Urgent Patients Research Articles

Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care

ObjectiveTo evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. MethodsProspective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0–18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates. ResultsThe distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23–2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17–79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70–0.98); specificity, 0.76 (95%CI: 0.75–0.76); NPV, 0.99 (95%CI: 0.99–1.00); overtriage rate, 23.0%, and undertriage, 11.5%. ConclusionThis study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.

Minimizing patients total clinical condition deterioration in operating theatre departments

The operating theatre is the most crucial and costly department in a hospital due to its expensive resources and high patient admission rate. Efficiently allocating operating theatre resources to patients provides hospital management with better utilization and patient flow. In this paper, we tackle both tactical and operational planning over short-term to medium-term horizons. The main goal is to determine an allocation of blocks of time on each day to surgical specialties while also assigning each patient a day and an operating room for surgery. To create a balance between improving patients welfare and satisfying the expectations of hospital administrators, we propose six novel deterioration rates to evaluate patients total clinical condition deterioration. Each deterioration rate is defined as a function of the clinical priorities of patients, their waiting times, and their due dates. To optimize the objective functions, we present mixed integer programming (MIP) models and two dynamic programming based heuristics. Computational experiments have been conducted on a novel well-designed and carefully chosen benchmark dataset, which simulates realistic-sized instances. The results demonstrate the capability of the MIP models in finding excellent solutions (maximum average gap of 4.71% across all instances and objective functions), though, requiring large run-times. The heuristic algorithms provide a time-efficient alternative, where high quality solutions can be found in under a minute. We also analyse each objective function’s ability in generating high quality solutions from different perspectives such as patients waiting times, the number of scheduled patients, and operating rooms utilization rates. We provide managerial insights to the decision makers in cases where their intention is to meet KPIs and/or maintaining trade-offs between patients and administrators expectations, more fair assignments, or ensuring that the most urgent patients are taken care of first.

Abstract 14482: Clinical Impact of Advances of Short-Term Mechanical Circulatory Support Devices and Therapeutic Strategies in Patients With Cardiogenic Shock

Introduction: Although revised US adult heart allocation system has provided the opportunity of urgent heart transplantation and improved clinical outcomes in urgent patients, it may not offer select temporary mechanical circulatory support (MCS) patients the opportunity and adequate time to recover to the point of waitlist removal. Severe donor shortages have increased the need for assessment of reversibility of cardiac function. Advances of MCS devices may provide the longer time to assess the appropriate therapeutic strategy. Hypothesis: The aim of this study was to evaluate the impact of bridge-to-decision (BTD) strategies which used recently developed short-term MCS devices strategies. Methods: We retrospectively reviewed the medical records of 108 patients who received BTD strategies from January 2017 to February 2022. Results: Etiology of cardiogenic shock were myocarditis (35.2 %), idiopathic cardiomyopathy (26.0 %) and ischemic cardiomyopathy (30.5 %). Ninety-three (86.1%) had been used any temporary MCS prior to BTD strategy using short-term MCS devices, including intra-aortic balloon pumping, peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) and low-flow percutaneous VAD. Sixty-five (60.2 %) had been inserted extracorporeal centrifugal-flow pump VAD (CF-VAD group), twenty-eight (25.9 %) had high-flow percutaneous VAD (P-VAD group) including with ECMO (ECPELLA) (50 %), and fifteen (13.9 %) had extracorporeal pulsatile-flow pump VAD (PF-VAD group). Duration of short-term MCS support was 42.5±44.1 days. Twenty-five (23.1 %) needed the conversion to other pumps. Forty-eight (40.7%) were withdrawn for recovery of cardiac function (mean duration to decision; 27.7±23.8 days), other forty-eight (40.7 %) were implanted durable implantable VAD for no-recovery of cardiac function (mean duration to decision; 48.4±40.7 days). Twenty patients (18.5 %) died. Clinical prognosis was comparable in three groups (P=0.943). Conclusions: BTD strategies using recently developed short-term MCS devices provided relatively long-term support duration to decision for definitive therapy, and showed favorable clinical outcomes. However, conversion or exchange to other pumps was needed for long-term support.

Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement

IntroductionPatient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. MethodsWe performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. ResultsThe study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56–4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. ConclusionsQuality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.

