Japanese Emergency Departments Research Articles

A cross‐sectional study of anterior cutaneous nerve entrapment syndrome at a Japanese emergency department

AbstractBackgroundAnterior cutaneous nerve entrapment syndrome (ACNES) is the most common cause of abdominal wall pain. This study aimed to clarify the proportion of ACNES cases among those of abdominal pain and the clinical characteristics and prognosis of the disease in an emergency department (ED) of a Japanese general hospital.MethodsThe medical records of patients from January 2014 to December 2023 were reviewed, and patients aged 15 years or older with abdominal pain with positivity for Carnett's sign, a good response to trigger point injection (TPI), and an ACNES diagnosis were included. The proportion of ACNES cases among the complaints related to abdominal pain in the ED between 2020 and 2023 was then determined. The recurrence rate was also determined using data from the medical records and telephone follow‐ups.ResultsTwenty‐one patients were included. Their median age was 50 years (range: 16–83 years), 13 (62%) were female, and 11 (52%) had acute‐onset pain. Follow‐up data were available for 11 patients (52%), seven (64%) of whom had recurrent pain for a median period of 1 week after the index visit. The proportion of ACNES cases among those of abdominal pain was 0.11%.ConclusionACNES might be uncommon among patients with abdominal pain in the ED setting although underdiagnosis of this condition might have led to an underestimation of the proportion of cases. Moreover, given the high recurrence rate of abdominal pain associated with ACNES, following up these patients is very important.

Treatment patterns and clinician stress related to care of out-of-hospital cardiac arrest patients with a do not attempt resuscitation order

ObjectiveThis research investigated treatment patterns for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders in Japanese emergency departments and the associated clinician stress. MethodsA cross-sectional survey was conducted at 9 hospitals in Okayama, Japan, targeting emergency department nurses and physicians. The questionnaire inquired about the last treated out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation. We assessed emotional stress on a 0–10 scale and moral distress on a 1–5 scale among clinicians. ResultsOf 208 participants, 107 (51%) had treated an out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation order in the past 6 months. Of these, 65 (61%) clinicians used a “slow code” due to perceived futility in resuscitation (42/65 [65%]), unwillingness to terminate resuscitation upon arrival (38/65 [59%]), and absence of family at the time of patient’s arrival (35/65 [54%]). Female clinicians had higher emotional stress (5 vs. 3; P = 0.007) and moral distress (3 vs. 2; P = 0.002) than males. Nurses faced more moral distress than physicians (3 vs. 2; P < 0.001). Adjusted logistic regression revealed that having performed a “slow code” (adjusted odds ratio, 5.09 [95% CI, 1.68–17.87]) and having greater ethical concerns about “slow code” (adjusted odds ratio, 0.35 [95% CI, 0.19–0.58]) were associated with high stress levels. ConclusionsThe prevalent use of “slow code” for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders underscores the challenges in managing these patients in clinical practice.

Characteristics of pediatric ocular trauma in a pediatric emergency department in Japan

IntroductionPediatric ocular trauma is a common complaint in pediatric emergency departments (ED) and is a major cause of acquired monocular blindness. However, data on its epidemiology and management in the ED are lacking. The objective of this study was to describe the characteristics and management of pediatric ocular trauma patients who visited a Japanese pediatric emergency department (ED). MethodsThe present, retrospective, observational study was conducted in a pediatric ED in Japan between March 2010 and March 2021. Children younger than 16 years who visited our pediatric ED and received the diagnosis of ocular trauma were included. ED visits for follow-up examinations for the same complaint were excluded. The patients' sex, age, arrival time, mechanism of injury, signs and symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were extracted from electronic medical records. ResultsIn total, 469 patients were included; of these, 318 (68%) were male, and the median age was 7.3 years. The incident leading to trauma occurred most frequently at home (26%) and most often involved being struck in the eye (34%). In 20% of the cases, the eye was struck by some body part. Tests performed in the ED included visual acuity testing (44%), fluorescein staining (27%), and computed tomography (19%). Thirty-seven (8%) patients underwent a procedure in the ED. Most patients had a closed globe injury (CGI), with only two (0.4%) having an open globe injury (OGI). Eighty-five (18%) patients required an urgent ophthalmological referral, and 12 (3%) required emergency surgery. Ophthalmological complications occurred in only seven patients (2%). ConclusionMost cases of pediatric ocular trauma seen in the pediatric ED were CGI, with only a few cases leading to emergency surgery or ophthalmological complications. Pediatric ocular trauma can be safely managed by pediatric emergency physicians.

