The practice and safety profile of endotracheal intubation in an emergency department: A single-center study in Shenzhen, China

Objectives:

Endotracheal intubation is an essential skill of every emergency department clinician. The current practice of emergency intubation in the emergency departments in China and its safety is largely unknown. This study aimed at evaluating the practice and the safety profile of emergency intubation in an emergency department in Shenzhen.

Methods:

This study was of retrospective design. It was conducted in the emergency department of a university affiliated hospital. All patients requiring emergency intubation from 1 January 2017 to 30 June 2018 were recruited. Data on demographic and clinical characteristics of patients and characteristics of intubations were collected and analyzed.

Results:

A total of 128 patients were analyzed. Patients with spontaneous intracerebral hemorrhage were most common. Airway protection for patency was the most common indication of intubation. Most intubations were performed by emergency department staff with direct laryngoscopy. The first attempt success rate was 93.8%. Serious adverse events were rare.

Conclusion:

The practice of endotracheal intubation in the emergency department is in line with international ones. The safety profile is good. A national registry of emergency airway management is recommended.

Prehospital electrocardiogram shortens ischaemic time in patients with ST-segment elevation myocardial infarction

INTRODUCTION

Total ischaemic time should be shortened as much as possible in patients with ST-segment elevation myocardial infarction (STEMI). This study evaluated whether prehospital 12-lead electrocardiogram (ECG) could shorten system delay in STEMI management.

METHODS

From November 2015 to November 2017, 15 ambulances equipped with X Series Monitor/ Defibrillator (Zoll Medical Corporation) were used in the catchment area of Queen Mary Hospital, Hong Kong. Prehospital ECG was performed for patients with chest pain; the data were tele-transmitted to attending emergency physicians at the Accident and Emergency Department (AED) for rapid assessment. Data from patients with STEMI who were transported by these 15 ambulances were compared with data from patients with STEMI who were transported by ambulances without prehospital ECG or who used self-arranged transport.

RESULTS

Data were analysed from 197 patients with STEMI. The median patient delay for activation of the emergency response system was 90 minutes; 12% of patients experienced a delay of >12 hours. There was a significant difference in delay between patients transported by ambulance and those who used self-arranged transport (P<0.001). For system delay, the use of prehospital ECG shortened the median time from ambulance on scene to first ECG (P<0.001). When performed upon ambulance on scene, prehospital ECG was available 5 minutes earlier than if performed in ambulance compartment before departure. Use of prehospital ECG significantly shortened AED door-to-triage time, AED door-to-first AED ECG time, AED door-to-physician consultation time, and length of stay in the AED (P<0.001 for all comparisons).

CONCLUSION

Prehospital ECG shortened ischaemic time prior to hospital admission.

Hong Kong needs a territory-wide registry for out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is an urgent disease entity, and the outcomes of OHCA are poor. This causes a significant public health burden, with loss of life and productivity throughout society. Internationally, successful programmes have adopted various survival enhancement measures to improve outcomes of OHCA. A territory-wide organised survival enhancement campaign is required in Hong Kong to maintain OHCA survival rates that are comparable to those of other large cities. One key component is to establish an OHCA registry, such as those in Asia, the United States, Europe, Australia, and New Zealand. An OHCA registry can provide benchmarking, auditing, and surveillance for identification of weak points within the chain of survival and evaluation of the effectiveness of survival enhancement measures. In Hong Kong, digitisation of records in prehospital and in-hospital care provides the infrastructure for an OHCA registry. Resources and governance to maintain a sustainable OHCA registry are necessary in Hong Kong as the first step to improve survival and outcomes of OHCA.

Prehospital 12-lead electrocardiogram for patients with chest pain: a pilot study

INTRODUCTION

After ST-segment elevation myocardial infarction (STEMI), it is vital to shorten reperfusion time. This study examined data from a pilot project to shorten the door-to-balloon (D2B) time by using prehospital 12-lead electrocardiogram (ECG).

METHODS

Fifteen ambulances equipped with X Series^® Monitor/Defibrillator (Zoll Medical Corporation) were deployed to the catchment area of Queen Mary Hospital, Hong Kong, from November 2015 to December 2016. For patients with chest pain, prehospital 12-lead ECG was performed and tele-transmitted to attending physicians at the accident and emergency department for immediate interpretation. The on-call cardiologist was called before patient arrival if STEMI was suspected. Data from this group of patients with STEMI were compared with data from patients with STEMI who were transported by ambulances without prehospital ECG or by self-arranged transport.

