Occupational therapy falls prevention program for elderly patients discharged home from emergency ward using the Person-Environment-Occupation Model
WHV Leung1, MLM Chu1, MSC Lee1, KM Ling1, YK To1, WT Toh1, YL Yung1, TCJ Chan1, KY Lo2 and SH Tsui2
1Department of Occupational Therapy, Queen Mary Hospital, Hong Kong
2Department of Accident and Emergency, Queen Mary Hospital, Hong Kong
Objective: To study fall risks in elderly patients discharged home from Emergency Medicine(EM) ward using the Person-Environment-Occupation (PEO) Model.
Methodology: Patients admitted to EM ward in Queen Mary Hospital were evaluated on their falls risks by nurses using the Falls Morse Scale. Those with falls risks were identified and further screened by occupational therapist (OT) if they satisfied the inclusion criteria of the elderly falls prevention OT program. Inclusion criteria included patients at or above 65 years old, residing at home, with fall history within one year and not referred for other community elderly service. OT provided falls prevention education and also offered a home visit to assess for falls risks for recruited patients. A visit to patient’s home was arranged within two weeks post-discharge for those who agreed to have home visit. Falls risks were identified by OT using the PEO Model which conceptualizes the dynamic interaction and interdependence of the three dimensions (person, environment, occupation) to result in a safe satisfying functional performance. Based on assessment results, recommendations targeting falls reduction were provided. Subsequent falls episodes and hospital admissions related to falls were monitored by monthly telephone follow-up for six months.
Results: During the period from April 2016 to June 2017, 583 cases with falls risks in EM ward were identified by nurses and then screened by OT. 156 cases satisfied the inclusion criteria. 36% of cases agreed to have an OT home visit. OT conducted home visit for 44 cases during the period. Falls risk factors were investigated using the PEO Model. Results showed no single risk factor accounted for the risks of falls. Instead, the person–occupation interaction (e.g. risky behavior) ranked the highest risk factor. Risky behavior (such as standing on foldable high stool to reach for objects placed on high level) posed higher risk of falls than other dimensions and each individual had his or her unique situation. It is important not just focus only on single factor such as environmental factor when performing home assessment. Results of subsequent falls episodes and hospitalization would be discussed after completion of data collection.
Conclusion: Elderly with falls risks discharged home from EM ward were visited by an OT who utilized the PEO Model to identify falls risks and gave specific recommendations to reduce further falls. Person-occupation interaction (e.g. risky behavior) was shown to pose the highest falls risk.
Predicting pneumonia in paediatric acute febrile respiratory illness
YYF Chan, CF Tse, KM Poon and CT Lui
Department of Accident and Emergency, Tuen Mun Hospital, Hong Kong
Background: It is a regular challenge for emergency and primary care physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in those stable patients without signs of respiratory distress. Decision to order chest roentgenogram was exclusively based on clinical gestalt, with highly variable practice and accuracy.
Method: This is a multicentre prospective study in 3 emergency departments. Children less than 6 years old with acute onset of fever and respiratory symptoms were recruited. Neonates, patients in clinical respiratory distress, requiring oxygen supplement, immunocompromised, or had chronic lung disease were excluded. Pneumonia was defined as a composite outcome of (1) new onset pneumonia in chest radiograph (CXR), or reattendance to any emergency department within 7 days and diagnosed pneumonia. Two independent assessors with agreement on CXR findings was defined as positive outcome. Split sample method was adopted for derivation and validation of a clinical prediction rule, the Paediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). The predictive model was derived by logistic regression. A clinical decision score was derived with weighing based on the adjusted odds ratio. The Paediatric AFRI Rule was validated and compared with the Bilkis Decision Rule and Bilkis Simpler Rule with ROC curve.