Medical Malpractice and Diagnostic Errors in Japanese Emergency Departments.

Emergency departments (ED) are unpredictable and prone to diagnostic errors. In addition, non-emergency specialists often provide emergency care in Japan due to a lack of certified emergency specialists, making diagnostic errors and associated medical malpractice more likely. While several studies have investigated the medical malpractice related to diagnostic errors in EDs, only a few have focused on the conditions in Japan. This study examines diagnostic error-related medical malpractice lawsuits in Japanese EDs to understand how various factors contribute to diagnostic errors. We retrospectively examined data on medical lawsuits from 1961-2017 to identify types of diagnostic errors and initial and final diagnoses from non-trauma and trauma cases. We evaluated 108 cases, of which 74 (68.5%) were diagnostic error cases. Twenty-eight of the diagnostic errors were trauma-related (37.8%). In 86.5% of these diagnostic error cases, the relevant errors were categorized as either missed or diagnosed incorrectly; the others were attributable to diagnostic delay. Cognitive factors (including faulty perception, cognitive biases, and failed heuristics) were associated with 91.7% of errors. Intracranial hemorrhage was the most common final diagnosis of trauma-related errors (42.9%), and the most common initial diagnoses of non-trauma-related errors were upper respiratory tract infection (21.7%), non-bleeding digestive tract disease (15.2%), and primary headache (10.9%). In this study, the first to examine medical malpractice errors in Japanese EDs, we found that such claims are often developed from initial diagnoses of common diseases, such as upper respiratory tract infection, non-hemorrhagic gastrointestinal diseases, and headaches.

Burnout among Japanese emergency medicine physicians: A multicentric questionnaire study.

Burnout negatively affects the wellness and performance of emergency physicians (EPs). This study aimed to clarify the actual prevalence of burnout and its associated factors among Japanese EPs. We conducted a cross-sectional questionnaire study of selected 27 Japanese emergency departments (EDs). We examined the Maslach Burnout Inventory-Human Services Survey score and its associations with ED-level- and EP-level factors in a multivariable analysis. A total of 267 EPs (81.9%) completed survey. Of these, 43 EPs (16.1%) scored severe emotional exhaustion (EE), 53 (19.8%) scored severe depersonalization (DP), and 179 (67.0%) scored severe personal accomplishment (PA), and 24 (8.9%) scored severely in all three domains. In our multivariable analysis, emergency medical service centers were associated with severe PA scores (odds ratio [OR], 10.56; 95% confidence interval [CI], 1.78-62.66; p = 0.009). A 3 to 6 hour-sleep period was associated with severe EE scores (OR, 2.04; 95% CI, 1.04-3.98; p = 0.036), and EPs in their 20s were associated with severe DP scores (OR, 7.37; 95% CI, 1.41-38.38; p = 0.018). Our results suggest that 8.9% of Japanese EPs are in higher degrees of burnout. In particular, Japanese EPs scored more severely on PA. To avoid burnout in Japanese EPs, it is important to improve the working environment by ensuring more than 6 h of sleep, providing more support for young EPs, and taking effective action to combat low EP self-esteem.

Utility of the Emergency Severity Index by Accuracy of Interrater Agreement by Expert Triage Nurses in a Simulated Scenario in Japan: A Randomized Controlled Trial

ObjectiveThe Emergency Severity Index (ESI) is a highly reliable and valid triage scale that is widely used in emergency departments in not only English language regions but also other countries. The Japan Triage and Acuity Scale (JTAS) is frequently used for emergency patients, and the ESI has not been evaluated against the JTAS in Japan. This study aimed to examine the decision accuracy of the ESI for simulated clinical scenarios among nursing specialists in Japan compared with the JTAS. MethodA parallel group randomized trial was conducted. In total, 23 JTAS–trained triage nurses from 10 Japanese emergency departments were randomly assigned to the ESI or the JTAS group. Nurses independently assigned triage categories to 80 emergency cases for the assessment of interrater agreement. ResultsInterrater agreement between the expert and triage nurses was κ = 0.82 (excellent) in the ESI group and κ = 0.74 (substantial) in the JTAS group. In addition, interrater agreement by acuity was level 2 = 0.42 (moderate) in the ESI group and level 2 = 0.31 (fair) in the JTAS group. Interrater agreement for triage decisions was classified in a higher category in the ESI group than in the JTAS Scale group at level 2. Triage decisions based on the ESI in Japan maintained the same level of interrater agreement and sensitivity as those in other countries. ConclusionThese findings suggest that the ESI can be introduced in Japan, despite its different emergency medical background compared with other countries.