RESULTS

From 841 patients with chest pain, 731 gave verbal consent and prehospital ECG was performed and transmitted. Of these, 25 patients with clinically diagnosed STEMI required emergency coronary angiogram with or without primary percutaneous coronary intervention. The mean D2B time for these 25 patients (93 minutes) was significantly shorter (P=0.003) than that for 58 patients with STEMI transported by ambulances without prehospital ECG (112 minutes) and that for 41 patients with STEMI with self-arranged transport (138 minutes). However, shorter reperfusion time was only recorded during daytime hours (08:00-17:59). No statistically significant difference in 30-day mortality was found.

CONCLUSION

Prehospital ECG is technologically feasible in Hong Kong and shortens the D2B time. However, shorter reperfusion time was only recorded during daytime hours.

Public access defibrillation in Hong Kong in 2017

The concept of public access defibrillation was proposed more than 20 years ago. Since then, various programmes have been implemented in many major cities although not all have been successful. Fourteen years ago, the question of whether Hong Kong needed public access defibrillation was raised. This article aimed to answer this question based on the best available evidence. Over the years, the clinical effectiveness of public access defibrillation in out-of-hospital cardiac arrest has been proven. Nonetheless various studies have indicated that among others, cost-effectiveness, knowledge and attitudes of the public, and incidence of ventricular fibrillation are important factors that will affect the likelihood of success of such programmes. In Hong Kong, because of the long interval between recognition of arrest and first defibrillation, public access defibrillation is probably needed. To ensure the success of such a programme, careful planning in addition to the installation of more automated external defibrillators are essential.

Evaluation of the Appropriateness of Acute Hospitalisations in Hong Kong

Objective

To test the validity of the Hong Kong version of Appropriateness Evaluation Protocol and estimate the prevalence of inappropriate acute hospitalisations in Hong Kong.

Methods

A retrospective chart review of two hundred randomly selected patients admitted to the specialty of Internal Medicine and General Surgery via the Accident & Emergency department of 2 regional hospitals in 2008. Comparison between the Hong Kong version of Appropriateness Evaluation Protocol and the consensus of an expert panel on appropriateness of admissions was made. The extent of agreement between the reviewer using the protocol and the expert panel was measured.

Results

The kappa coefficient for agreement was 0.73 (95% confidence interval: 0.63-0.83). The prevalence of inappropriate acute hospitalisations was 29%.

Conclusions

The Hong Kong version of Appropriateness Evaluation Protocol is a valid tool for assessing the appropriateness of acute hospitalisations.

The Attitude of the Medical Students of the University of Hong Kong towards Emergency Medicine

Introduction

Understanding how medical students view the Specialty of Emergency Medicine is important. The knowledge helps the leaders in Emergency Medicine better plan the development of the specialty. In the medical literature, few studies primarily investigated this subject. Most were on the career choice of medical students. This study aimed at addressing this knowledge gap.

Methods

It was a cross-sectional questionnaire survey of the year 3 to 5 medical students studying at the Li Ka Shing Faculty of Medicine, the University of Hong Kong. The questionnaire measuring their attitude consisted of 16 items in 3 domains: overall merits of Emergency Medicine, the role and function of emergency physicians and the career prospect in Emergency Medicine. Descriptive statistics were used for data analysis. Their attitude was represented by an attitude score with 80 being most positive and 16 most negative.

Results

A total of 298 students participated in the survey. The response rate was 64.5%. The overall median attitude score was 59. Year 5 students had a statistically significant higher score. Emergency Medicine ranked third in their first specialty choice after qualification. There was no statistical relationship between a student's attitude score and the specialty choice.

Conclusion

The students' overall attitude towards Emergency Medicine was positive. Senior students held a more positive attitude. A student's specialty choice after qualification did not seem to relate to their attitude towards the specialty. (Hong Kong j.emerg.med. 2014;21:67-72)

The Effect of Wearing a Face Mask on Body Temperature

Objective

To investigate the effect of wearing a face mask on body temperature in healthy subjects.

Methods

The study was of repeated measures design. It was conducted from July to August 2003 in two accident & emergency departments on Hong Kong Island. Staff of the two departments, who were free from any active disease at the time of measurement, were recruited. Their body temperature (oral and aural) was measured while they were not wearing a mask and at 30 minutes after they had worn a mask (either surgical mask or N95 mask). Paired t-test was used for significance testing. Pearson product-moment correlation coefficient was calculated to elucidate the relationship between oral and aural temperature measurement.

Results

Ninety-three subjects were included. Oral temperature was significantly higher when a mask was worn (p=0.002, 95% CI 0.06–0.26). When considered separately, only those wearing N95 mask demonstrated such significance (p=0.005, 95% CI 0.088–0.454). The correlation coefficient for oral/aural temperature measurements was 0.219 (without mask, p=0.035) and 0.169 (with mask, p=0.104).

Conclusion

Wearing a face mask may increase the oral temperature in healthy subjects. However, the difference may not be clinically significant.

