Emergency department critical care unit for critically ill cardiovascular patients: An observation study

BACKGROUND

We investigated an intensive care model for acute critically cardiovascular emergency patients in the emergency department (ED) as compared with those in the coronary care unit (CCU) after ED visits.

METHODS

We performed a retrospective cohort analysis of patients with acute cardiovascular emergency admitted to the intensive care unit in the ED (EICU) or CCU from January 1, 2010 to March 31, 2011 in an university-affiliated medical center. All clinical characteristics or predictors possibly related to in-hospital mortality were documented, completed, and measured via electronic medical records review. The clinical independent variables with p < 0.1 in univariate analysis were further analyzed by using multiple logistic regression. Survival analysis of the predictors for hospital mortality was assessed by Kaplan-Meier survival curves.

RESULTS

A total of 964 patients were recruited in this study. Of all patients, 328 were enrolled in the EICU group, whereas 636 were enrolled in the CCU group. Multiple regression analysis of both EICU and CCU mortality demonstrated that Acute Physiology and Chronic Health Evaluation II scores were common predictors of mortality in both groups of patients. Based on these scores, Kaplan-Meier survival curves showed no statistically significant differences of cumulative survival rates in both the 7-day and in-hospital survival between both groups.

CONCLUSION

Our study demonstrated a feasible and qualified model of intensive care delivery accomplished by collaboration of emergency physicians and cardiologists for acute critically ill cardiovascular emergency patients after initial ED management. Our results suggest that an expanded multicenter study should be conducted to further test and confirm this intriguing model.

Interhospital transfer neurological deterioration in patients with spontaneous intracerebral haemorrhage: incidence and risk factors

OBJECTIVE

To explore the incidence and risk factors for interhospital transfer neurological deterioration (IHTND) in patients with spontaneous intracerebral haemorrhage (SICH).

METHODS

Consecutive adult patients with first-ever SICH referred to our emergency department (ED) and transported by ambulance from July 2011 through June 2015 were eligible for this prospective observational study. Enrolled patients had SICH with elapsed time <12 hours and a nearly normal Glasgow Coma Scale (GCS) score (≥13) at presentation. IHTND was defined as GCS score drop ≥2 points during the time from last GCS measure in first ED (shortly before transport) and first measure in second ED (shortly after arrival), which was confirmed by the accompanying nurse practitioner. The potential risk factors for IHTND were screened by χ² test, unpaired t test (parametric data) or Mann-Whitney U test (non-parametric data) in univariate analysis. Multiple logistic regression analysis was used to adjust for other covariates.

RESULTS

Among 217 enrolled patients, 36 (16.6%) had IHTND. After adjustment for other covariates in multiple logistic regression analysis, the significant predictors of IHTND were arrival systolic blood pressure ≥180 mm Hg (p=0.026, OR=2.741, 95% CI 1.126 to 6.674), infratentorial ICH (p=0.015, OR=3.182, 95% CI 1.248 to 8.113), presence of intraventricular haemorrhage (p=0.023, OR=2.533, 95% CI 1.137 to 5.645) and larger ICH (by 1 mL increment of haematoma, p=0.013, OR=1.027, 95% CI 1.006 to 1.048).

CONCLUSIONS

About one-sixth of referred not comatose patients with SICH developed IHTND. Some risk factors were identified for the first time. Modifying procedures for proper transfer of patients at high-risk for IHTND might help in safely transferring patients with SICH.

Association between hyperglycaemic crisis and long-term major adverse cardiovascular events: a nationwide population-based, propensity score-matched, cohort study

OBJECTIVE

Hyperglycaemic crisis was associated with significant intrahospital morbidity and mortality. However, the association between hyperglycaemic crisis and long-term cardiovascular outcomes remained unknown. This study aimed to investigate the association between hyperglycaemic crisis and subsequent long-term major adverse cardiovascular events (MACEs).