Exploring the components of the quality of death in Japanese emergency departments: A qualitative study

BackgroundThe need to care for patients who die in the emergency department is increasing in Japan, and emergency nurses are required to provide end-of-life care to ensure that patients experience a good death. However, the components of the quality of death and what constitutes a good death for patients dying in the emergency department are unclear. AimThis study aimed to explore the components of the quality of death for patients who die in emergency departments of Japanese hospitals. MethodsThis study employed a qualitative design. An inductive content analysis was conducted based on semi-structured interviews with 26 participants, which included 15 emergency nurses, five emergency physicians, and six bereaved families. ResultsSeven components of quality of death were identified: (1) transition to the end-of-life phase after receiving the best treatment, (2) dying without suffering, (3) having the patient's wishes respected, (4) having a loved one nearby, (5) maintaining human dignity, (6) having no change in appearance, and (7) not making the family feel guilty. ConclusionThese components suggested that emergency nurses should: support patients' receipt of the best treatment and foster their smooth transition to the end-of-life phase at the appropriate time, ensure that the patients in the end-of-life phase spend time with their loved ones immediately before their death, enable the maintenance of human dignity and patient identity of end-of-life patients, and make sure that the families of end-of-life patients do not feel guilt.

Characteristics of Patients With Congenital Heart Disease Requiring ICU Admission From Japanese Emergency Departments.

To evaluate the characteristics of patients with congenital heart disease requiring ICU admission from emergency departments and determine the associations between the reasons for emergency department visits and specific congenital heart disease types or cardiac procedures. Retrospective observational study using data from a Japanese multicenter database. Twelve PICUs and 11 general ICUs in Japan. All patients requiring ICU admission from an emergency department during 2013-2018, divided into two groups: with congenital heart disease and without congenital heart disease groups. None for this analysis. Of the 297 patients with congenital heart disease (9.2% of a total of 3,240 patients), more than half had moderate-to-high complexity congenital heart disease; most of them were pediatric patients who had visited specialized congenital heart disease centers. All the patients' clinical outcomes were similar. Regarding the reasons for emergency department admission, seizure was significantly associated with a single ventricle anatomy (odds ratio, 3.3; 95% CI, 1.1-10.0), post-Glenn shunt placement (odds ratio, 5.6; 95% CI, 1.1-29.4), and a Fontan-type operation status (odds ratio, 6.3; 95% CI, 1.5-25.5). Sepsis and gastrointestinal bleeding were associated with asplenia (odds ratio, 21.1; 95% CI, 4.3-104 and odds ratio, 21.0; 95% CI, 3.1-141, respectively); gastrointestinal bleeding was also associated with systemic-to-pulmonary artery shunt placement (odds ratio, 18.8; 95% CI, 2.8-125) and a Fontan-type operation status (odds ratio, 17.0; 95% CI, 2.6-112). Arrhythmia was associated with a single ventricle anatomy (odds ratio, 21.0; 95% CI, 3.1-141), systemic-to-pulmonary artery shunt placement (odds ratio, 18.8; 95% CI, 2.8-125), and a Fontan-type operation status (odds ratio, 17.0; 95% CI, 2.6-112). Classification of the reasons for emergency department admission by congenital heart disease type and surgical stage may guide clinicians in the selection of appropriate treatments in such settings.

本邦救急医療施設における薬物分析環境の現状と課題(Current state of drug analysis in Japanese emergency departments – a nationwide survey)