From Alpha to Omicron: A Radiation Oncology Network's Biocontainment-Based COVID-19 Experience

PurposeTo develop the safest possible environment for treating urgent patients with COVID-19 requiring radiation, we describe the unique construction of negative air pressure computed tomography simulator and linear accelerator treatment vaults in addition to screening, delay, and treatment protocols and their evolution over the course of the COVID-19 pandemic. Methods and MaterialsConstruction of large high-efficiency particulate air filter air-flow systems into existing ductwork in computed tomography simulator rooms and photon and proton treatment vaults was completed to create negative-pressure rooms. An asymptomatic COVID-19 screening protocol was implemented for all patients before initiation of treatment. Patients could undergo simulation and/or treatment in the biocontainment environments according to a predefined priority scale and protocol. Patients treated under the COVID-19 protocol from June 2020 to January 2022 were retrospectively reviewed. ResultsNegative air-flow environments were created across a regional network, including a multi-gantry proton therapy unit. In total, 6525 patients were treated from June 2020 through January 2022 across 5 separate centers. The majority of patients with COVID-19 had radiation treatment deferred when deemed safe. A total of 42 patients with COVID-19, who were at highest risk of an adverse outcome should there be a radiation delay, were treated under the COVID-19 biocontainment protocol in contrast to those who were placed on treatment break. For 61.9% of patients, these safety measures mitigated an extended break during treatment. The majority of patients (64.3%) were treated with curative intent. The median number of biocontainment sessions required by each patient was 6 (range, 1-15) before COVID-19 clearance and resumption of treatment in a normal air-flow environment. ConclusionsConstructing negative-pressure environments and developing a COVID-19 biocontainment treatment protocol allowed for the safe treatment of urgent radiation oncology patients with COVID-19 within our department and strengthens future biopreparedness. These biocontainment units set a high standard of safety in radiation oncology during the current or for any future infectious outbreak.

REU dental students’ knowledge about protection methods and the COVID-19 infected patients' treatment protocols in prosthodontics

Introduction: Corona Virus Disease 2019 (COVID-19) became a global pandemic disaster in early 2020, and it is currently wreaking havoc in many parts of the planet. Prosthodontics units have been forced to halt their clinical operations due to the pandemic. As a result, in the aftermath of the pandemic, several clinics and private practices substantially reduced the number of non-deferrable urgent care prosthodontics patients they treated during the initial wave of the epidemic. Method: This is cross-sectional research that was done via an online survey among REU dentistry students. This research involved 500 students from clinical levels 8 through 12. An online questionnaire was created that included demographic information, as well as questions about knowledge, attitude, and practice regarding the management of COVID-19 suspected patients in prosthodontic clinics. Results: Revealed that a significant proportion of the study was based on females comprising 56.9% and 6th level of dentistry. The majority of them thought that corona patients could be asymptomatic, and according to them, airborne is the main route of transmission. Using the rubber increases the airborne particles. Packets should be disposed of with hygiene and medical waste protocols. Dentists agree that gypsum must be treated as infectious clinical waste.

P-090 EMERGENCY INTRAPERITONEAL ONLAY MESH REPAIR OF INCARCERATED VENTRAL E INCISIONAL HERNIA

Abstract Aim Abdominal wall hernia surgery is the frequent surgical operation. Incarceration and strangulation are the complications for patients going to emergency surgery clinics.Laparoscopic approach in emergency is controversial. IPOM treatment permits safe hernia reduction, accurate abdominal exploration,diagnosis and treatment of unknown hernia. Material and Methods in one year,we operated 12 urgent ventral hernia patients with IPOM technique. All patientsshowed hemodynamic stability. We evaluated safety of hernia reduction, conversion rate,operative time,hospital stay, and prosthesis infection. Results Nine patients underwent surgery for incarcerated incisional hernia, 3 patients for primary incarcerated ventral hernia. We used a laparoscopic approach. In 10 cases,we placed an intraperitoneal mesh. In two cases, we converted to open surgery, because of small bowel injury. It was never necessary to perform Intestinal resection for strangulated hernia.Contents of hernia sacs were omentum (7 patients), large bowel (1 patients), 4 omentum and small bowel (4 patients). Patients presented signs of small bowel obstruction. Average size of the defect was 6cm.Average operative time was 91 min, the mean post-operative hospital stay was 3.5 days. Post-operative complications weren't recorded. There wasn't mortality. During the follow-up none patients had mesh infection or hernia recurrence. Conclusion In emergency the Intraperitoneal Onlay Mesh Repair of Incarcerated Ventral and Incisional Hernia allowed safe adesiolysis, bowel reduction. Laparoscopic approach was associated to low post-operative complications even in emergency setting.