PARTICIPANTS AND METHODS

This population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database for the period of 1996-2012. A total of 2171 diabetic patients with hyperglycaemic crisis fit the inclusion criteria. Propensity score matching was used to match the baseline characteristics of the study cohort to construct a comparison cohort which comprised 8684 diabetic patients without hyperglycaemic crisis. The risk of long-term MACEs was compared between the two cohorts.

RESULTS

Six hundred and seventy-six MACEs occurred in the study cohort and the event rate was higher than that in the comparison cohort (31.1% vs 24.1%, p<0.001). Patients with hyperglycaemic crisis were associated with a higher risk of long-term MACEs even after adjusting for all baseline characteristics and medications (adjusted HR=1.76, 95% CI 1.62 to 1.92, p<0.001). Acute myocardial infarction had the highest adjusted HR (adjusted HR=2.19, 95% CI 1.75 to 2.75, p<0.001) in the four types of MACEs, followed by congestive heart failure (adjusted HR=1.97, 95% CI 1.70 to 2.28, p<0.001). Younger patients with hyperglycaemic crisis had a higher risk of MACEs than older patients (adjusted HR=2.69 for patients aged 20-39 years vs adjusted HR=1.58 for patients aged >65 years).

CONCLUSIONS

Hyperglycaemic crisis was significantly associated with long-term MACEs, especially in the young population. Further prospective longitudinal study should be conducted for validation.

Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study

OBJECTIVES

To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition.

SETTING

A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan.

PARTICIPANTS

Adult ED visits (aged ≥18 years) during 2009-2013, with or without receiving CT, were enrolled as the study participants.

MAIN OUTCOME MEASURES

For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay.

RESULTS

In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013).

CONCLUSIONS

ED CT utilisation rates increased significantly during 2009-2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective.

Contrast Medium Exposure During Computed Tomography and Risk of Development of End-Stage Renal Disease in Patients With Chronic Kidney Disease: A Nationwide Population-Based, Propensity Score-Matched, Longitudinal Follow-Up Study

The aim of the study was to investigate the long-term association between contrast medium exposure during computed tomography (CT) and the subsequent development of end-stage renal disease (ESRD) in patients with chronic kidney disease (CKD). We conducted a population-based cohort study using Taiwan's National Health Insurance Research Database. A total of 7100 patients with nonadvanced CKD who underwent contrast medium-enhanced CT were identified and served as the study cohort. To avoid selection bias, we used the propensity score to match 7100 nonadvanced CKD patients, who underwent noncontrast medium-enhanced CT to serve as the comparison cohort. The age, sex, index year, and frequency of undergoing CTs were also matched between the study and comparison cohorts. Participants were followed until a new diagnosis of ESRD or December 31, 2011. Hazard ratios (HRs) with 95% confidence interval (95% CI) were calculated using the Cox proportional hazards regression. Contrast medium exposure was not identified as a risk factor for developing ESRD in nonadvanced CKD patients after confounders adjustment (adjusted HR = 0.91; 95% CI, 0.66-1.26; P = 0.580). We further divided the patients who underwent CTs with contrast medium use into ≤1 exposure per year on average, >1 and <2 exposure per year on average, and ≥2 exposure per year on average. After adjusting for confounders, we identified a much higher risk for developing ESRD in the 2 groups of >1 and <2 exposure per year on average and ≥2 exposure per year on average (adjusted HR = 8.13; 95% CI, 5.57-11.87 and adjusted HR = 12.08; 95% CI, 7.39-19.75, respectively) compared with the patients who underwent CTs without contrast medium use. This long-term follow-up study demonstrated that contrast medium exposure was not associated with an increased risk of ESRD development in nonadvanced CKD patients.

Trends in computed tomography utilisation in the emergency department: A 5 year experience in an urban medical centre in northern Taiwan

BACKGROUND

Steady increase in computed tomography (CT) utilisation in the ED was observed in countries such as the USA, Canada, China and Korea; however, limited empirical data are available regarding Taiwan.

OBJECTIVE

The objective of the present study is to quantify and compare trends in CT utilisation in the ED over a 5 year period in a medical centre in Taiwan.