要旨【目的】1999年に日本中毒学会より「分析が有用な薬毒物」15品目が提言されている。これをふまえ，救急医療施設の薬物分析環境の現状把握を目的に全国調査を行った。【対象】2017年4月の時点で救急科専門医指定施設もしくは救命救急センターである計546施設に対しアンケート調査を行った。【結果】246施設から回答があった。濫用薬物スクリーニングキット使用状況は，Triage DOA 80.9%，Instant–VIEW 7.3%。即時分析可能施設は，メタノール 2.8%，バルビツール酸系薬物 19.5%，ベンゾジアゼピン系薬物 2.4%，ブロムワレリル尿素 0.8%，三環系抗うつ薬 1.2%，アセトアミノフェン 12.2%，サリチル酸 4.1%，テオフィリン 44.3%，有機リン系農薬 2.0%，カーバメート系農薬 1.6%，グルホシネート 1.2%，パラコート 2.4%，ヒ素 0.8%，シアン化合物 1.2%，メタンフェタミン 1.2%であった。【結語】急性薬物中毒診療において，薬毒物分析は臨床判断や学術的検証を行ううえで重要である。しかし，救急医療の現場では1999年に提言された15品目のうち多くが未だ即時分析できる環境にない。推奨品目の提言とあわせ，一般救急医療施設でも分析可能となるよう，安価な検査系の開発や，検査に対する保険点数の付与といった介入を行う必要がある。

The current status of bereavement follow-up in Japanese emergency departments: A cross-sectional nationwide survey

IntroductionThe aim of this study was to investigate the current status of bereavement follow-up in Japanese emergency departments. MethodsThis study employed a cross-sectional design and conducted a nationwide survey of all emergency departments in Japan. Self-reported questionnaires were sent to the nurse leaders of each emergency department. ResultsOf 289 nurse leaders approached, 145 (50.2%) responded. Only 17.9% emergency departments provided bereavement follow-up strategies, and the most frequent strategy was referral to a specialist for psychological treatment. Most nurse leaders perceived that bereavement follow-up is necessary, and the greatest need of the bereaved as perceived by the nurse leaders was explanation of the patient’s death. However, 60% of the nurse leaders perceived bereavement follow-up to be necessary but difficult, and the major challenges in bereavement follow-up were lack of time, knowledge, and skill. ConclusionIn contemporary Japan, the prevalence of bereavement follow-up strategies offered by emergency departments was low, and although most nurse leaders perceived follow-up as necessary, it could not be provided because of limitations in human resources and staff training.

Current state of drug analysis in Japanese emergency departments: a nationwide survey.

In 1999, the Japanese Society for Clinical Toxicology proposed 15 toxicants that would be useful for analysis: methanol, barbiturates, benzodiazepines, bromovalerylurea, tricyclic acid, acetaminophen, salicylic acid, theophylline, organic phosphorus pesticides, carbamate pesticides, glufosinate, paraquat, arsenic, cyanide, and methamphetamine. We aimed to reveal the current state of drug analysis for acute poisoning in the emergency department of Japanese hospitals. From 1 April, 2017, we undertook a questionnaire survey in the emergency departments of 546 hospitals designated as educational institutions for emergency physicians. Responses were obtained from 246 hospitals (45.1%). Among drug abuse screening kits for qualitative testing, 80.9% used the Triage Drugs of Abuse Panel and 7.3% used Instant-View M-1. Analytical results have always been immediately obtained by 2.8% of facilities for methanol, 19.5% for barbiturates, 2.4% for benzodiazepines, 0.8% for bromovalerylurea, 1.2% for tricyclic acid, 12.2% for acetaminophen, 4.1% for salicylic acid, 44.3% for theophylline, 2.0% for organic phosphorus pesticides, 1.6% for carbamate pesticides, 1.2% for glufosinate, 2.4% for paraquat, 0.8% for arsenic, 1.2% for cyanide, and 1.2% for methamphetamine. In the treatment of acute poisoning, drug analysis is important for both clinical judgment and academic verification. However, many of the 15 toxicants proposed to be useful for analysis in 1999 are not yet immediately analyzed in the emergency department of Japanese hospitals. Furthermore, it is necessary to develop inexpensive testing systems and to provide insurance points for testing so that analysis can be carried out by emergency departments.

Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study

BackgroundSevere accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH.MethodsThe J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI).ResultsOf the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72–0.86) was the highest among all factors. The other factors were serum potassium (0.65; 95% CI: 0.55–0.73), lactate (0.67; 95% CI: 0.57–0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46–0.65), systemic inflammatory response syndrome (SIRS) (0.60; 95% CI: 0.50–0.69), and 5A severity scale (0.77; 95% CI: 0.68–0.84).DiscussionAlthough serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by the hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality.ConclusionsThe SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.