Out-of-hospital cardiac arrest in Hong Kong: a territory-wide study

INTRODUCTION

Out-of-hospital cardiac arrest is a global health care problem. Like other cities in the world, Hong Kong faces the impact of such events. This study is the first territory-wide investigation of the epidemiology and outcomes of out-of-hospital cardiac arrest in Hong Kong. It is hoped that the findings can improve survival of patients with cardiac arrest.

METHODS

This study was a retrospective analysis of the prospectively collected data on out-of-hospital cardiac arrest managed by the emergency medical service from 1 August 2012 to 31 July 2013. The characteristics of patients and cardiac arrests, timeliness of emergency medical service attendance, and survival rates were reported with descriptive statistics. Predictors of 30-day survival were evaluated with logistic regression.

RESULTS

A total of 5154 cases of out-of-hospital cardiac arrest were analysed. The median age of patients was 80 years. Most arrests occurred at the patient's home. Ventricular fibrillation or ventricular tachycardia was identified in 8.7% of patients. The median time taken for the emergency services to reach the patient was 9 minutes. The median time to first defibrillation was 12 minutes. Of note, 2.3% of patients were alive at 30 days or survived to hospital discharge; 1.5% had a good neurological outcome. Location of arrest, initial electrocardiogram rhythm, and time to first defibrillation were independent predictors of survival at 30 days.

CONCLUSION

The survival rate of out-of-hospital cardiac arrest patients in Hong Kong is low. Territory-wide public access defibrillation programme and cardiopulmonary resuscitation training may help improve survival.

Public knowledge of how to use an automatic external defibrillator in out-of-hospital cardiac arrest in Hong Kong

INTRODUCTION

The survival rate of out-of-hospital cardiac arrest in Hong Kong is low. A long delay between collapse and defibrillation is a contributing factor. Public access to defibrillation may shorten this delay. It is unknown, however, whether Hong Kong's public is willing or able to use an automatic external defibrillator. This study aimed to evaluate public knowledge of how to use an automatic external defibrillator in out-of-hospital cardiac arrest.

METHODS

A face-to-face semi-structured questionnaire survey of the public was conducted in six locations with a high pedestrian flow in Hong Kong.

RESULTS

In this study, 401 members of the public were interviewed. Most had no training in first aid (65.8%) or in use of an automatic external defibrillator (85.3%). Nearly all (96.5%) would call for help for a victim of out-of-hospital cardiac arrest but only 18.0% would use an automatic external defibrillator. Public knowledge of automatic external defibrillator use was low: 77.6% did not know the location of an automatic external defibrillator in the vicinity of their home or workplace. People who had ever been trained in both first aid and use of an automatic external defibrillator were more likely to respond to and help a victim of cardiac arrest, and to use an automatic external defibrillator.

CONCLUSION

Public knowledge of automatic external defibrillator use is low in Hong Kong. A combination of training in first aid and in the use of an automatic external defibrillator is better than either one alone.

Clinical profile of patients with undiagnosed human immunodeficiency virus infection presenting to a local emergency department: a pilot study

OBJECTIVES

To investigate the clinical profile of patients unaware of having human immunodeficiency virus (HIV) infection on presentation to the emergency department and provide a direction for future prospective studies on undiagnosed HIV infection in emergency department patients.

DESIGN

Retrospective, descriptive case series.

SETTING

A university teaching hospital in Hong Kong. Patients Patients who were diagnosed for the first time with HIV infection or acquired immunodeficiency syndrome after presenting to the accident and emergency department from 2001 to 2011. Main outcome measures Demographic and clinical characteristics of the recruited patients.

RESULTS

Forty-four patients satisfied the inclusion criteria and were analysed. Most patients (36%) were 40 to 49 years old. Heterosexual practice was admitted by 73% of them. Fever (48%) was the commonest presenting symptom. Ten patients died during their index admission. There were no significant differences between those who died and survivors with regard to gender, age, triage category, and CD4 cell counts. Nor were there any significant differences in gender, age distribution, and sexual orientation in these patients compared with the sample used in surveillance studies by the Centre for Health Protection in Hong Kong.

CONCLUSION

Patients unaware of HIV infection are not commonly encountered in accident and emergency department settings. Targeted screening of males aged between 20 and 49 years may increase the yield of HIV testing in such settings.