Results: Out of the 967 children evaluated, 530 of them had taken CXR, with 90 having positive outcome. The Cohen’s Kappa was 0.937 for the agreement between the two assessors for the roentgenogram. PAFRI Rule was derived with logistic regression with 5 weighed predictors to form a scoring system: Duration of fever <3 days (0 score), 3–4 days (2 scores), 5–6 days (4 scores), ≥7 days (5 scores), chills (2 scores), nasal symptoms (–2 scores), abnormal chest exam (3 scores), SpO2 ≤ 96% or tachypnoea (3 scores). With the validation group, the area under Receiving Operating Characteristic curve of the Paediatric AFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. The PAFRI Rule is statistically significantly better than the Bilkis Decision Rule and Bilkis Simpler Rule. PAFRI ≥ 0 gives a sensitivity of 91.7% and negative predictive value of 97.7%, whereas PAFRI ≥ 4 can achieve up to specificity of 90%.
Conclusion: The PAFRI rule can be used to a reference tool for guiding need for referral or taking roentgenogram for paediatric patients, while adopting a higher cut off (≥ 4) may be considered for triaging the patients for higher priority with high specificity.
Frailty at front door. A winter surge collaborative service measure
YM Chau1, KA Wan1, MC Wan2 and PG Kan1
1Department of Accident and Emergency, Ruttonjee & Tang Shiu Kin Hospital, Hong Kong
2Department of Geriatrics, Ruttonjee & Tang Shiu Kin Hospital, Hong Kong
Background: As Hong Kong population ages and life expectancy increases, by 2021, more than 20% of Hong Kong residents are expected to be 65 years or older. The elderly admission and burden on hospital services will increase especially during the winter surge period. Geriatric patients typically manifest a complex mix of chronic diseases and underlying psychosocial problems. To deliver a holistic medical model for geriatric patients with multiple comorbidities and strengthen the front door gate keeping for in-patient services, a new care model with early tripartite collaboration between the geriatricians, community caretakers and emergency physicians is developed to provide alternate care pathway for selected geriatric patients. We have conducted a pilot study of the new model- “Frailty at Front Door”.
Objective: To provide a joint medical care between the geriatric and emergency medicine specialists with early mobilization of community services for the frail elderly to decrease the admission and reattendance to the emergency department.
Methods: Patients more than 65 years old, who were triaged as urgent or semi urgent were assessed by the emergency physicians. If the patients had borderline indications for medical admission and may potentially be managed in alternative pathway, they were enrolled in the program. The Geriatric team would complete the comprehensive geriatric assessment with Edmond frailty score and clinical frailty scale in the emergency department (Graph 1 integrated management workflow). A conjoint care plan was worked out with emergency physicians to facilitate direct discharge from emergency department, with the support of comprehensive, enhanced community care (Graph 2). Phone follow up was arranged to monitor the patients’ clinical conditions for one month. Satisfaction survey was also conducted.
Integrated management workflow.
Discharge options.
Results: There were totally 40 patients with median age 83 years old (interquartile range 73–86) recruited over the 11-week period. Patient characteristics are shown in Table 1 and Graph 3. Among the 40 patients, about 68% were considered as at least vulnerable to severe frail in clinical frailty scale assessment. 33 patients (80%) were discharged directly from emergency department. 85% of these patients had no reattendance to emergency department in 28 days (Graph 4).
Patient characteristics.Outcome of the Frailty at Front Door Project.
%/number
Total number of cases recruited
40 (2 December 2016 to 17 February 2017)
Age, median
83 (IQR 73–86)
Sex
Male Female
45% (18) 55% (22)
Residence
Home with caretaker Day time alone lives alone Old age home
62.5% (25) 12.5% (5)12.5% (5) 12.5% (5)
Diagnosis of patients by Emergency physician.
Outcomes.
Conclusions: The early involvement of geriatric and community care teams within emergency department can decrease the admission to 80% and avoid reattendance rate up to 85% within the first 28 days. The program also shown possibilities of providing the emergency department with more management options and strengthen collaboration with hospital and community health teams.