Wait time management strategies at centralized intake system for hip and knee replacement surgery: A need for a blended evidence-based and patient-centered approach

ObjectivesDelays in access to specialty care and elective hip and knee total joint replacement (TJR) surgery remain a major concern among patients with osteoarthritis (OA) in Canada. Centralized intake systems as a wait time management strategy in the face of resource constraints can increase access and patient flow through the system but are not standard practice. We examine how wait time management strategies for the assessment and triaging referrals in a centralized intake system can inform quality improvement initiatives. DesignWe developed a discrete-event simulation model using all referrals to the Edmonton Bone and Joint Centre centralized intake system from 2012 to 2016 for the base case model. We assessed the combined effect of three wait time management strategies: improved prioritization, improved sorting through screening, and increased conservative management. Outcomes were measured in terms of patient flow and wait times. ResultsThe screener sees more patient referrals (7094 compared to 6922), and the number of patients who proceed to surgery is reduced by 282 patients (4%) in the wait time management scenario compared to the base case model. Wait times from referral to surgery are reduced by 54 days for surgical patients. Furthermore, urgent surgical patients experienced lower wait times in all stages of care than non-urgent patients, with wait times from referral to surgery reduced by 86 days. ConclusionsTriaging processes addressing prioritization, screening and conservative management of non-surgical patients can improve patient flow and significantly reduce patient wait times in a centralized intake process for TJR.

The impact of COVID-19 pandemic on the urgency of patients admitted to the emergency department

BackgroundThe COVID-19 pandemic brought important changes in access to the Emergency Department (ED). At present, an analysis of how the COVID-19 pandemic has changed not only the number but also the nature of the urgency of ED access is not available. This study aimed to verify the effect of the COVID-19 pandemic on the urgency of patients admitted to the ED utilizing timebased analyses. MethodsA quasi-experimental interrupted time series analysis based on a retrospective review of data from all ED admissions occurring at the Merano Hospital (Italy) from 1 January 2015 to 30 June 2021 was conducted. ResultsFrom January 2015 to June 2021, 416,560 patients were admitted to the ED. Since the pandemic outbreak, the trend of urgent patients (classified as orange and red by triage) remained unchanged compared to the pre-pandemic period (p = 0.095, p = 0.155). In contrast, patients classified as blue (non-urgent) increased exponentially since the outbreak of the pandemic (p < 0.001). ConclusionThe present study reported stability in urgent codes (orange and red) since the pandemic outbreak while a dramatic increase in non-urgent codes (blue and green) is reported. The results of the study may indicate the need to find health policy solutions to manage this large increase in nonurgent patients requiring assessment in EDs since the outbreak of the pandemic.

Hemadsorption treatment for antithrombotic drug removal in emergency cardiac surgery – cost-benefit analysis comparing patient outcomes

Abstract Background Intraoperative hemadsorption is indicated for ticagrelor and rivaroxaban removal in patients undergoing urgent cardiac surgery and has been previously shown to reduce bleeding complications. However, whether this application is cost effective is currently unknown. Methods Between June 2017 and June 2021, we evaluated the outcomes of 72 consecutive patients (age 65±11 years) with acute coronary syndrome (ACS) pretreated with ticagrelor who underwent urgent coronary artery bypass grafting (CABG) at our institution. Intraoperative hemoadsorption (IH) was used in all cases (IH-Pat). We estimated the mean cost per patient, and a bootstrap analysis was performed based on individual data from the case series. We compared the results with “historical patients” who were operated under the same conditions between June 2015 and June 2017 but without IH (n=22). Results Bilateral internal mammary artery (BIMA) was used in 67.7% of all cases. Use of IH was associated with significantly shorter operation times (277±65 min vs. 320±75 min; P=0.014) and significantly less postoperative 24-hours chest tube drainage (277±65 mL vs. 866±262 mL; P&amp;lt;0.001). Only two rethoracotomies (2.8%) had to be performed. In addition, patients operated without IH required significantly more blood products and had a significantly higher rate of rethoracotomy, resulting in longer ICU stays. The variable that had the highest impact on the level of cost savings was the operation duration. The overall cost saving with IH were calculated at over 4200±1100€ with operation time, ICU stay and blood product costs being the top contributors. Conclusions The results suggest that the clinical benefits derived from IH in ticagrelor-treated patients requiring urgent cardiac surgery patients could result in significant cost savings of over 4200±1100 € per patient. Funding Acknowledgement Type of funding sources: None.

