Delay In Admission Research Articles

Clinical characteristics and treatment of thallium poisoning in patients with delayed admission in China.

Thallium is highly toxic and its effects are cumulative. The clinical symptoms of thallium poisoning are non-specific, thereby delaying admission and treatment. This study aimed to summarize the clinical features and treatment experience of patients with delayed admission who experience thallium poisoning.We conducted a retrospective descriptive analysis of patients in our hospital from 2008 to 2018 who had thallium poisoning and experienced a delay in hospital admission. The time from symptom onset to admission was assessed. The patients were divided into 3 groups and descriptive analyses of their clinical characteristics, including basic patient information, symptoms, laboratory test results, examination findings, treatment methods, outcomes, and follow-up information, were conducted.A total of 34 patients with thallium poisoning were included: 8 were admitted to the hospital early or with mild delay, 9 had a moderate delay, and 17 had a severely delayed admission. The time from illness onset to admission was 13 (interquartile range, 7.5-26) days. Some patients with delayed admission had significant symptoms associated with central nervous system damage, and changes in magnetic resonance images and electroencephalograms were also noted. After admission, all patients received Prussian blue treatment, and some patients with relatively high blood concentration received blood purification treatments. Following treatment, the blood and urine thallium concentrations of all patients decreased significantly, and their symptoms were alleviated.Our results show that delayed patient admission in cases of thallium poisoning is associated with greater risk of central nervous system damage. Use of Prussian blue combined with blood purification treatments might improve patients' conditions.

Handling Transients of Dynamic Real-Time Workload Under EDF Scheduling

Real-time dynamic workload consists of tasks that can arbitrarily join and leave the system at run-time. To avoid incurring deadline misses, tasks that request to join the system must pass an admission test, which has to cope with potential scheduling transients originated by the residual effect of the tasks that previously left the system. This phenomenon may require some tasks to suffer an admission delay before being accepted for execution. This paper focuses on uniprocessor earliest-deadline first (EDF) scheduling with constrained deadlines and explicitly considers methods for handling scheduling transients in the presence of dynamic real-time workload. A generalized analysis framework is first presented to overcome several limitations of the existing approaches (including the support for overlapping transients), and is then used to derive methods for computing bounds on the admission delays incurred by tasks. Building on such results, an on-line protocol is proposed to handle the admission control of a dynamic workload, which also comes with a variant that can execute in polynomial time to favor its practical application. Furthermore, the paper shows how the presented analysis can be used off-line for analyzing mode-changes among static task sets. Experimental results are finally presented to evaluate the proposed algorithms.

Mortality profile of confirmed cases of swine flu attending a tertiary care center of Udaipur region of Rajasthan, India

Background: Mortality profile is an analytical tool used to identify the various factors responsible for poor outcome of disease and it can also use to evaluate quality and efficiency of healthcare providers. The aim of this study is to summarise the clinical and epidemiological factors as well as to identify the risk factors associated with mortality among swine flu cases.Methods: It is a cross-sectional, descriptive, hospital-based study conducted on 62 deceased patients due to swine flu reported at Maharana Bhupal Government Hospital, Udaipur, Rajasthan during the outbreak of influenza A H1N1 in the year 2015. A standardized pre-structured questionnaire with consent was filled by help of bed head tickets and by interview of attendants of deceased patients.Results: Deaths were higher among age group of 31-45 years (35.48%). Case fatality rate for male patients (13.88%) was higher. Mortality was highest in females of rural background 27(43.55%). Majority of deceased patients (70.97%) had delay of 4-7 days in admission after onset of symptoms. Diabetes, cardiovascular diseases and pregnancy was the major risk factors for poor outcome.Conclusions: Delay in diagnosis and admission may be the reason for higher mortality rate. The most common co morbid illness was Diabetes mellitus, cardiovascular diseases (Ischemic heart disease, Rheumatic heart disease, Hypertension) and pregnancy.

