Frontiers in Emergency Medicine (E-Journal)
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Resource Utilization and Cost of Hospitalized Patients with COVID-19 in Iran: Rationale and Design of a Protocol
Get PDFThere is little data on direct medical costs and how to overcome the shock introduced by the novel Coronavirus (COVID-19) which emerged in Wuhan, China. The aim of this report is to present the methodology of an observational study for analyzing the resource utilization and direct medical costs of hospitalization. A multicenter retrospective observational study will be conducted on hospitalized patients with COVID-19 in selected hospitals of Tehran University Medical Sciences from February 2020 to June 2020. Cost calculations will be based on micro-costing approaches according to the health insurance perspective. Demographic, clinical, and cost data for the aforementioned patients will be collected through reviews of medical and financial records using a self-made questionnaire categorized in three parts (Form No. 1). The first part consists of demographic characteristics, the second part includes clinical information (e.g., symptoms, comorbidities, and complications), and the third part consists of resource utilization and cost data. Descriptive statistics (means, frequencies, percentages, and 95% confidence intervals) will be used to report data. With this report we sought to provide a valuable framework for estimating the direct medical costs of COVID-19 for hospitalized-patients basis on the severity of presentation. This will be the core for an assessment of the economic burden of COVID-19 in different presentations of the disease
Electrocardiographic Findings of COVID-19 Patients and Their Correlation with Outcome; a Prospective Cohort Study
Get PDFIntroduction: Being infected with COVID-19 is associated with direct and indirect effects on the cardiopulmonary system and electrocardiography can aid in management of patients through rapid and early identification of these adversities. Objective: The present study was designed aiming to evaluate electrocardiographic changes and their correlation with the outcome of COVID-19 patients. Methods: This Prospective cohort study was carried out on COVID-19 cases admitted to the emergency department of an educational hospital, during late February and March 2020. Electrocardiographic characteristics of patients and their association with in-hospital mortality were investigated. Results: One hundred and nineteen cases with the mean age of 60.52±13.45 (range: 29-89) years were studied (65.5% male). Dysrhythmia was detected in 22 (18.4%) cases. T-wave inversion (28.6%), pulmonale P-wave (19.3%), left axis deviation (19.3%), and ST-segment depression (16.8%) were among the most frequently detected electrocardiographic abnormalities, respectively. Twelve (10.1%) cases died. There was a significant correlation between in-hospital mortality and history of diabetes mellitus (p=0.007), quick SOFA score > 2 (p<0.0001), premature ventricular contraction (PVC) (p=0.003), left axis deviation (LAD) (p=0.039), pulmonale P-wave (p<0.001), biphasic P-wave (p<0.001), inverted T-wave (p=0.002), ST-depression (p=0.027), and atrioventricular (AV) node block (p=0.002). Multivariate cox regression showed that history of diabetes mellitus, and presence of PVC and pulmonale P-wave were independent prognostic factors of mortality. Conclusions: Based on the findings of the present study, 18.4% of COVID-19 patients had presented with some kind of dysrhythmia and in addition to history of diabetes, presence of PVC and pulmonale P-wave were among the independent prognostic factors of mortality in COVID-19 patients
Clinical Characteristics of Fatal Cases of COVID-19 in Tabriz, Iran: An Analysis of 111 Patients
Get PDFIntroduction: The rapid worldwide spread, in addition to the morbidity and mortality associated with the novel coronavirus disease 2019 (COVID-19), have raised concern throughout the world. Identifying the characteristics of patients who died of COVID-19 is essential to implement preventive measures. Objective: We aimed at investigating these characteristics among the Iranian population in Tabriz. Methods: In this case series, we analyzed clinical characteristics, laboratory parameters, and imaging findings of 111 patients with a reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 diagnosis who died during hospitalization. The studied patients had been admitted to the hospital between February 2020 and May 2020. Results: The median age of patients was 73 years (IQR, 62-82 years) and approximately 70% of them were male. The median oxygen saturation on admission was 88% (IQR, 80-92%) and dyspnea, cough, and fever were the most common presenting symptoms. Among comorbidities, diabetes, hypertension, and cardiovascular diseases were more frequently observed among patients who had a fatal outcome. While ground-glass opacity was the most commonly reported finding on chest computed tomography, 5% of the patients had no abnormal finding on imaging. Chloroquine was the most frequently used medication for treatment. Conclusion: Our results showed that the majority of COVID-19 deaths occurred in male elderly with decreased levels of oxygen saturation and elevated levels of lactate dehydrogenase and erythrocyte sedimentation rate on admission
Sex Differences in Risk Factors Profile and Angiographic Pattern of the Patients Undergoing Coronary Angiography