Point of care prehospital ultrasound in Basic Emergency Services in Portugal.

Background and AimsThe Point of Care Ultrasound and Point‐of‐Care Ultrasound in Resource‐Limited Settings are differentiated diagnostic methods using ultrasound, essential in urgent patients screening, allowing better guidance in the diagnostic process and therapeutic approach. This study intends to observe the impact of these techniques in two Basic Emergency Services (SUB) in Portugal.MethodsA longitudinal study was carried out in two remote locations in Portugal (SUB N and SUB S). Data were collected by trained radiographers in each location, and a total of 972 exams were considered. Imaging findings were documented by exam type, the exam normality and the resolution after exam. χ 2 and Cramer's V tests were performed to check significant correlations between the variables.ResultsRegarding the type of echographic findings, 289 (29.7%) were considered normal, 628 (64.6%) were classified as abnormal and 55 (5.7%) were considered inconclusive. As for the type of resolution, 58% had local resolution, 24% were referred to a hospital emergency service and 18% referred to ambulatory care. Regarding the Location versus Resolution after exam versus Findings variables, it was verified a stronger statistically significant association for the exams considered “Abnormal” (Cramer's V = 0.414; p < 0.001). In the variables Location versus Findings versus Resolution after exam, it was verified a stronger statistical significance for “Referral to Ambulatory” (Cramer V = 0.443; p < 0.001) although Referral for Hospital (Cramer V = 0.252; p = 0.003) or Local Resolution (Cramer V = 0.252; p < 0.001) also had a moderate association strength.ConclusionUltrasonography is a useful diagnostic tool for patients screening, having an influence on patient management in remote settings. Given the limited literature in Portugal about this matter, further research and literature will be needed to support and complement the results of this study.

Clinical and Surgical Consequences of COVID-19 Pandemic for Patients with Urological Problems

Objective: To discuss the impact of COVID-19 on Urological practice and their management and to review some of the available recommendations reported in the literature. Materials and Methods: In the current review the PubMed database was searched to identify all the related reports discussing the impact of COVID-19 on urological field and how the urological issues and cases can be managed is discussed. Results: The COVID-19 pandemic is the latest and biggest global health threat. Medical and surgical practices have changed dramatically to cope with the current challenge. This changes include postponements of most of the elective out patient’s visits and urological procedures to save facilities and resources for urgent cases and patients with COVID-19. Conclusion: Over the coming months, healthcare workers including urologists will be facing increasingly difficult challenges and consequently they should adopt triage strategy to avoid wasting of medical resources and they should endorse sufficient protection procedures to guard against infection when dealing with COVID-19 patients. Bangladesh J. Urol. 2021; 24(1): 33-36

Diagnostic ultrasound examinations during evacuation of urgent patients by ambulance helicopters: literature review

Relevance. The use of ultrasound diagnostics at the place of providing medical care to an urgent patient is one of the promising directions in the development of emergency medicine. At the same time, of particular interest is the possibility of using diagnostic ultrasound in an ambulance helicopter, given the lack of clear algorithms and standards for its application, as well as the limited number of publications on this problem.Intention. Analysis of publications on the use of urgent ultrasound examination in an ambulance helicopter.Methodology. A search was made for scientific publications on the topic on the electronic resource PubMed, in the Google Scholar search system for the period from 2000 to 2021.Results and discussion. The main algorithms used for ultrasound diagnostics of an urgent patient in an ambulance helicopter are Focused Assessment with Sonography for Trauma (FAST), point-of-care ultrasound (POCUS), Rapid Ultrasound in SHock (RUSH), Bedside Lung Ultrasound in Emergency (BLUЕ), prehospital ultrasonography (PHUS), etc. They help exclude damage to vital organs and emergency pathology – pneumo- and hemothorax, hemoperitoneum, hemopericardium, large fractures and others that affect the tactics of treatment and patient routing; there is also the possibility of ultrasound navigation for a number of medical and diagnostic procedures. According to the results of published studies and clinical observations, prehospital ultrasound examination of urgent patients is successfully used during medical evacuation by an ambulance helicopter in emergency medical services in many countries of the world (both by doctors and other medical personnel), making it possible to diagnose a number of lifethreatening conditions with a fairly high accuracy, without loss of time and without damage to patient’s health. An important aspect of the successful application of the method during flight is the training of qualified personnel. The prospects for the development of the method are the development of more advanced ultrasound scanners and sensors adapted to flight conditions, as well as the use of telemedicine technologies for remote analysis of ultrasound images.Conclusion. The experience of using prehospital diagnostic ultrasound in an ambulance helicopter requires further data accumulation and systematic analysis, but the method is already undoubtedly useful in determining the tactics of treatment and the route of hospitalization of urgent patients with acute trauma and a number of other pathological conditions.