Environmental Factors But Not Viral Etiologies Affect the Outcome of Hospitalized Children with Pneumonia, 2009-2018

Background: A comprehensive analysis on meteorological, clinical and epidemiological features of respiratory viruses has been rarely described. Here we aimed to analyze the impact of demographic, viral etiological, and meteorological effects on clinical outcome of hospitalized children with acute respiratory tract infections (ARTIs). Methods: A surveillance of hospitalized children with ARTIs was conducted in one sentinel hospital from 2009 to 2018 in Chongqing, China. Respiratory specimens were collected and tested for the presence of eight common respiratory viruses. Host related factors, clinical information, meteorological factors were used for the random forest (RF) algorithm and linear regression model analysis to determine the factors that might affect the development and severity of pneumonia. Findings Altogether 7533 children with ARTIs were enrolled, with 6580 developing pneumonia, including 990 with severe pneumonia. Altogether 70.35% (5269/7490) children were positive for at least one virus, 1411 with two kinds of viruses and 375 with ≥three kinds of viruses. Children were more likely to develop severe pneumonia when the infections occurred under meteorological factors with lower temperature, larger temperature difference, higher wind speed, precipitation, SO2, PM10, NO2 and PM2.5. These metrological variables, together with the host related factor (age < 15 months old, lower body weight, longer delay in admission), can attain a good accuracy (AUC, 0.92) in predicting the disease severity, while viral infection status contributed with less effect in the model. Interpretation The meteorological factors had remarkable impacts on the development of severity pneumonia, which was less affected by the respiratory viral etiologies. Funding Statement: This study was supported by the China Mega-Project for Infectious Diseases grant (2018ZX10713002, 2018ZX10101003-002, 2017ZX10103004), the Natural Science Foundation of China (81825019, 81621005) and the Fundamental Research Funds for the Central Universities & Peking University Medicine Seed Fund for Interdisciplinary Research (BMU2018MX009). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Declaration of Interests: The authors declare no competing interest. Ethics approval number: The study was reviewed and approved by the ethical review committees of CHCMU.

Factors related to delayed intensive care unit admission from emergency department—A retrospective cohort study

The delays in transferring patients from emergency department (ED) to intensive care unit (ICU) are known to be linked with several adverse events, including prolonged ICU stay and increased hospital mortality. The factors associated with delayed ICU admission include shortage of ICU beds, organizational factors, ED overcrowding, and patient-related factors, including sepsis as admission diagnosis. The aim of this study was to examine ED-related factors associated with prolonged ED stay. The study population consisted of adult patients admitted (n=479) from ED to ICU between 31 May 2016 and 19 March 2017 in Oulu University Hospital. A patient's ED length of stay (LOS) exceeding 180minutes was considered delayed. Most of the patients (380, 79.3%) were admitted to the ICU within 3hours of hospital admission. In a logistic regression analysis, odds ratios (ORs) for ED LOS>180minutes were as follows: for Glasgow Coma Scale score>9, 2.73 (1.39-5.32); for thrombocytes<100×109 /mmol, 6.69 (2.32-19.26); for absence of pre-arrival notification, 5.27 (3.04-9.14); and for radiological examination, 3.95 (1.72-9.10). Trauma and intoxicated patients had shorter ED LOS while patients with medical conditions had more often prolonged admissions. The delays in ICU admissions were linked to therapeutic and diagnostic procedures and absence of pre-arrival notification. Patients were admitted to the ICU on the basis of diagnosis instead of clinical risk. However, the delays were not associated with worsening outcome, which indicates that sufficient care can be provided at the ED while the ICU admission is pending.

Burn scenario in a single North-Eastern State of India: A 5-year retrospective study

Introduction: The exact figure of burn injuries is still unavailable in many states of India. Some northeast Indian states with their unique social structure, hilly terrain, and practice of shifting (Jhum) cultivation the pattern of burn injuries in these states may be different.Materials and Methods: The burn records between March 2012 and April 2017 were retrospectively studied from all the district and private hospitals of the state. The demographic profiles, etiologies, delay in admission, percentage, and degrees of burn, hospital days, managements, and outcome on a single hill state of India were reviewed and analyzed. Results and Observations: The total number of patients studied was 450 with a mean age of 18.94 years. There were 281 male (62.4%), 168 female (37.3%), and one missing sex data, out of which 17 (4.2%) expired. Majority of the admission were in the winter season. The most common etiology was scald burn (55%). Suicidal intent was recorded in 8 patients (1.8%). The mean percentage of burn was 21.72%.Conclusion: The pattern of burn cases in the state showed marked variance from studies of other larger states of the country. Lifestyle modification, improving living standard, and active NGO participation seem to influence the low incidence of burn in the state.

