suggest that retroperitoneal packing should be highly recommended for bleeding subsequent to pelvic fracture, in addition to other modalities of treatment.

Telephone and Teleradiology-Guided Thrombolysis Can Achieve Similar Outcome as Thrombolysis by Neurologist On-site.

BACKGROUND: Because of the limitation of on-site neurology workforce, telestroke was implemented to overcome this barrier. We explored the efficacy and safety of intravenous (IV) stroke thrombolysis service by telestroke when neurologist was not available on-site. METHODS: From January 2009 to December 2012, we compared patients treated with IV stroke thrombolysis by telestroke in the form of telephone consultation with teleradiology, to patients treated after in-person assessment by the same team of neurologists in a regional hospital. Door-to-needle time, symptomatic intracranial hemorrhage, and functional outcome at 3 months were prospectively collected and compared between the groups. RESULTS: In all, 152 patients were treated with IV thrombolysis; 102 patients were treated with neurologist on-site; whereas 50 patients were treated by internists with telestroke. Fifty-two percent of the telemedical group achieved excellent outcome compared to 43% of the neurologist on-site group (P = .30). Symptomatic intracranial hemorrhage rate (4.0% versus 4.9%, P = 1.0) and mortality (8.3% versus 11.9%, P = .49) were comparable. Using the multiple logistic regression analysis, age, baseline stroke severity, and extent of early ischemic change on brain computed tomography scan, are independent predictors for excellent outcome, whereas the presence of neurologist on-site is not correlated with the outcome. CONCLUSIONS: Patients treated without neurologist on-site achieved similar outcome. Telephone consultation and teleradiology-guided IV stroke thrombolysis, with the support of on-site internist appeared safe and efficacious.

A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.

BACKGROUND: Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome. METHODS: This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279. FINDINGS: 3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a specificity of 11.0% (10.0-12.2). INTERPRETATION: This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide. FUNDING: Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International (Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand, and Progressive Group (Taiwan).

Seven-year excess mortality, functional outcome and health status after trauma in Hong Kong.

PURPOSE: The purpose was to investigate long-term health impacts of trauma and the aim was to describe the functional outcome and health status up to 7 years after trauma. METHODS: We conducted a prospective, multi-centre cohort study of adult trauma patients admitted to three regional trauma centres with moderate or major trauma (ISS ≥ 9) in Hong Kong (HK). Patients were followed up at regular time points (1, 6 months and 1, 2, 3, 4, 5, 6, and 7 years) by telephone using extended Glasgow Outcome Scale (GOSE) and the Short-Form 36 (SF36). Observed annual mortality rate was compared with the expected mortality rate estimated using the HK population cohort. Linear mixed model (LMM) analyses examined the changes in SF36 with subgroups of age ≥ 65 years, ISS > 15, and GOSE ≥ 5 over time. RESULTS: At 7 years, 115 patients had died and 48% (138/285) of the survivors responded. The annual mortality rate (AMR) of the trauma cohort was consistently higher than the expected mortality rate from the general population. Forty-one percent of respondents had upper good recovery (GOSE = 8) at 7 years. Seven-year mean PCS and MCS were 45.06 and 52.06, respectively. LMM showed PCS improved over time in patients aged < 65 years and with baseline GOSE ≥ 5, and the MCS improved over time with baseline GOSE ≥ 5. Higher mortality rate, limited functional recovery and worse physical health status persisted up to 7 years post-injury. CONCLUSION: Long-term mortality and morbidity should be monitored for Asian trauma centre patients to understand the impact of trauma beyond hospital discharge.

Return to work after injury in Hong Kong: prospective multi-center cohort study.

PURPOSE: Trauma remains a major cause of morbidity and disability worldwide; however, reliable data on the health status of an urban Asian population after injury are scarce. The aim was to evaluate 1-year post-trauma return to work (RTW) status in Hong Kong. METHODS: This was a prospective, multi-center cohort study involving four regional trauma centers from 2017 to 2019 in Hong Kong. Participants included adult patients entered into the trauma registry who were working or seeking employment at the time of injury. The primary outcome was the RTW status up to 1 year. The Extended Glasgow Outcome Scale, 12-item Short Form (SF-12) survey and EQ5D were also obtained during 1-, 3-, 6-, 9-, and 12-month follow-ups. Multivariable Cox proportional hazards regression analysis was used for analysis. RESULTS: Six hundred and seven of the 1115 (54%) recruited patients had RTW during the first year after injury. Lower physical requirements (p = 0.003, HR 1.51) in pre-injury job nature, higher educational levels (p < 0.001, HR 1.95), non-work-related injuries (p < 0.001, HR 1.85), shorter hospital length of stay (p = 0.007, HR 0.98), no requirement for surgery (p = 0.006, HR 1.34), and patients who could be discharged home (p = 0.006, HR 1.43) were associated with RTW within 12 months post-injury. In addition, 1-month outcomes including extended Glasgow Outcome Scale ≥ 6 (p = 0.001, HR 7.34), higher mean SF-12 physical component summary (p = 0.002, HR 1.02) and mental component summary (p < 0.001, HR 1.03), and higher EQ5D health index (p = 0.018, HR 2.14) were strongly associated with RTW. CONCLUSIONS: We have identified factors associated with failure to RTW during the first year following in Hong Kong including socioeconomic factors, injury factors and treatment-related factors and 1-month outcomes. Future studies should focus on the interventions that can impact on RTW outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03219424.

Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience.

BACKGROUND: Our objective is to evaluate the mortality and outcomes of hemodynamically unstable patients with pelvic fractures treated with a protocol that directs the patient to either early pelvic angiography or early retroperitoneal pelvic packing. METHOD: This is a retrospective review of prospectively collected database at a local trauma center. Hemodynamically unstable pelvic fracture patients received treatment according to our hospital protocol during two different time periods. Before June 2008, these patients underwent early angiography (ANGIO group, n=13), and from June 2008 onward, these patients underwent early pelvic packing and subsequent angiography if there was continued hemorrhage from the pelvis (PACKING group, n=11). The mechanism of injury, physiologic parameters, blood transfusion requirements, time to intervention, trauma scores, and mortality were recorded. RESULTS: Mean time to intervention in the ANGIO group was longer than that in the PACKING group, although this was not statistically significant (139.5 minutes vs. 78.8 minutes, respectively, p=0.248). Mortality in the ANGIO group was higher than that in the PACKING group; however, this was also not significant (69.2% vs. 36.3%, p=0.107). After univariate analysis, factors associated with mortality included systolic blood pressure, Glasgow Coma Score, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, pH, and base excess. In the PACKING group, one patient died of uncontrolled hemorrhage from a liver laceration. In the ANGIO group, three patients died of uncontrolled hemorrhage from the pelvic fracture. CONCLUSION: Early experience in our institution suggests that early pelvic packing with subsequent angiography if needed is as good as angiography with embolization in treating patients with hemodynamically unstable pelvic fractures.

Characteristics and Outcomes of Patients Referred to an Emergency Department-Based End-of-Life Care Service in Hong Kong: A Retrospective Cohort Study.

BACKGROUND: This study describes the characteristics and outcomes of patients referred to an emergency department (ED)-based end-of-life (EOL) service in a tertiary acute hospital in Hong Kong. We examine how emergency physicians (EPs) perform in recognizing and managing dying patients. METHODS: From September 2010 to April 2018, patients referred to this EOL service in this hospital were included. A group of 5 EPs assessed whether the referred patient would die within a few days. Dying patients (EOL group) were admitted to ED-based EOL service whereas those not likely dying within few days (non-EOL group) would continue management in respective specialty wards. Baseline characteristics of these 2 groups were compared. The time-to-death and use of opioids and anticholinergics were compared. RESULTS: In total, 783 of 830 patients assessed were recognized as being in dying phase, with 688 admitted under ED-based EOL care. Their demographics and characteristics were described. Mean time from assessment to death (time-to-death) was significantly less in EOL group (38.93 hours) than in non-EOL group (250.36 hours; P = .004). Mean time-to-death was not significantly different between those under EP-based EOL service or not. The ED-based EOL care had significantly more patients receiving symptomatic treatment. INTERPRETATION: The characteristics of patients under an ED-based EOL service are described. Emergency physicians are capable of recognizing dying patients. Emergency department-based EOL service does not alter the dying process and offers adequate palliation of symptoms. Emergency physician should assume a more active role in providing adequate EOL care to suitable patients.

A study of serum sodium level among Hong Kong runners.