How Should Deceased Donor Organs Be Allocated? The Patient's Perspective Derived from Semi-Structured Interviews.

PurposeThe gap between the supply and demand for deceased donor organs is increasing worldwide, while patients on waiting lists for organ transplantation die. This situation requires ethical donor organ allocation rules. The patients’ perspective on donor organ allocation rules offers a highly relevant and unique perspective that may differ from the perspectives of physicians and the general public.Patients and MethodsSemi-structured telephone interviews were conducted with the regional group coordinators of the federal self-help organization for organ transplanted patients and their relatives in Germany in early 2021. Twelve interviews were conducted with patients and relatives of transplantation patients who received transplants for the affected organs including the lungs, heart, kidney, and liver. Transcripts were analyzed using the deductive framework method which was based on an earlier study. All criteria were reported following the COREQ statement.ResultsParticipants emphasized aspects of “medical urgency” and “effectiveness/benefit” of transplantation and associated trade-offs as well as the recipient’s responsibility for organ failure (“own fault”), the appreciation for the gifted graft and the patient’s capability of taking care of it (“appreciation/responsibility”). Patients acknowledged that urgent patients should be prioritized and they showed a clear preference toward allocation rules that strive to maximize both the life years and quality of life gained by transplantation.ConclusionThe patients’ perspective is unique in that patients agree on certain rules for allocation and share many preferences, but also have a hard time finding clear cutoff points when considering selecting a participant for allocation. Patient representatives should therefore be consulted in the debate on donor organ allocation rules.

Vascular headache an traumatic brain injury

In a medical emergency, the most urgent patients at significant risk of death are those witha cerebrovascular accident and those with traumatic brain injury. Many are admitted withdiminished conscience status (coma) and focal neurological deficits. In the evaluation ofthese patients, neuroimaging is indispensable in order to identify the type of lesion andthe location of the brain where it is located.In the case of stroke, we can subdivide it into hemorrhagic and ischemic. Among hemorrhagic hemorrhages, we can mention (1) spontaneous intracerebral hematomasand (2) hemorrhages due to rupture of an intracranial aneurysm, with subarachnoidhemorrhage leading.Patients with head trauma are critical; even those who arrive at the hospital alert andoriented can decrease their level of consciousness in a few hours due to an intracranialhematoma, edema, or cerebral contusion.Thus, the availability of performing neuroimaging evaluations, using computed tomography and magnetic resonance imaging, or even digital angiography, is vital for continuoussupervision of this type of patient. The exams often require repetition several times due tothe rate of evolution of vascular lesions and after head trauma.A warning sign in these types of patients is headache. In the intracranial aneurysmal rupture, we classically have the thunderclap headache, an explosive, sudden pain mentionedas the worst pain the individual has suffered in his or her life. The pericranium and someintracranial structures are sensitive to nociceptive stimuli, such as the dura mater, largearteries, and venous sinuses. The brain is relatively insensitive to painful stimuli.This narrative review aims to inform the importance of neuroimaging assessment of patients with stroke and traumatic brain injury in an emergency department. In conclusion,a neuroimaging evaluation is paramount in addition to a neurological and physicalexamination of the critically ill patient with cerebrovascular disease or who has suffereda traumatic brain injury

Appointment Scheduling Problem under Fairness Policy in Healthcare Services: Fuzzy Ant Lion Optimizer