Modern problems of stroke at different hospitalization stages based on the data of the Regional Vascular Center of Tyumen

To analyze clinical and organizational aspects of stroke patients care and factors affecting the outcomes of the disease at the prehospital and inpatient stages. The medical documentation of patients with acute vascular lesions of the brain who were admitted and were subsequently treated at the Regional Vascular Center in Tyumen in 2016-2018 was studied retrospectively. At the first stage, factors affecting the delay in admission of patients (n=173) to the hospital were identified. At the second stage, the frequency and nature of discrepancies in diagnoses were determined, as well as the main factors affecting mortality at each stage of hospitalization of patients. For this purpose, 1330 accompanying documents and 508 case histories of patients with transient ischemic attacks and cerebral infarction were studied. The main factor affecting the transfer of patients to the hospital outside the 'therapeutic window' was living alone (58.8%, p=0.01). There was a significant number of discrepancies in the diagnoses of the referring institution (73.7% in out-patient clinics and 61.9% in other referring hospitals (p<0.001)), the emergency department and the specialized vascular department of the inpatient department which were significantly correlated with the mortality rate. In cases when all three diagnoses differed, the probability of a fatal outcome increased from 18.9 to 80.0% (p<0.001).

Pre-intensive care unit intubation and subsequent delayed intensive care unit admission is independently associated with increased occurrence of ventilator-associated pneumonia.

Critically ill intubated patients are at risk for ventilator-associated pneumonia. However, intubation may not occur in intensive care unit (ICU) and subsequent ICU admission may be delayed. To evaluate whether intubation >24 h prior ICU admission and delay in ICU admission is associated with ventilator-associated pneumonia (VAP) in non-trauma critically ill patients. Prospective observational study conducted in a medical-surgical ICU of a tertiary hospital. Consecutive patients with >48 h of invasive mechanical ventilation and >72 h hospitalization, were recruited in the study. Pre-ICU intubation and delay in ICU admission, demographical, clinical, microbiological data and ICU interventions were assessed as risk factors for VAP and ICU mortality. 100 patients were included in the study. Pre-ICU intubation and delayed (>24 h) ICU admission (PDA patients) (P=0.014, OR=3.294, confidence interval 1.268-8.557) and SOFA score on ICU admission (P=0.045, OR=1.154, confidence interval 1.003-1.328) were independent risk factors for VAP in ICU care setting. Yet, PDA patients, presented significantly increased incidence of VAP due to MDR bacteria, mainly from Acinetobacter baumannii. Acinetobacter baumannii infection was the only independent risk factor for ICU mortality (P=0.049, OR=3.253, confidence interval 1.006-10.521). SOFA score on ICU admission, presented a fair prognostic accuracy of overall ICU mortality (SOFA≥8.5, AUC=0.850, P<0.001). Pre-ICU intubation and delayed ICU admission was independent risk factor for VAP Acinetobacter baumannii infection and a high SOFA score on ICU admission were predictors of increased ICU mortality.

Rapid incremental closed traction reduction of cervical facet fracture dislocation: the Stoke Mandeville experience.