METHODS

Electronic chart review was performed in a medical centre with an annual ED census of 80 000 patients. Subjects >20 years of age who underwent CT scans during ED visits from 1 January 2005 to 31 December 2009 were identified.

RESULTS

Among the 333 673 adult ED visits, 43 635 received CT scans, with a utilisation rate of 131 per 1000. Within the 5 year span, patient volume increased by 7.7%, whereas CT utilisation increased by 42.7%. The rates of increase in patient volume and CT utilisation were 5.0% and 32.4% in non-trauma; 19.7% and 97.8% in trauma. CT scans were mostly performed on the head (47%), abdomen (36%), followed by chest (10%) and miscellaneous (7%). An increase of 168% in spinal CTs for trauma patients was observed. An increase in CT utilisation was found in all age groups with a proportionate increase with increasing age in both trauma and non-trauma.

CONCLUSION

ED CT utilisation has increased at a rate far exceeding the growth in ED patient volume. This may be attributed to the improved utility of CT in diagnosing serious pathology, more diagnostic indications for CT, ready availability and the necessity for diagnostic certainty in the ED.

Correction: Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury

[This corrects the article DOI: 10.1371/journal.pone.0133146.].

Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation

Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p<0.001), a lower rate of ileum involvement (26.7% vs. 77.4%, p<0.001) and a higher rate of ascites (96.7% vs. 64.2%, p<0.001) compared with patients with AMI. Neither pneumatosis intestinalis (p<0.001) nor portomesenteric gas (p<0.01) were detected in SIIH patients but were observed in AMI patients. A receiver-operating characteristic (ROC) curve analysis showed that the optimal cut-off value for maximal intestinal wall thickening between groups was 10.4 mm and the area under the ROC curve between groups was 0.752 (p<0.0001). A multiple logistic regression analysis showed that the independent predictors of SIIH were non-involvement of the ileum (odds ratio, OR, 6.998; p=0.001), maximal intestinal wall thickening ≥10.4 mm (OR, 5.748; p=0.040) and ascites (OR, 13.348; p=0.023). The area under the ROC curve for the model was 0.854 (p<0.001). Conclusion The independent predictors of SIIH from AMI after abdominal CT in acute abdominal patients include non-involvement of the ileum, intestinal wall thickening ≥10.4 mm, and ascites.

Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan

BACKGROUND

In-hospital cardiac arrest (IHCA) is a catastrophic complication for patients while admitted in a medical institution. The outcome of IHCA remains poor, and understanding of the prognostic factors for survival outcome after IHCA is lacking, specifically in an oriental population.

METHODS

A retrospective observational cohort study of 382 patients with IHCA who required resuscitation was conducted in an urban tertiary hospital in Taiwan. Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.

RESULTS

The incidence of IHCA was 3.25 per 1000 admissions. These patients had a mean age of 67.2 ± 21.7 years and were mostly men (66.5%). The rate of successful ROSC was 66%, and the rate of survival to hospital discharge was 11.8%. A stepwise decrease in ROSC was observed with additional resuscitation efforts. Independent predictors for survival to hospital discharge were being female, a resuscitation duration of <20 minutes, and no use of epinephrine during resuscitation. A 68% ROSC success rate and an 84% survival to discharge rate was recorded in patients receiving resuscitation for <30 minutes. Young patients seemed the most likely to benefit from longer resuscitation attempts (>30 minutes), as observed in survival to hospital discharge.

CONCLUSION

Based on data from a single hospital registry in East Asia, a shorter duration of resuscitation was demonstrated to be a predictor of immediate survival with ROSC and survival to hospital discharge.

Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury

BACKGROUND

Ultramarathon is a high endurance exercise associated with a wide range of exercise-related problems, such as acute kidney injury (AKI). Early recognition of individuals at risk of AKI during ultramarathon event is critical for implementing preventative strategies.

OBJECTIVES

To investigate the impact of speed variability to identify the exercise-related acute kidney injury anticipatively in ultramarathon event.