This study addresses the application of the Integer Linear Programming technique for the patient Appointment Scheduling Problem (ASP). In this research, we propose a Mixed-Integer Linear Programming (MILP) model to formulate the problem and treat patients admitted to hospitals and stay in a queue based on their general health status (urgent or regular patients). Moreover, the ASP has two main objectives that often provide early patient admissions. The first objective is based on fairness policy as an essential factor in the healthcare service to help minimize patient waiting time. The second one is to maximize the efficiency of healthcare services in line with patients’ satisfaction. Moreover, we have addressed the Fuzzy Ant Lion Optimization (FALO) strategy and Non-dominated Sorting Genetic Algorithm II (NSGA-II) are utilized to compare and solve the resulting multi-objective ASP. As the application of the model, fairness policy is analyzed in scenario 1 using FALO, and in scenario 2, NSGA-II is applied. The performances of the solution algorithms are then tested using datasets of a big regional hospital in Shanghai. The outcomes indicate potential advantages of implementing the presented approach. In particular, the suggested FALO increases the fairness and patients’ satisfaction by more than 80% while reducing the waiting times by 50% within the basic appointment scheduling system.

Analysis of risks and restrictions in hospitalization of urgent patients by ground transport

Relevance. Mortality from accidents, poisoning, acute diseases and injuries in Russia and the world remains high. For a number of urgent conditions, fast medical evacuation to a medical facility and prompt specialized care are critical. In a metropolis, there are a number of features that limit the work of ambulance ground teams (AGT). Intention. To analyze medical evacuation of patients to a hospital in a metropolis (the city of Moscow as an example) using ground transportation, with its shortcomings and limitations. Methodology. Patterns prehospital and early hospital mortality of patients in need of emergency medical care were analyzed, main reasons for the fastest possible transportation to a specialized hospital were determined. The statistics of road traffic accidents involving ambulances in Moscow for 2019-2020 were analyzed. Average traffic loads in Moscow for the period of 2017-2019 were estimated. Cases of rendering emergency medical care to Muscovites outside the city and in places without a road transport system were analyzed. Results and Discussion. The main causes of death before arrival of ambulance teams are blood loss of various origins (28 %), burn shock (6 %), poisoning with various substances (31 %), traumatic brain injury and stroke (12 %), acute coronary syndrome (7 %) and a number of other conditions. If resuscitation measures are required, risks of death increase by 10.7 % for every 10 minutes of waiting for an ambulance. One-day outcomes were influenced by time to hospital admission for cardiovascular diseases (26.9-30.1 % mortality rate ); diseases and injuries of the central nervous system, i.e. stroke, head injury (25.2-25.5 % mortality rate); internal bleeding (12.6-15.2 % mortality rate). In Moscow in 2019, an average of 2.8 ambulance vehicles got into road accidents daily. This probability amounted to 2.78 x10-3 and was 2.5 times higher than for other vehicles (1.11 x10-3). The main restrictions for ground transportation in a metropolis are as follows: unpredictable traffic conditions increase time to hospital admission, difficulty transporting patients from remote areas, including off-road locations. Conclusion. When urgent patients are admitted to a specialized hospital by road in a metropolis, there are a number of restrictions that must be taken into account when organizing emergency medical care. The main potential risks of increased time to hospital admission in Moscow is unpredictable road traffic.

The impact of COVID-19 on Emergency Department length of stay for urgent and life-threatening patients

ObjectivesTo determine the impact of the Coronavirus disease-2019 (COVID-19) pandemic on the length of stay (LOS) and prognosis of patients in the resuscitation area.MethodsA retrospective analysis of case data of patients in the resuscitation area during the early stages of the COVID-19 pandemic (January 15, 2020– January 14, 2021) was performed and compared with the pre-COVID-19 period (January 15, 2019 – January 14, 2020) in the First Affiliated Hospital of Soochow University. The patients’ information, including age, sex, length of stay, and death, was collected. The Wilcoxon Rank sum test was performed to compare the LOS difference between the two periods. Fisher's Exact test and Chi-Squared test were used to analyze the prognosis of patients. The LOS and prognosis in different departments of the resuscitation area (emergency internal medicine, emergency surgery, emergency neurology, and other departments) were further analyzed.ResultsOf the total 8278 patients, 4159 (50.24%) were enrolled in the COVID-19 pandemic period group, and 4119 (49.76%) were enrolled pre-COVID-19 period group. The length of stay was prolonged significantly in the COVID-19 period compared with the pre-COVID-19 period (13h VS 9.8h, p < 0.001). The LOS in the COVID-19 period was prolonged in both emergency internal medicine (15.3h VS 11.3h, p < 0.001) and emergency surgery (8.7h VS 4.9h, p < 0.001) but not in emergency neurology or other emergency departments. There was no significant difference in mortality between the two cohorts (4.8% VS 5.3%, p = 0.341).ConclusionThe COVID-19 pandemic was associated with a significant increase in the length of resuscitation area stay, which may lead to resuscitation area crowding. The influence of the COVID-19 pandemic on patients of different departments was variable. There was no significant impact on the LOS of emergency neurology. According to different departments of the resuscitation area, the COVID-19 pandemic didn’t significantly impact the prognosis of patients.