Retrospective case series study. To determine the success rate and neurological outcomes of rapid incremental closed traction reduction (RICTR) of cervical dislocations with spinal cord compression in the National Spinal Injuries Centre (NSIC), between June 2006 and December 2011. Tertiary spinal injuries centre, Stoke Mandeville Hospital, UK. A list of cervical trauma patients who were admitted to NSIC between January 2006 and December 2011 was retrieved from the hospital's electronic records, consultant and admission logbooks. Patients, admitted within 7 days of cervical facet dislocation and spinal cord injury (SCI), were included. Retrospective data collection and analysis was done using a data collection form and an Excel spreadsheet. Seventeen patients have met the eligibility criteria of the study. One patient was excluded because he only had nerve root symptoms. The procedure was successful in 44% of the cases. Eighty-six percent of patients in the successful RICTR group improved in their discharge motor index score (MIS), whereas 43% improved in their post-reduction MIS. Overall, 81% of the cohort had improvements in their discharge MIS. Our RICTR success rate was low compared to the reported average success rate in the literature, likely due to delays in admission. Neurological outcomes were favourable in the majority of patients at discharge. In our opinion, early admission and RICTR attempts could have improved the results and therefore we would recommend that RICTR procedures are done for suitable patients in the Emergency Departments of Major Trauma Centres (MTC).

Clinical audit of intensive care unit admission relating to hypertensive disorders of pregnancy

Objective To assess the current practice in managing hypertensive disorders of pregnancy (HDP) and provide possible interventions to improve the quality of care. Methods A checklist was developed based on Chinese Medical Association's guideline on HDP. A criteria-based audit was conducted on 66 HDP patients who were admitted to the Intensive Care Unit (ICU) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School between January 1, 2014 and December 31, 2016. The quality of care during antepartum and hospitalized period were evaluated, and patient factors were also considered. We also collected data on patients' demographics, complications of HDP, acute physiology and chronic health evaluation (APACHE) Ⅱ score and duration of hospital stay. T or Mann-Whitney U test or Chi-square test was performed. Results (1) From 2014 to 2016, the number of deliveries in Nanjing Drum Tower Hospital was 18 573, with 1 561 cases (8.4%) of HDP. Among the 66 cases being audited, 44 (66.7%) were preeclampsia; 16 (24.2%) were preeclampsia complicated by chronic hypertension; six (9.1%) were eclampsia; no maternal death was reported. (2) Complications of HDP in this study included heart failure (17 cases, 25.8%), hemolysis, elevated liver enzyme levels, low platelet count (HELLP) syndrome (15 cases, 22.7%), anemia and/or thrombopenia requiring transfusion (12 cases, 18.2%), renal dysfunction (seven cases, 10.6%), eclampsia (six cases, 9.1%), pulmonary edema/acute respiratory distress syndrome (five cases, 7.6%), placenta abruption (four cases, 6.1%), cerebral venous and sinus thrombosis (two cases, 3.0%), cerebral hemorrhage (one case, 1.5%) and hepatic rupture (one case, 1.5%). Their APACHEⅡ score was 9.0±3.9. The duration of ICU and hospital stay was 2 (1-30) d and 8 (4-32) d, respectively. (3) Compared with the gravidas who registered during antenatal care, those without registrations were older [(33.0±6.0) vs (29.1±5.4) years old, t=-2.616], having less antenatal visits [2 (0-4) vs 5 (2-10) times, Z=110.000] and higher blood pressure on admission [(177.0±24.1) vs (155.5±24.6) mmHg of systolic blood pressure (t=-3.322), and (116.4±14.6) vs (108.0±18.7) mmHg of diastolic blood pressure (t=-3.013, 1 mmHg=0.133 kPa)], and only a few of them were nulliparas [23.8%(5/21) vs 71.1%(32/45), χ2=13.006] (all P<0.05). (4) Among the 66 cases, seven (10.6%) had preeclampsia history, but none of them received aspirin for HDP prevention; 21 (31.8%) did not have regular testing of blood pressure during antenatal check; 24 (36.4%) did not receive proper antenatal evaluation when hypertension was identified. (5) After excluding 20 cases directly admitted upon the first diagnosis of HDP, the rest 46 were managed in the outpatient department. Eighteen of them (39.1%) did not have blood pressure monitoring and 26 of them (56.5%) did not have a regular test of hemoglobin, platelet, urine protein, liver or renal function. (6) Twenty-nine gravidas (43.9%) suffered a delay in referral or admission. (7) All gravidas received magnesium sulphate administration. Thirty-three cases with severe hypertension (systolic blood pressure≥160 mmHg or diastolic blood pressure≥110 mmHg) were given antihypertensive drugs with satisfactory blood pressure control. Thirty-six cases with living fetus (26-34+6 gestational weeks) received antenatal dexamethasone. Termination of pregnancy was delayed in three cases after admission. Conclusions The management of HDP is not good enough in patients' education, screening for high-risk population, early diagnosis and antenatal care. Quality improvement efforts should be focused on strengthening patient education, training of doctors in primary and secondary hospitals, implementing protocols on antepartum care of preeclampsia and establishing a referral system for patients with severe obstetric complications. Key words: Hypertension, pregnancy-induced; Intensive care units; Clinical audit

Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015.

This study aimed to provide an assessment of medical malpractice claims involving pediatric patients cared for in emergency department and urgent care settings. We performed a retrospective review of all closed malpractice claims involving children (0-17 years old) originating from emergency department or urgent care centers from the Physician Insurers Association of America's Data Sharing Project database for a 15-year period (2001-2015). Reported data collected include medical specialty involved, medical diagnoses, chief medical factors, severity of resulting injury, claim disposition, average indemnity, and average defense costs. A total of 728 closed claims in pediatric emergency care settings were reviewed. Money was paid to the claimant in 30% of cases (220/728), with a total of US $70.3 million (average $319,513) paid to patients or families during the 15-year period. The most common resulting medical conditions were cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs. Error in diagnosis was the most common chief medical factor (41%), whereas those that involved failure or delay in admission to the hospital, which was the eighth most common chief medical factor, resulted in the highest average indemnity. Of the 728 closed claims, 220 involved a patient death (30%), but claims involving major permanent injury more often resulted in a payment. Of the 57 cases that went to trial, verdicts favored the physician in 47 cases (82%). Cardiac conditions, appendicitis, and disorder of the male genital organs are the most common medical conditions, and error in diagnosis is the most common chief medical factor in pediatric emergency care malpractice suits. It is important for providers practicing in these settings to be familiar with the common diagnoses and chief medical factors involved in these claims.

A study on short term outcome of stroke in a rural tertiary care center of Sub Himalayan Terai

Background: Stroke is the second most common cause of mortality in the world, causing immense morbidity and economic burden. The proper knowledge of the factors which influence the good clinical outcome in stroke is utmost strength of the clinicians in India, where post stroke rehabilitative measures are limited.Aims and Objective: To find out the association of outcome of stroke with different risk factors.Materials and Methods: A descriptive observational design study was formulated for a period of six months on hundred stroke patients in internal medicine unit of at North Bengal Medical College &amp; Hospital, India. Patients were selected after proper screening by inclusion and exclusion criteria. The “In-hospital-outcome” of CVA patient was determined by Glasgow outcome scale. The neurological condition was determined by National Institute of Health Stroke Scale (NIHSS). The Modified Rankin Scale and Barthel Index were utilized to asses disability status of patient in different period of hospital admission. The data were analyzed by EPI INFO software.Results: Clinical outcome showed statistically significant (P&lt;0.05) correlation with age, sex, level of consciousness, blood pressure, diabetes, past history, mass effect, size and depth of infarction and intra-ventricular extension of intra cerebral bleeding. Other parameters like type of stroke (ischemic or hemorrhagic), delay in admission, dyslipidemia, presence of heart disease, smoking, alcoholism, family history, depth and volume of intra cerebral bleeding, although showed poorer clinical outcome, their correlation was not statistically significant.Conclusion: In-hospital outcome of stroke as determined by Glasgow outcome scale correlates with diverse clinical parameters including various risk factors.Asian Journal of Medical Sciences Vol.9(4) 2018 1-9

Incidencia y características clínicas del síndrome de Guillain-Barré en la comarca de Osona (Barcelona, España) (2003-2016)