First extracorporeal cardiopulmonary resuscitation (ECPR) program for refractory cardiac arrest in Hong Kong: Collaboration of AED, ICU and CCU
PC Lam1, CW Ngai2, PY Ng2 and WC Sin2
1Department of Accident and Emergency, Queen Mary Hospital, Hong Kong
2Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong
Introduction: Patients presenting with cardiac arrest have high mortality despite conventional cardiopulmonary resuscitation (CPR). The survival rates of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) are only about 1.25% and 5% respectively. Moreover, survivors often have severe neurological deficits. The latest American Heart Association guidelines in 2015 suggested consideration of Extracorporeal CPR (ECPR) as an alternative treatment to conventional CPR in selected patients. We analyzed the early results of an ECPR program in Queen Mary Hospital.
Methods: This is a single centre, retrospective analysis conducted in Queen Mary Hospital. OHCA and IHCA patients with refractory pulselessness were managed with CPR and percutaneous cannulation of femoral artery and vein for veno-arterial ECMO. Patients with suspected myocardial infarction then received coronary angiogram in the cardiac catheterization laboratory. The primary outcome was 30-day survival. The secondary outcome was hospital discharge with good neurological outcome (Cerebral Performance Categories 1 or 2), predictors of 30-day-survival.
Results: A total of 32 patients received ECPR (16 OHCA and 16 IHCA) from March 2015 to December 2016. The median age was 52.5 (IQR 38.5–62) years. 25 patients were male sex (78.1%). 17 patients (53%) were diagnosed with acute myocardial infarction, 4 patients (12.5%) with myocarditis, and other diagnoses included aortic aneurysm, pulmonary embolism, drug overdose, and cardiomyopathy. Emergency coronary angiogram was performed in 19 patients (59%) and primary percutaneous coronary intervention (PCI) was performed in 13 patients (41%). The 30-day survival for the entire study was 34.4% (11 patients), and 28.1% (9 patients) was discharged from hospital with a good neurological outcome. There were no differences in baseline characteristics such as age, sex, and comorbidity between survivors and non-survivors. The rate of immediate CPR upon arrest was significantly higher in survivors (9 out of 9, 100%) than in non-survivors (11 out of 23, 47.8%) (p = 0.012).
Conclusion: We achieved a 30-day survival rate comparable to international centers of 34.4%. Patients who received immediate CPR had better outcomes. Further studies are necessary to establish more well-defined inclusion criteria for ECPR in order to better utilize healthcare resources.
Elderly out-of-hospital cardiac arrest – A population-wide analysis of prehospital registry data
Leung SC1, Leung R2, Fan KL3 and Leung LP2
1Department of Accident and Emergency, Queen Mary Hospital, Hong Kong
2Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
3Accident and Emergency Department, The University of Hong Kong – Shenzhen Hospital, Shenzhen, China
Introduction: With the highest life expectancy and one of the most aged population in the world, healthcare system in Hong Kong is now managing more elderly patients in out-of-hospital cardiac arrest (OHCA). This study aims to describe the epidemiology, outcomes, and predictors of survival from OHCA in geriatric population using territory-wide prehospital data.
Methods: This retrospective cross-sectional study analysed consecutive OHCA patients aged 65 years or above, who were transferred by emergency ambulance service from 1st August 2012 to 31st July 2013. The primary outcome was 30-day survival. The secondary outcome was neurological recovery. Patients’ demographic data, site of arrest, presence of witness, initial cardiac rhythm, availability of bystander cardiopulmonary resuscitation (CPR) and defibrillation, resuscitation in emergency department, and prehospital time variables were described. Associations among independent variables and study outcomes were evaluated with univariate logistic regression. Survivors and non-survivors were compared using Mann-Whitney U and Chi-squared tests for continuous and categorical variables, respectively.