OBJECTIVE: Hyponatremia and the associated life-threatening complications have emerged as an important issue among marathon runners. This study was conducted to estimate the serum sodium level among local marathon runners and to identify the associated risk factors of dysnatremia. DESIGN: Prospective observational cohort study. SETTING: Hong Kong Marathon 2008. PARTICIPANTS: Subjects were approached at their convenience to participate in the study. Only full-marathon runners were recruited. They were to have had an unremarkable medical and drug history. INTERVENTIONS: Demographic data, training information, previous marathon experience, anticipated drinking strategy, details of fluid consumption throughout the race, weight change, finishing time, and physical complaint. MAIN OUTCOME MEASURES: Post-race serum sodium level. RESULTS: Of the 6488 entries to the race, 370 runners (5.7%) were recruited. Among them, 272 (73.5%) completed the race and attended for blood sampling and data collection. One runner (0.4%) had hyponatremia (133 mmol/L) and 35 runners (12.9%) had hypernatremia (>145 mmol/L), whereas 236 runners (86.7%) had normal serum sodium (135-145 mmol/L) after the race. No symptomatic dysnatremia was found. A mean weight reduction of 0.70 kg was found after the race. An average of 1.9 L of fluid was consumed during the race and 2.5 L if the fluid consumed immediately before and after the race was also included. Hypernatremia was seen in runners who were better trained before the race, those who performed better, and those who drank less water after the race. CONCLUSIONS: This is the largest prospective observational cohort study of dysnatremia conducted on athletes completing a standard marathon in Asia. No case of symptomatic dysnatremia was found.

Emergency medicine as a specialty in Asia.

Aim: We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed. Methods: The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper. Results: Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM. Conclusion: The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

Management of acute agitation in Hong Kong and comparisons with Australasia.

BACKGROUND: Little is known about the use of sedation drugs for the management of acute agitation in Hong Kong's Accident and Emergency Departments (AEDs) and how it compares with Australasian practice. OBJECTIVE: The aim of this study was to determine drug preferences, clinicians' perceived confidence in management, barriers/gaps in training and perceived usefulness of existing clinical practice guidelines (CPGs) in Hong Kong. METHOD: A validated questionnaire was used, with case vignettes typical of patients presenting to AEDs with acute agitation. The questionnaire was distributed by hand to all trainees and fellows of the Hong Kong College of Emergency Medicine (HKCEM). Two reminders were sent. RESULTS: Of 483 HKCEM members, 280 (58.0% [95% CI 53.5-62.3]) responded. For monotherapy, 46.8% (95% CI 41.0-52.6) of respondents chose haloperidol to manage the undifferentiated patient, followed by midazolam (33.9%, 95% CI 28.6-39.7) and diazepam (13.9%, 95% CI 10.4-18.5). Most respondents (83.6%, 95% CI 78.8-87.5) would not administer combination therapy. Respondents were confident in managing agitation overall. The lack of local/institutional CPGs (55.7%, 95% CI 49.9-61.4) was perceived as an important barrier. Institutional guidelines were considered the most useful CPGs (66.4%, 95% CI 60.7-71.7). Most respondents (72.9%, 95% CI 67.4-77.7) perceived a HKCEM endorsed CPG would be useful. CONCLUSION: Haloperidol and benzodiazepines are frequently used as monotherapy for the management of acute agitation in Hong Kong's AEDs. Management in Hong Kong differs from Australasian practice in that combination therapy is less common and clinicians' choice of sedation drugs are less variable overall. Results suggest that future work on CPG development and training regarding the safe use of combination therapy would be well received.

Functional outcome after head injury: comparison of 12-45 year old male and female hormonally active patients.

OBJECTIVES: Head injury is the leading cause of death in patients with major trauma, but little is known of post-trauma rehabilitation morbidity in Hong Kong. The purpose of this study was to identify factors affecting functional outcome in hormonally active patients 6 months after head injury. METHODS: Secondary analysis of the trauma registry database with data collected prospectively at two trauma centres between January 2001 and December 2007. Demographic and trauma data for patients aged 12-45 years with a head Abbreviated Injury Score ≥3 were analysed. The Glasgow outcome scale (GOS) was used for assessment and was assessed 6 months after head injury. The primary outcome measure was a composite poor outcome, namely "dead, vegetative and severely disabled" measured using the GOS. RESULTS: Of 698 patients included in the study (mean age 29 years; range 12-45 years; 75.8% male), 581 (83.2%) had a good outcome, and 117 (16.8%) met the primary outcome measure, namely a poor outcome, including 88 (12.6%) patients who died. 453 (64.9%) patients had an injury severity score (ISS) of 16-40, and 102 (14.6%) patients had an ISS>40. 220 (31.5%) patients underwent head injury related operation. The mean length of stay in the intensive care unit (ICU) was 3.9 days. Univariate analysis showed that high ISS, Emergency Department (ED) systolic blood pressure (SBP)>160mmHg or <90mmHg, respiratory rate<12/min or >24/min, low ED Glasgow Coma Score (GCS), trauma call activation, head related operation and ICU admission were related to poor outcome. Multivariate analysis showed that high ISS, low or high ED SBP and low ED GCS were related to poor functional outcome. CONCLUSION: This study showed that ISS, ED SBP and ED GCS were related to poor functional outcome. Gender showed no statistically significant relationship with functional outcome.