METHODS

This is a prospective, observational study using data from a 100 km ultramarathon in Taipei, Taiwan. The distance of entire ultramarathon race was divided into 10 splits. The mean and variability of speed, which was determined by the coefficient of variation (CV) in each 10 km-split (25 laps of 400 m oval track) were calculated for enrolled runners. Baseline characteristics and biochemical data were collected completely 1 week before, immediately post-race, and one day after race. The main outcome was the development of AKI, defined as Stage II or III according to the Acute Kidney Injury Network (AKIN) criteria. Multivariate analysis was performed to determine the independent association between variables and AKI development.

RESULTS

26 ultramarathon runners were analyzed in the study. The overall incidence of AKI (in all Stages) was 84.6% (22 in 26 runners). Among these 22 runners, 18 runners were determined as Stage I, 4 runners (15.4%) were determined as Stage II, and none was in Stage III. The covariates of BMI (25.22 ± 2.02 vs. 22.55 ± 1.96, p = 0.02), uric acid (6.88 ± 1.47 vs. 5.62 ± 0.86, p = 0.024), and CV of speed in specific 10-km splits (from secondary 10 km-split (10th - 20th km-split) to 60th - 70th km-split) were significantly different between runners with or without AKI (Stage II) in univariate analysis and showed discrimination ability in ROC curve. In the following multivariate analysis, only CV of speed in 40th - 50th km-split continued to show a significant association to the development of AKI (Stage II) (p = 0.032).

CONCLUSIONS

The development of exercise-related AKI was not infrequent in the ultramarathon runners. Because not all runners can routinely receive laboratory studies after race, variability of running speed (CV of speed) may offer a timely and efficient tool to identify AKI early during the competition, and used as a surrogate screening tool, at-risk runners can be identified and enrolled into prevention trials, such as adequate fluid management and avoidance of further NSAID use.

Early changes of the anemia phenomenon in male 100-km ultramarathoners

BACKGROUND

Sports anemia is a widely observed phenomenon after prolonged running. There are various factors that contribute to sports anemia, including hemodilution, exercise-induced oxidative stress, iron deficiency, gastrointestinal bleeding, hematuria, and hemolysis resulting from foot-strike and/or from compression of contracting muscles on capillaries. Until now, there has been no published report that describes the overall hematological, urinary, and fecal consequences in Asian male ultramarathoners after a 100-km (62.5-mile) ultramarathon event.

METHODS

A total of 25 male runners were recruited into our study. Blood was drawn 1 week before, immediately after, and then 24 hours subsequent to the race. Hematological samples were analyzed for the anemia phenomenon. Additionally, urinary and fecal samples were collected before and after the race for detection of occult blood.

RESULTS

The blood hemoglobin and erythropoietin values of the recruited runners showed a statistically significant rise in the immediate post-race values and a rapid drop in values at 24 hours post-race. Blood concentrations of red blood cells and hematocrit were significantly lower at 24 hours post-race compared with pre-race. The white blood cell count, interleukin-6, tumor necrosis factor-alpha, high-sensitivity C-reactive protein, and ferritin all showed significant increases both immediately after and 24 hours post-race compared with pre-race hematological values. There were immediate decreases of both haptoglobin and iron, as well as an increase of total iron-binding capacity levels in post-race blood tests. For both urinary and fecal samples, there was a statistically significant difference between the pre- and post-race results in occult blood.

CONCLUSION

Running a 100-km ultramarathon will induce substantial sports anemia, and oxidative stress response, hemolysis, hematuria, and gastrointestinal bleeding are typical factors that contribute to its onset.

Acute pancreatitis with an intramural duodenal hematoma

The patient was a 43-year-old man admitted to the hospital with intermittent epigastric pain and vomiting, without any evidence of trauma. Blood tests showed elevated lipase/amylase levels. Abdominal computed tomography (CT) revealed pancreatitis complicated by an intramural duodenal hematoma (IDH). He was conservatively treated, and one month after admission, follow-up panendoscopy showed normal duodenal mucosa without luminal narrowing. Non-traumatic IDH is typically associated with coagulation abnormalities. Abdominal CT is an excellent tool for diagnosis in cases of acute abdomen. However, the pathogenesis of and relationship between IDH and pancreatitis remain unknown.