Outcomes of simultaneous carotid endarterectomy and coronary artery bypass grafting: A single centre experience.

Stroke following a coronary artery bypass surgery is a well-known complication often predisposed by carotid artery disease. Perioperative risk of stroke after on-pump cardiac surgery can overall affect 2% of patients. Patients with 80-99% unilateral carotid artery stenosis carry a 4% risk of stroke. Significant carotid artery stenosis is present in 3-10% of patients who are candidates for coronary artery bypass grafting (CABG). Those patients might be considered for either simultaneous or staged carotid endarterectomy and CABG to reduce the risk of stroke and death. The purpose of this study was to evaluate preoperative and intraoperative risk factors for myocardial infarction (MI), stroke and death and assess complications occurring during the early postoperative period after simultaneous CABG/CAE procedure. A single centre retrospective analysis of 134 patients from 2015 to 2019 who underwent simultaneous CABG/CEA was performed. At the same period, a total of 2827 CABG were performed, of which 4.7% were simultaneous interventions. We excluded staged CEA/CABG procedures, off-pump CABG and urgent CABG patients. All patients included in the study met the criteria for elective CABG for triple-vessel or left main trunk symptomatic coronary artery disease (CAD) with asymptomatic >70% carotid stenosis or symptomatic ipsilateral >50% carotid stenosis regardless of the degree of contralateral carotid artery stenosis. Patient demographics, comorbidities and operative details were reviewed. The primary endpoint was to assess the intraoperative and 30-day risk of stroke and death after simultaneous CEA/CABG procedure. Simultaneous CEA/CABG is effective procedure that can be performed in high-risk symptomatic patients with acceptable results. Predictors of postoperative stroke were smoking (P = 0.011), history of MI (P = 0.046), history of CABG (P = 0.013), and history of stroke/TIA (P = 0.005). Significant risk factors for adverse major postoperative complications after simultaneous CEA/CABG procedure were cardiac arrhythmia (AF or AFL) (P = 0.045), previous MI (P < 0.001), and smoking (P = 0.001). Synchronous CEA/CABG procedure can be performed with acceptable results in patients having a high risk of stroke, septuagenarians and older.

Long-Term Thoracic Endovascular Repair Follow-Up from 1999 to 2019: A Single-Center Experience

Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990s and long-term follow-up studies are warranted in current guidelines. Patients undergoing TEVAR were consecutively included from 1999 to 2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU), and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth, and death. Patients were included at the time of treatment and censored at death or first reintervention depending on the analysis. Primary end point was all-cause death; secondary end point was reintervention. Survival and failure analyses were done using STATA IC 16.0 and truncated at 15years of follow-up. Two hundred and fifty six patients were included and 63% were men. Their mean age at intervention was 66.2±14.5years and they were followed for a mean of 5.2±4.5years. Indications for TEVAR were acute aortic syndrome in 40.6%, chronic aortic disease in 44.5%, and traumatic rupture in 14.8%. Technical success was seen in 94.1% of the operations, and the left subclavian artery was covered in 27.7%. A 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (P<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24hr of treatment. Overall, long-term mortality recorded 112 (43.8%) deaths, 29 patients had reinterventions (11.3 %, 95% confidence interval: 7.7-15.9), and aneurysms accounted for 62.1% of all reinterventions. Twenty four (82.8%) reinterventions occurred within the first 5years. This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30days; this difference diminishes at the end of follow-up. Most endoleaks occur within the first 5 years, although new endoleaks continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.