Results: 3919 included elderly cases contributed to 76% of OHCA cases in all age groups during the study period. It corresponded to 416 arrests per 100,000 person-years, which outnumbered the overall population (72 arrests per 100,000 person-years). Most occurred in residential homes (50.3%), followed by nursing homes (38.4%). In-hospital resuscitation was not initiated in 64.4% cases. The 30-day survival rate was 1.5%. 0.8% achieved favourable neurological status on discharge, as defined by Cerebral Performance Category Scores of 1 or 2. The odds of 30-day survival dropped 11% with each year of age increase. Nursing home residents were less likely to survive (0.39%). Survival deteriorated with delays of activation of emergency medical service, ambulance arrival, and first defibrillation. If cardiac arrests were witnessed aboard ambulances, the survival odds were 10 times higher. Patients who received bystander CPR by police, and treatment with public access defibrillation (PAD) before ambulance arrival, outlived who did not by 13 times and 12 times, respectively. Initial ventricular fibrillation and pulseless ventricular tachycardia had better prognosis (Adjusted OR = 8.78, CI = 4.81 – 16.03, p < 0.001).
Conclusion: The incidence of elderly OHCA was high and survival remained low. Chain of survival needs to be reinforced. Structured training for police officers, nursing home staff, home carers, and the public at large should be promulgated to shorten delays to CPR, defibrillation and ambulance service.
Prediction of pneumonia in acute febrile respiratory illness
CF Tse, Fiona YY Chan, KM Poon and CT Lui
Department of Accident and Emergency, Princess Margaret Hospital, Hong Kong
Background: It is a common challenge for emergency physicians to distinguish pneumonia from upper respiratory infections in patients with acute febrile respiratory symptoms. Risk stratifying prediction rule would assist the ordering of chest roentgenogram by emergency physicians.
Method: This is a prospective multicenter study. 537 adults aged at least 18 who were recruited. Those requiring resuscitation or were hypoxaemic were excluded. Pneumonia was defined as a composite outcome of new onset infiltrates in chest X-ray (CXR), or re-attendance within 7 days and diagnosed pneumonia. Two independent assessors with agreement were defined as the positive outcome. The demographics, symptoms, vital signs and clinical signs of the pneumonia and normal group were compared. A predictive model, the Acute Febrile Respiratory Illness (AFRI rule) was derived by logistic regression. The AFRI rule was internally validated with bootstrap resampling and was compared to the Diehr and Heckerling rule.
Results: In the 363 patients who had undergone CXR, 100 had CXR confirmed pneumonia. The Cohen’s Kappa was 0.936 for the agreement between the two assessors for the roentgenogram. AFRI rule was derived with logistic regression with 7 weighed predictors summed up to AFRI score: age ≥ 65 (1 score), peak temperature within 24 hours ≥ 40°C (2 score), fever duration ≥ 3 days (2 score), sore throat (–2 score), abnormal breath sounds (1 score), history of pneumonia (1 score) and SpO2 ≤ 96% (1 score). With the bootstrap resampling, the AFRI rule was demonstrated to be more accurate than the Diehr and Heckerling rule (area under ROC curve 0.816, 0.721 and 0.566 respectively, p < 0.001). At cutoff of AFRI ≧ 0, the rule had 95% sensitivity, while negative predictive value was 97.2%. CXR may be avoided for patients having a score of <0. At cutoff of AFRI ≧ 3, specificity of AFRI rule was 90.2% and positive predictive value was 47.6%. Triage initiated CXR may be considered at AFRI score ≥ 3 to pick up pneumonia.
Conclusion: AFRI score at two cut off could facilitate emergency physicians to reduce unnecessary CXR and the early pick up of pneumonia by triage initiated CXR. Further external validation would be required.
Accidental ingestion of desiccants and oxygen absorber
IW Wong1, CH Ng2 and CK Chan2
1Department of Accident & Emergency, United Christian Hospital, Hong Kong
2Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong
Objectives: To (1) characterize the clinical features of desiccants and oxygen absorber ingestion, (2) identify predictors for development of clinical features after ingestion.
Design: Retrospective observational study. Setting: Patients with desiccants and oxygen absorber ingestion from July 2008 to March 2017, derived from the database of Hong Kong Poison Information Centre.
Results: In all, 274 patient records were identified, of which 19 were excluded based on pre-defined criteria and 255 were analysed. The most common symptoms were related to the local irritative effects on the digestive tract, such as oropharyngeal irritation, vomiting and abdominal pain. Univariate analysis showed that age, ingestion of calcium oxide or unknown type of desiccant are associated with development of symptoms.