Get PDFIntroduction: Coronary artery disease (CAD) is a costly problem and its presentations and risk factors may differ by sex. Objective: This study aimed to evaluate the risk factors profile and angiographic pattern of the patients undergoing coronary angiography, according to their gender. Methods: This cross-sectional study was conducted on 741 patients who were referred for coronary angiography from March to August 2018 at Imam Ali cardiovascular center, western Iran. Using a checklist, we collected the demographic, clinical, biochemical, and lab parameters and angiographic findings in these patients. Also, differences between groups were compared using Chi-square and independent t-tests. Results: Women were different from men in terms of the prevalence of hypertension (71.7% vs. 45.3%), diabetes mellitus (34.9% vs. 17.8%), and hypercholesterolemia (26.4% vs. 17.1%). Whereas, men were more likely to be smoker (28.7% vs. 0%) and obese (42.09±16.68 vs. 29.12±4.72). Total Cholesterol and Triglycerides were higher in women compared to men, which were statistically significant. Glucose plasma was significantly higher in women compared to men (p=0.01). Both atherogenic (low-density lipoprotein (LDL)) and protective (high-density lipoprotein (HDL)) cholesterol were higher in women than men. Women were more likely to take antiplatelet (i.e. Aspirin) and antihypertensive therapies (i.e. beta-Blocker, angiotensin receptor blockers (ARBs), and angiotensin converting enzyme (ACE) inhibitors) than men. Also, it was shown that, Men were more likely to have two-vessel disease (p=0.041) and three-vessel disease (P=0.013) compared to women. Disease in the right coronary artery (RCA) (28.9% vs. 14.4%), circumflex (LCx) (26.0% vs. 15.3%), and left anterior descending (LAD) (37.8% vs. 26.4%) was more plausible to occur in men compared to women (p≤0.05). Conclusion: Access and use of health care programs are needed to control CAD risk factors. The findings of the current study showed the significance of gender in the extent of coronary artery blockages
Factors Affecting Emergency Medical Technicians’ On-Scene Decision-Making in Emergency Situations: A Qualitative Study
Get PDFIntroduction: To save lives and reduce the disability and death of the patients, emergency medical technicians (EMTs) must make timely decisions in complex and, sometimes, life-threatening situations. Since the pre-hospital decision-making is a continuous and important process. Objective: The present study aims to identify the factors affecting EMTs’ on-scene decision-making in emergency situations. Methods: A qualitative approach using in-depth semi-structured interviews and field observations was employed to explore the factors influencing EMTs’ on-scene decision-making in emergency situations. Purposeful sampling was performed with 19 participants including 12 EMTs, 3 dispatchers, 3 medical directions physicians and one EMS manager as a policy maker. Interviews were conducted from October 2018 to March 2018 and the data were analyzed using Graneheim and Lundman’s content analysis approach. Results: Eight categories and 18 sub-categories emerged to describe the factors effective in emergency medical technicians’ on-scene decision-making. they were cultural context (community’s culture and organizational culture), interactions (malingering, threat and violence and considerations), competencies (acquisitive and intrinsic); personal feeling (positive feeling and negative feeling), authority (structural and in processing), education (public and professional), special conditions (patient’s clinical situation, weather conditions, mission’s time and mission’s location), and organizational resource (facility and equipment, and human resources). Conclusions: To facilitate EMTs’ on-scene decision-making, it is recommended to clarify the EMTs’ responsibilities, promote the community’s culture, modify people’s expectations, police monitoring and control and value the star of logo on EMTs' uniform. The EMTs’ on-scene decision-making process should also be explored
Personal Protective Equipment for Protecting Healthcare Staff during COVID-19 Outbreak: A Narrative Review
Get PDFContext: The World Health Organization (WHO) declared a pandemic state as the coronavirus spread across the world. Personal protective equipment (PPE) has become a critical subject during the COVID-19 outbreak. It is necessary to prevent coronavirus transmission to healthcare workers (HCWs) as providing care. They are at high risk of exposure to coronavirus. The aim of this study was to provide a brief review of some routes of transmission of COVID-19, what, when and why PPE is recommended base on the route of transmission. Evidence acquisition: In this review, articles were extracted from the Google Scholar, Scopus, Web of Science, and PubMed search engines. The main keywords for search were coronavirus, COVID-19, personal protective PPE, healthcare, transmission, contact, and protect.Results: Findings showed the COVID-19 transmission rate in the HCWs that wore PPE significantly decreased. All HCWs must use appropriate and adequate PPE in order to minimize the COVID-19 transmission. Conclusion: Although still uncertainty remains around COVID-19 transmission and it is early to have conclusion on its prevention, most of recommendations and guidance have emphasized to apply the PPE during COVID-19 outbreak among HCWs
A Rare Case of Sickle Cell Anemia Crisis Triggered by Plasmodium Falciparum Malaria
Get PDFMalaria is a common public health problem in Sub-Saharan African countries such as Niger and one child dies every two minutes due to this disease. Although the defense mechanism is not clear, sickle cells are 90% protective especially for Plasmodium falciparum malaria. In Niger, malaria is among the first to be considered in patients admitted to the emergency departments (EDs) with high fever. It is important for physicians to resolve the clinical manifestation in a patient who admits due to acute abdominal pain and high fever in a hospital with limited facilities. Failure to provide information about the patient’s history and admission to the ED alone led to a delay of diagnosis and treatment of this rare coexistence