Impact of the academic calendar cycle on survival outcome of injured patients: a retrospective cohort study at a community emergency department in Japan

BackgroundCommencement of a new academic cycle is presumed to be associated with poor patient outcomes. However, supportive evidence is limited for trauma patients treated in under-resourced hospitals, especially those who require specialized interventions and with little physiological reserve. We examined whether a new academic cycle affects the survival outcomes of injured patients in a typical Japanese teaching hospital.MethodsThis historical cohort study was conducted at a Japanese community emergency department (ED). All injured patients brought to the ED from April 2002 to March 2018 were included in the analysis. The primary exposure was presentation to the ED during the first quartile of the academic cycle (April–June). The primary outcome measure was the hospital mortality rate.ResultsOf the 20,945 eligible patients, 5282 (25.2%) were admitted during the first quartile. In the univariable analysis, the hospital mortality rate was similar between patients admitted during the first quartile of the academic year and those admitted during the remaining quartiles (4.1% vs. 4.4%, respectively; odds ratio [OR], 0.931; 95% confidence interval [CI] 0.796–1.088). After adjusting for the potential confounding factors of the injury severity score, age, sex, Glasgow coma scale score, systolic blood pressure, trauma etiology (blunt or penetrating), and admission phase (2002–2005, 2006–2009, 2010–2013, and 2014–2018), no statistically significant association was present between first-quartile admission and trauma death (adjusted OR 0.980; 95% CI 0.748–1.284). Likewise, when patients were subgrouped according to age of > 55 years, injury severity score of > 15, Glasgow coma scale score of < 9, systolic blood pressure of < 90 mmHg, requirement for doctor car system dispatches, emergency operation, emergency endotracheal intubation, and weekend and night presentation, no significant associations were present between first-quartile admission and hospital mortality in both the univariable and multivariable analysis.ConclusionsAt a community hospital in Japan, admission at the beginning of the academic year was not associated with an increased risk of hospital mortality among trauma patients, even those requiring specialized interventions and with little physiological reserve. Our results support the uniformity of trauma care provision throughout the academic cycle in a typical Japanese trauma system.

Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study

IntroductionIn cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan. MethodThe J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables. ResultsOf 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C–30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31–7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68–5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32–4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13–6.21). ConclusionThe independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.

Adherence rate of quality-of-care indicators for Staphylococcus aureus bacteremia is extremely low in Japanese emergency and critical care departments: a multicenter retrospective observational study.

Aim Staphylococcus aureus bacteremia causes significant morbidity and mortality and requires specific management to prevent complications. Most studies evaluating quality of care have been carried out in Europe and North America, and accurate epidemiological data are lacking in Asia. We aimed to describe the epidemiology and evaluate the quality of care for S. aureus bacteremia in Japan.MethodsFrom February 2011 to January 2014, we undertook a multicenter retrospective observational study in 10 departments of emergency and critical care in Japan. We included 118 hospitalized adult patients with S. aureus bacteremia and evaluated three quality‐of‐care indicators: follow‐up blood culture, treatment duration, and echocardiography.ResultsThe mean age of the patients was 63.5 ± 17.0 years. The major source of bacteremia was pneumonia (n = 22, 19%), followed by skin and soft tissue infection (n = 18, 15%). Thirty patients (25%) died in the hospital. Follow‐up blood culture was performed in 21/112 patients (19%). The duration of antimicrobial treatment was sufficient in 49/87 patients (56%). Echocardiography for patients with clinical indication was undertaken in 39/59 patients (66%). Any of the three indicators were inadequate in 101/118 (86%).ConclusionThe rate of adequate care for S. aureus bacteremia is low in Japan. The low adherence rate for follow‐up blood culture was particularly notable. Staphylococcus aureus bacteremia can be an important target of quality improvement interventions.

Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study

BackgroundAlthough human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps.MethodsThis nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban.ResultsOf the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis.ConclusionsIn Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.

Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan.

BackgroundA reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway.MethodsThis historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation.ResultsOf the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034).ConclusionsIn this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.

Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries.