IntroductionAccording to most studies, the incidence of Guillain-Barré syndrome increases with age, with a peak incidence occurring between 70 and 80 years of age. The objective of this study is to describe the incidence (overall and by sex and age group) and clinical characteristics of Guillain-Barré syndrome in Osona (Barcelona, Spain). MethodsWe performed a retrospective, descriptive, population-based study covering the period 2003 to 2016. ResultsThe global incidence of Guillain-Barré syndrome is 2.07 cases per 100,000 person-years. Incidence increases with age, except for small peaks during childhood and between 40 and 50 years, and reaches a maximum of 6.26 cases per 100,000 person-years above the age of 80. The incidences of the different variants were: AIDP, 72.1%; AMAN, 16.3%; ANSAN, 4.7%; and Miller Fisher syndrome, 4.7%. A total of 41.9% of patients had a history of respiratory tract infections, and 20.9% had a history of gastrointestinal infections. Protein in the cerebrospinal fluid was found in 76.7%. EMG findings suggested demyelination in 73.7% of the patients and axonal degeneration in 26.3%. A total of 20.9% of patients needed ventilatory support. Six-month mortality was 9.3%. Variables associated with worse prognosis were age over 80 years, delay in admission, previous gastrointestinal infection, and AMAN variant. ConclusionsThe incidence observed in our study is in the upper range of estimated incidence rates reported in European and North American studies. The syndrome may be underdiagnosed in elderly patients; physicians must be vigilant to the possibility of the disease, which is associated with a high mortality rate if it is not treated early.

Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients.

ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. A retrospective cohort study. Single academic tertiary care hospital. Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. None. Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.

Business Process Re-engineering for Bed Allocation Process in a Tertiary Care Hospital in Mumbai

A proficient bed allotment system in the hospital reflects effective management. Minimizing the waiting time and appropriate bed allocation ensures quality of care and optimum utilization of hospital resources. The hospital management must respond to the growing needs of the patient care by reducing the admission delays and communication delays among health care providers. The objective of the study was to understand the bed allocation process, to evaluate reasons for delay in bed allotment and to minimize the waiting time for new admissions in a 750-bedded tertiary care hospital. The study was conducted by taking a random sample of 35 beds of general category. The admission time was recorded through hospital information system and by interviewing the nursing and housekeeping staff. The study revealed that the delay in communication from nurse station to admission counter was the major reason followed by delay in billing process and delay in preparing bed by the housekeeping staff.

Assessment of Efficacy of Comparison of Total I.V. Anaesthesia Using Propofol with an Inhalation Technique: A Hospital Based Study

Background: Postoperative nausea and vomiting can be particularly problematic in ambulatory surgery as it may lead to delay in discharge or unscheduled admission to hospital. Additionally, it has been reported as the anaesthetic complication that is of most concern to patients. Multiple factors, including the anaesthetic agent delivered, are associated with an increased incidence of PONV and the optimal strategy for preventing PONV continues to be debated. Aim of the study: To assess the efficacy of comparison of total I.V. anesthesia Using Propofol with an Inhalation Technique. Materials & Methods: The study was conducted in the department of anesthesia of R.B.M. Hospital, Bharatpur, Rajasthan, India. For the study we selected patient’s admitting to the surgical ward of the medical hospital of the institute. A total of 16 patients were selected for the study. An informed written consent was obtained from each patient after explaining them the procedure and significance of the study verbally. The patients were randomly grouped into two groups, Group 1 and Group 2. Patients in Group 1 underwent anesthesia by IV procedure and patient’s in Group 2 underwent anesthesia by inhalation method. Patients were followed up and monitored for pain, sedation score, nausea and vomiting in the post-operative period for 48 h. Results: A total of 16 patients were included in the study. The patients were randomly grouped into Group 1 and Group 2. We observed that mean age of patients in group 1 was 36.31+12.21 years and in group 2 was 32.21+10.98 years. Number of male patients in group 1 was 5 and in group 2 were 4. We observed that majority of cases had Grade 0 and 1 operative area. Conclusion: The hat total I.V. anesthesia using Propofol offers no significant advantage over inhalation anesthetic technique.