Comparison of Glasgow Coma Scale with Physiologic Scoring Scales in Prediction of In-Hospital Outcome of Trauma Patients; a Diagnostic Accuracy Study
Get PDFIntroduction: Limitations of Glasgow coma scale (GCS) led the researchers to designing new physiologic scoring systems such as revised trauma score (RTS), rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS), and worthing physiological scoring system (WPSS). However, it is not yet known whether these models have any advantage over GCS. Objective: The present study attempted to compare the values of 4 physiologic scoring systems including RTS, RAPS, REMS and WPSS with GCS in predicting in-hospital mortality of trauma patients. Methods: The present diagnostic accuracy study was performed on trauma patients presenting to emergency departments of 4 hospitals in Iran throughout 2017. Patients were clinically evaluated and were followed until discharge from hospital. Finally, the status of patients regarding mortality and poor outcome (death, vegetative status, severe disability, and moderate disability) was recorded and predictive value of GCS was compared with physiologic scales. Results: Area under the ROC curve of GCS in prediction of in-hospital mortality was not significantly different from that of REMS (0.89 vs. 0.91; p=0.298), RAPS (0.89 vs. 0.88; p=0.657), and WPSS (0.89 vs 0.91; p=0.168) but was significantly more than RTS (0.89 vs. 0.85; p=0.002). In addition, area under the ROC curves of GCS, REMS, RAPS, WPSS and RTS in prediction of poor outcome were 0.89, 0.88, 0.88, 0.91, and 0.81, respectively. Area under the ROC curve of GCS in prediction of poor outcome did not differ from area under the ROC curves of REMS (0.89 vs. 0.88; p=0.887), RAPS (0.89 vs. 0.88; p=0.601) and WPSS (0.89 vs. 0.91; p=0.113) but was significantly higher than RTS (0.89 vs. 0.81; p<0.0001). Conclusions: Findings of the present study indicated that GCS is still the best method for evaluating injury severity and trauma patients’ outcome in the emergency department; because it is easier to calculate and assess than many physiologic scales and it has a better performance in predicting in-hospital mortality and poor outcome compared to RTS
Bracing the Emergency Department for the COVID-19 Era
Get PDFThe COVID-19 pandemic in a matter of few months has wreaked havoc across the globe. However as per the WHO, the worst may not be over yet and COVID-19 is going to stay with us for a long time. The coronavirus is highly contagious, and in the current scenario containment measures in the form of lockdowns and curfew may only be useful in transiently flattening the curve and not disease elimination. The absence of an effective vaccine and/or treatment, means that morbidity and mortality associated with COVID-19 is going to increase in the foreseeable future. For the emergency physicians (EPs) working on the frontlines, the battle may have just begun. Any patient coming to emergency room (ER), with COVID-19 related symptoms or otherwise, could be a potential source for the spread of coronavirus infection in the hospital. With most of the ER’s being overcrowded, the place itself will act as amplifier which could lead to a catastrophe. Ever since the beginning of this pandemic, our focus has completely shifted to only COVID-19 related symptoms which is proving detrimental for the other non-COVID emergencies. We hereby put forth certain possible solutions which may be useful for the smooth functioning of our emergency departments (EDs)
Prognostic Value of Routine Biochemistry Profile of Liver Transplant Patients Admitted to the Emergency Department with a Suspected Infection
Get PDFIntroduction: Since patients who have undergone liver transplantation should take immunosuppressants for life, the prevalence of systemic infections after this procedure is very high. These infections are associated with increased mortality and morbidity. Objective: This study aimed to investigate the prognostic value of routine biochemistry profile and its relationship with mortality in liver transplant patients admitted to the emergency department (ED) with a suspected infection. Methods: Patients who had undergone liver transplantation were included in the study. The patients were divided into three groups of culture-negative, culture-positive and control. White blood cell (WBC) count, hemoglobin (Hb), platelet (Plt), international normalized ratio (INR), creatinine (Cr), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values as well as vital sign findings were comparatively evaluated in terms of their ability to show the presence of any infection and their correlation with mortality. Results: Totally, 142 patients were enrolled and were divided into the following three groups: 41 cases in culture-negative group, 30 cases in culture-positive group, and 71 cases in control group. There was not any significant difference between study groups in terms of age and sex ratio (p>0.05). The Hb and Plt values of the culture-positive patients were significantly lower, and their INR was significantly higher compared to those in control group (p<0.05). Fever, Hb, Plt, INR, AST and ALT values were factors that had a significant correlation with mortality in patients with an infection whethere culture-positive or culture-negative ones (p<0.05). Conclusions: In patients admitted to the ED with a history of liver transplantation, we recommend the evaluation of vital signs and Hb, PLt, and INR values to determine whether there is an infection or not. We can also state that mortality risk is higher in cases with low Hb and Plt levels and high INR, ALT, and AST values