Validation of the Hong Kong accident and emergency triage guidelines

OBJECTIVE. To validate the Hong Kong Accident and Emergency Triage guidelines. DESIGN. Retrospective chart review. SETTING. The Accident and Emergency Department of a tertiary hospital in Hong Kong. PARTICIPANTS. Patients who attended the Accident and Emergency Department on one day in February 2012. MAIN OUTCOME MEASURES. The inter-rater reliability in two pairs of nurses grouped according to experience and validity as compared with an expert panel. RESULTS. Of the 100 patients recruited and triaged into levels 1 to 5, the weighted kappa coefficient (inter-rater reliability) for the two pairs of nurses was 0.699 and 0.717, respectively. The weighted kappa coefficient for validity was 0.766. When only patients in triage levels 3 and 4 were included, the weighted kappa coefficient for reliability dropped to 0.632 and 0.585, respectively. The weighted kappa coefficient for validity also decreased to 0.558. CONCLUSIONS. The overall inter-rater reliability and validity of the Guidelines appeared acceptable. Further revision of the Guidelines on triaging patients to levels 3 or 4 is probably necessary.

Who should be admitted to hospital? Evaluation of a screening tool

OBJECTIVE

To develop a tool for evaluating the appropriateness of acute hospital admissions in Hong Kong and test its reliability.

DESIGN

The tool was based on the Appropriateness Evaluation Protocol and consensus of local Emergency Medicine specialists. Reliability was tested through retrospective chart review.

SETTING

Tertiary teaching hospital, Hong Kong.

PATIENTS

Seventy-five randomly selected patients, who were admitted to the specialty of Internal Medicine or General Surgery via the Accident and Emergency Department in 2006, were reviewed.

MAIN OUTCOME MEASURES

The intra-rater and inter-rater agreement on appropriateness of an admission.

RESULTS

A 19-criterion protocol for assessing the appropriateness of acute hospitalisations was constructed. The kappa coefficient for intra-rater agreement was 0.73 (95% confidence interval, 0.58-0.88) and that for inter-rater agreement was 0.67 (95% confidence interval, 0.51-0.83).

CONCLUSION

The new protocol was shown to have substantial reliability for evaluating whether an acute hospital admission was appropriate. The findings in this study provide a basis for testing the validity of the new protocol as well as determining the extent of inappropriate acute hospital admissions in Hong Kong.

Prognosis of patients with ventricular fibrillation in out-of-hospital cardiac arrest in Hong Kong: prospective study

OBJECTIVE

To determine the prognosis of patients with ventricular fibrillation in out-of-hospital cardiac arrest in Hong Kong and examine its relationship with the other links in the chain of survival.

DESIGN

Prospective descriptive study.

SETTING

Three accident and emergency departments, Hong Kong.

PARTICIPANTS

Patients older than 18 years with non-traumatic out-of-hospital cardiac arrest who were transported to the hospitals by ambulance between 15 March 1999 and 15 October 1999.

MAIN OUTCOME MEASURES

Demographic data, characteristics of the cardiac arrest and the response times of the emergency medical service according to the Utstein style, and survival to hospital discharge rate.

RESULTS

Three hundred and twenty patients were included. The incidence of ventricular fibrillation in this group of patients was 14.1%. The chance of survival to hospital discharge was significantly higher for patients with ventricular fibrillation than those with other rhythms of cardiac arrest (4.4% versus 0.7%). Approximately 40.0% of all cardiac arrests were witnessed. The bystander cardiopulmonary resuscitation rate was low at 15.6%. The median intervals for recognition to activation of the emergency medical service, time to cardiopulmonary resuscitation, time to defibrillation, and time to advanced life support were 1, 8, 9, and 27 minutes, respectively.

CONCLUSION

Patients with ventricular fibrillation in out-of-hospital cardiac arrest have a better chance of survival than those with other cardiac rhythms. Further improvement requires simultaneous strengthening of all four links in the chain of survival.

Out-of-hospital cardiac arrest in Hong Kong

OBJECTIVES

To evaluate the effectiveness of the local emergency medical services system in resuscitation of out-of-hospital cardiac arrest and identify areas for improvement.

METHODS

This was a prospective descriptive study of adults with nontraumatic out-of-hospital cardiac arrest treated in the three accident & emergency departments that serve the whole of Hong Kong Island from March 15, 1999, to October 15, 1999. Patient characteristics, circumstances of cardiac arrest, final outcomes, and response times of the ambulance service were recorded according to the Utstein style.

RESULTS

Three hundred twenty patients were included. There was male predominance, and the mean age was 71.5 years. The majority of cardiac arrests occurred at patients' homes. In 57.5% of cases the arrest was not witnessed. The bystander cardiopulmonary resuscitation (CPR) rate was 15.6%. The most common electrocardiographic (ECG) rhythm at scene was asystole. Ventricular fibrillation or pulseless ventricular tachycardia constituted 14.1%. The average call to dispatch interval was 1.04 minutes. The average call to CPR interval was 9.82 minutes. The average total prehospital interval was 27.55 minutes. The overall immediate survival rate was 14.1% and the rate of survival to hospital discharge was 1.25%.

CONCLUSION

The prognosis of out-of-hospital cardiac arrest in Hong Kong was dismal. Every link in the chain of survival has to be improved.