The Factors Associated with Outcomes in Surgically Managed Ruptured Cerebral Aneurysm.

Ruptured cerebral aneurysm is a life-threatening condition that requires urgent medical attention. In Malaysia, a prospective study by the Umum Sarawak Hospital, Neurosurgical Center, in the year 2000-2002 revealed an average of two cases of intracranial aneurysms per month with an operative mortality of 20% and management mortality of 25%. Failure to diagnose, delay in admission to a neurosurgical centre, and lack of facilities could have led to the poor surgical outcome in these patients. The purpose of this study is to identify the factors that significantly predict the outcome of patients undergoing a surgical clipping of ruptured aneurysm in the local population. A single center retrospective study with a review of medical records was performed involving 105 patients, who were surgically treated for ruptured intracranial aneurysms in the Sultanah Aminah Hospital, in Johor Bahru, from July 2011 to January 2016. Information collected was the patient demographic data, Glasgow Coma Scale (GCS) prior to surgery, World Federation of Neurosurgical Societies Scale (WFNS), subarachnoid hemorrhage (SAH) grading system, and timing between SAH ictus and surgery. A good clinical grade was defined as WFNS grade I-III, whereas, WFNS grades IV and V were considered to be poor grades. The outcomes at discharge and six months post surgery were assessed using the modified Rankin's Scale (mRS). The mRS scores of 0 to 2 were grouped into the "favourable" category and mRS scores of 3 to 6 were grouped into the "unfavourable" category. Only cases of proven ruptured aneurysmal SAH involving anterior circulation that underwent surgical clipping were included in the study. The data collected was analysed using the Statistical Package for Social Sciences (SPSS). Univariate and multivariate analyses were performed and a P-value of < 0.05 was considered to be statistically significant. A total of 105 patients were included. The group was comprised of 42.9% male and 57.1% female patients. The mean GCS of the patients subjected to surgical clipping was 13, with the majority falling into the good clinical grade (78.1%). The mean timing of the surgery after SAH was 5.3 days and this was further categorised into early (day one to day three, 45.3%), intermediate (day four to day ten, 56.2%), and late (after day ten, 9.5%). The total favourable outcome achieved at discharge was 59.0% as compared to 41.0% of the unfavourable outcome, with an overall mortality rate of 10.5%. At the six-month post surgery review (n = 94), the patients with a favourable outcome constituted 71.3% as compared to 28.7% with an unfavourable outcome. The mortality, six months post surgery was 3.2%. On a univariate analysis of early surgical clipping, patients with a better GCS and good clinical grade had a significantly better outcome at discharge. Based on the univariate study, six months post surgery, the timing of the surgery and the clinical grade remained significant predictors of the outcome. On the basis of the multivariate analysis, male patients of younger age, with a good clinical grade, were associated with favourable outcomes, both at discharge and six months post surgery. In this study, we concluded that younger male patients with a good clinical grade were associated with a favourable outcome both at discharge and six months post surgery. We did not find the timing of the surgery, size of the aneurysm or duration of surgery to be associated with a patient's surgical outcome. Increasing age was not associated with the surgical outcome in a longer term of patient's follow up.

From Emergency Department to Intensive Care Unit, Does The Delay Matter to Trauma Patients?

Introduction:Emergency department (ED) overcrowding with critically ill trauma patients has been a major concern globally. It has been shown that longer stays in the hospital before Intensive Care Unit (ICU) admission have a higher mortality rate.Objective:The objective of this study was to find whether the delay in ICU admission from ED is associated with significant mortality in a trauma patient.Methods:A prospective trauma registry data of 232 patients collected from the ED of JPNATC trauma center between September 2015 and March 2016 were used in the study. The study participants were all admitted trauma patients. Dead-on-arrival patients were excluded from the study.Results:All included patients had a blunt injury at the time of arrival. Of 232 patients, 66 died during treatment and 166 were discharged. Of these, 196 (84.5%) were male and 36 (15.5%) were female. Most of the patients among 66 who died were referred from different hospitals; however, most survivors arrived directly at JPNATC as compared to another group (P < 0.001). Waiting time in ED was calculated by the difference between arrival time and ED disposition time. There was statistically significant difference found in ED waiting time in both the groups (P = 0.015); however, the odds ratio is closer to 1, that is, 0.998. Similarly, age, gender, oxygen saturation, Glasgow Coma Scale, ICU stay days, heart rate, referring status, and injury severity score were found to be significant at the level of 25% under univariate analysis.Conclusion:The ED delay is not associated with adverse outcome in terms of mortality. Other factors may play a much greater role in determining the prognosis.