An unusual case of silent acute ST-elevation myocardial infarction following amphetamine use

We report a case of silent acute ST-elevation myocardial infarction associated with amphetamine use in a 62 years old diabetic man. The patient was devoid of chest pain and had a normal cardiac enzyme analysis at the initial presentation. A routine electrocardiogram demonstrated acute inferior wall ST-elevation myocardial infarction. Coronary angiography confirmed a total occlusion of the posterior lateral branch of right coronary artery. The patient underwent successful percutaneous transluminal coronary angioplasty with stent placement. Amphetamine abuse may play a role in acute myocardial infarction. Adverse cardiovascular manifestations of amphetamine can occur with sudden overt chest pain or present insidiously. In view of the potential association of amphetamine and myocardial infarction, physicians should not rely only upon clinical symptoms. This report highlights the diabetic patients with amphetamine abuse should undergo a routine electrocardiogram in such circumstances.

The association between on-scene blood pressure and early neurological deterioration in patients with spontaneous intracerebral haemorrhage

OBJECTIVE

To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH).

METHODS

This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the -2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness.

RESULTS

After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs.

CONCLUSIONS

Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END.

How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia

OBJECTS

The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED).

METHOD

We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT.

RESULTS

The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007).

CONCLUSION

Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.

Improved survival outcome with continuous chest compressions with ventilation compared to 5:1 compressions-to-ventilations mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BACKGROUND

Fewer pauses and better chest compression quality are thought to improve overall survival following cardiac arrest. This study aimed to measure the outcomes of adult nontraumatic out-of-hospital cardiac arrests (OHCAs) treated with 5:1 compressions-to-ventilations (Thumper 1007) or continuous chest compressions with ventilation (Thumper 1008 CCV) mechanical cardiopulmonary resuscitation (CPR) within a specified period of time.

METHODS

A retrospective observational cohort study of 515 adults with OHCA was conducted at the emergency department of an urban tertiary hospital. There were 307 patients in the Thumper 1007 phase (January 2008 to December 2009) and 208 patients in the Thumper 1008 CCV phase (January 2010 to May 2011). Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.

RESULTS

Patients in the Thumper 1007 and Thumper 1008 CCV phases had comparable results with the following exceptions: less hypertension (42.4% vs. 62.0%), cerebrovascular accidents (11.4% vs. 25.0%), and faster emergency medical service response time intervals (mean, 3.7 vs. 4.5 minutes) with the Thumper 1007. The average ambulance transport time was 6.1 minutes in both phases. The rates of ROSC [35.1% vs. 23.5%; adjusted odds ratio (OR), 1.616; 95% confidence interval (CI), 1.073-2.432] and survival to hospital discharge (10.1% vs. 4.2%; adjusted OR 2.431; 95% CI, 1.154-5.120) were significantly higher with the Thumper 1008 CCV than with the Thumper 1007. Favorable neurologic outcome upon discharge, defined as cerebral performance category scores of 1 (good performance) or 2 (moderate disability), was not significantly different between the two phases [1.6% (5/307) vs. 1.9% (4/208); p = 0.802]. The Thumper 1008 CCV provided significantly faster average chest compression rates and shorter no-chest compression intervals than the Thumper 1007 after activation.

CONCLUSION

In an emergency department with short ambulance transport times, continuous chest compressions with ventilation through mechanical CPR showed improved outcomes, including ROSC and survival to hospital discharge, in an adult with OHCA. However, there are a variety of confounding influences that may affect the validity of conclusions that have been drawn.

Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan

OBJECTIVE

To investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation.

DESIGN

This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from 'on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and 'objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using χ(2) statistics or t test.

RESULTS

Of the 20,512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165).

CONCLUSION

The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.