BackgroundThe Canadian Triage and Acuity Scale is a valid triage system. The system was translated and implemented in the Japanese emergency departments (EDs) from 2012. This system was named the Japanese Triage and Acuity Scale; however, the validation studies of the Japanese Triage and Acuity Scale have been limited. In addition, for a patient with multiple complaints, it could become challenging, due to its requirement of a single complaint. Therefore, we hypothesized that a modified version of the Japanese Triage and Acuity Scale using first-order modifiers without chief complaint detection is accurate.MethodsA retrospective cohort study evaluated a correlation between the modified triage scale level and outcomes of all adult emergency department patients at a Japanese hospital.Construct validity of the modified triage scale level was assessed based on comparisons of total admission rate (including hospitalizations, emergency department deaths) and length of stay between triage levels.ResultsThe distributions of five levels of the triage scale (level 1 is the most urgent) among the 17,121 cases are as follows: 1:451, 2:1148, 3:7703, 4:7652, and 5:167. Total admission rates by each level were 1:89.8, 2:68.2, 3:26.4, 4:6.6, and 5:0.6 %, which progressively increased from level 5 to 1 and were significant (p < 0.01). Compared with patients in level 3, the odds of total admission rates were 14.4, 5.1, 0.27, and 0.030 for the patients in levels 1, 2, 4, and 5. The length of stay was longer in the patients with the more urgent levels except for those with level 1.ConclusionsThe modified version of the Japanese Triage and Acuity Scale is a valid predictor of total admission and length of stay and may enable the nurses to triage patients without detecting the chief complaints.

Inappropriate Antibiotic Use for Acute Asthma in Japanese Emergency Departments

Background: Little is known about the extent that acute asthma is inappropriately treated with antibiotics in Japanese emergency departments (EDs).Objectives: We examined the proportion and predictors of inappropriate antibiotic use for adults with acute asthma in the Japanese EDs.Methods: We conducted a chart review study in 23 Japanese EDs. Subjects were ED patients aged 18 to 54 years with acute asthma between 2009 and 2011. To examine predictors of inappropriate antibiotic use, we performed multi‐level logistic regression analysis at both the patient‐ and ED‐level modeling EDs as a random variable.Results: Among 1380 patients in the overall study, the analytic cohort comprised 1311 patients. Overall, antibiotics were inappropriately prescribed for 4.4% (95% confidence interval [CI], 3.4%–5.7%). In the multi‐level logistic regression analysis, higher annual ED asthma visit volume was significantly associated with a lower proportion of inappropriate antibiotic use (odds ratio per 100‐visit increase, 0.3 ; 95%CI, 0.2–0.6).Conclusions: In this large multicenter study in Japan, we found that approximately 4% of ED patients with acute asthma were inappropriately treated with antibiotics. We also demonstrated that the inappropriate use of antibiotics largely differed across the EDs and was less common in EDs with a more annual ED asthma visits. Organized knowledge translation initiatives are warranted to address this gap in emergency asthma care.

Resource Utilization in the Emergency Department of a Tertiary Care University-Based Hospital in Tokyo Before and After the 2011 Great East Japan Earthquake and Tsunami

The objective of this study was to determine the resource utilization of a tertiary care Japanese emergency department (ED) that was not immediately adjacent to the area of the 2011 Great East Japan earthquake and tsunami. A retrospective chart review was performed at a tertiary care university-based urban ED located approximately 290 km from the primary site of destruction secondary to an earthquake measuring 9.0 on the Richter Scale and the resulting tsunami. All patients who presented for a period of twelve days before and twelve days after the disaster were included. Data were collected using preformed data collection sheets, and stored in an Excel file. Abstracted data included gender, time in the ED, intravenous fluid administration, blood transfusion, oxygen, laboratories, electrocardiograms (ECGs), radiographs, ultrasound, diagnoses, surgical and medical referrals, and prescriptions written. Ten percent of the charts were reviewed for accuracy, and an error rate reported. Data were analyzed using 2-tailed t-tests, Fisher's exact tests or rank sum tests. Bonferroni correction was used to adjust P values for multiple comparisons. Charts for 1193 patients were evaluated. The error rate for the abstracted data was 3.2% (95% CI, 2.4%-4.1%). Six hundred fifty-seven patients (53% male) were evaluated in the ED after the earthquake, representing a 23% increase in patient volume. Mean patient time spent in the ED decreased from 61 minutes to 52 minutes (median decrease from 35 minutes to 32 minutes; P = .005). Laboratory utilization decreased from 51% to 43% (P = .006). The percentage of patients receiving prescriptions increased from 48% to 54% (P = .002). There was no change in the number of patients evaluated for surgical complaints, but there was an increase in the number treated for medical or psychiatric complaints. There was a significant increase in the number of people utilizing the ED in Tokyo after the Great East Japan earthquake and tsunami. Time spent in the ED was decreased along with laboratory utilization, possibly reflecting decreased patient acuity. This information may help in the allocation of national resources when planning for disasters.