The association of duration of boarding in the emergency room and the outcome of patients admitted to the intensive care unit

BackgroundThe demand for critical care beds is increasing out of proportion to bed availability. As a result, some critically ill patients are kept in the Emergency Department (ED boarding) awaiting bed availability. The aim of our study is to examine the impact of boarding in the ED on the outcome of patients admitted to the Intensive Care Unit(ICU).MethodsThis was a retrospective analysis of ICU data collected prospectively at King Abdulaziz Medical City, Riyadh from ED between January 2010 and December 2012 and all patients admitted during this time were evaluated for their duration of boarding. Patients were stratified into three groups according to the duration of boarding from ED. Those admitted less than 6 h were classified as Group I, between 6 and 24 h, Group II and more than 24 h as Group III. We carried out multivariate analysis to examine the independent association of boarding time with the outcome adjusting for variables like age, sex, APACHE, Mechanical ventilation, Creatinine, Platelets, INR.ResultsDuring the study period, 940 patients were admitted from the ED to ICU, amongst whom 227 (25%) were admitted to ICU within 6 h, 358 (39%) within 6–24 h and 355 (38%) after 24 h. Patients admitted to ICU within 6 h were younger [48.7 ± 22.2(group I) years, 50.6 ± 22.6 (group II), 58.2 ± 20.9 (group III) (P = 0.04)]with less mechanical ventilation duration[5.9 ± 8.9 days (Group I), 6.5 ± 8.1 (Group II) and 10.6 ± 10.5 (Group III), P = 0.04]. There was a significant increase in hospital mortality [51(22.5), 104(29.1), 132(37.2), P = 0.0006) and the ICU length of stay(LOS) [9.55 days (Group I), 9.8 (Group II) and 10.6 (Group III), (P = 0.002)] with increase in boarding duration. In addition, the delay in admission was an independent risk factor for ICU mortality(OR for group III vs group I is 1.90, P = 0.04) and hospital mortality(OR for group III vs Group I is 2.09, P = 0.007).ConclusionBoarding in the ED is associated with higher mortality. This data highlights the importance of this phenomenon and suggests the need for urgent measures to reduce boarding and to improve patient flow.

Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot

AimsThe establishment of a vascular surgeon-led emergency diabetic foot service in 2006 has evolved to provide lower limb wound care for patients with and without diabetes. We aimed to determine whether the service was associated with sustained, improved limb salvage rates for the whole population, analyse key aspects of service provision and compare outcomes against published studies. MethodsThe vascular unit serves a largely rural population of approximately 240,000. Data was collected prospectively on lower limb amputations, arterial and minor surgical interventions from 2006 to 2015, and retrospectively retrieved for 2004–2005, prior to service commencement. Data was also collected on referral patterns, volume of patient admissions and attendances, and delays. Lower limb amputation rates were compared against published data and analysis of admission trends and delays employed non-parametric tests. ResultsAge/gender adjusted major lower limb amputations for the populations with and without diabetes were 412/100,000 in 2004 and 15/100,000 in 2005 respectively. Following service introduction, major amputations reduced and since 2012 have been sustained at between 15–44/100,000 and 1–3/100,000 for patients with and without diabetes respectively, comparing favourably with published data. Vascular interventions have remained static, but referrals of patients directly to the service and numbers of minor procedures have increased. ConclusionsThe sustained decreases in all major lower limb amputations that have coincided with the development of a core team approach to providing rapid access and comprehensive care for patients with emergency diabetic foot problems may indicate that this service design benefits patients with and without diabetes.