Conclusion: The type of desiccant ingested is the most important predictor for the development or absence of symptoms after ingestion.
2D barcode wristband for unique patient identification in Accident and Emergency Department of Pok Oi Hospital
FT Chung, KM Poon, Wai YL Sam, So YL Mary, Wong WM Billy, Leung YY Helen and KL Ong
Accident and Emergency Department, Pok Oi Hospital, Hong Kong
Introduction: Patient mis-identification is often encountered in the Accident and Emergency Department (AED) due to its over-crowded environment, high patients’ turn-over rate and lots of life-saving emergency procedures. We treasure correct patient identification as it is one of the most fundamental ways in fostering patient safety and the quality of care. Pok Oi Hospital (POH) is the third Accident & Emergency Department in Hong Kong to implement the 2D barcode patient wristband system.
Objectives: To enhance correct patient identification on specimen collection by implementing 2D barcode wristband to all patients who attended the Accident & Emergency Department in POH.
Program: Since 16th December 2016, all POH AED patients would wear a 2D barcode wristband upon triage. The triage nurse is responsible for checking patient’s identity using core identifiers (i.e. the name and the identity card number) before applying the wristband to patients. It facilitates various procedures including blood taking and specimen collection. It helps to reduce the incidence of patient mis-identification because the specimen label would not be generated if there is mis-match between patient’s wristband and specimen job sheet as being identified by the 2D barcode scanner. In order to facilitate implementation of 2D barcode wristband program, various educational materials, including the teaching video, are provided to our colleagues to familiarize the correct procedure of applying the wristband to patients and generating the specimen labels.
Results: There is no problem of applying the wristband to patients upon triage or collecting patients’ specimen. There is so far zero incidence of patient mis-identification of blood or other specimen collection in our emergency department.
Conclusion: The implementation of 2D barcode wristband to all patients attending POH AED was carried out smoothly in our department and it helps to enhance correct patient identification in our department.
Recommendation: In future, the application of 2D barcode wristband system could be expanded to other aspects, for example prescribing drugs sheet, referral letter or sick leave certificates upon patient disposal. It may be incorporated into the electronic medication system of drug administration to patient in Emergency Department.
Accidental geriatric poisoning in Hong Kong
CK Chan and ML Tse
Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong
Objective: (1) To identify the commonest agents involved in accidental geriatric poisoning in Hong Kong. (2) To compare the corresponding figures in younger adults.
Design: Retrospective observation study.
Setting: Geriatric patients with age 70 or above, recorded as accidental poisoning cases in Hong Kong Poison Information Centre between 1st January 2016 to 31st December 2016, were included in the study group. Adult patients with age 18 to 69 presented in the same time period as accidental poisoning were included in the control group.
Result: 160 and 1049 patients were identified in the study group and control group respectively. The commonest agents involved in accidental geriatric poisoning are animal bite and sting (29 cases, 18.1%), household products (18 cases, 11.2%), Chinese herbal medicine (18 cases, 11.2%), cardiovascular drugs (16 cases, 10%), diabetes drugs (10 cases, 6.3%), pain killer (10 cases, 6.3%), proprietary Chinese medicine (10 cases, 6.3%). Compare with the younger adults, there are statistically significant differences with more geriatric patients involved in pharmaceutical poisonings; and less geriatric patients involved in wilderness poisoning:
Number of cases in geriatric patients
Number of cases in younger adult patients
P value (Chi Square test)
Animal bite & sting
29 (18.1%)
364 (40.3%)
<0.0001
Household products poisoning
18 (11.2%)
85 (8.1%)
0.240
Chinese herbal medicine poisoning
18 (11.2%)
98 (9.3%)
0.536
Cardiovascular drugs poisoning
16 (10%)
6 (0.6%)
<0.0001
Proprietary Chinese medicine poisoning
10 (6.3%)
27 (2.6%)
0.023
Diabetes drug poisoning
10 (6.3%)
10 (1%)
<0.0001
Analgesic poisoning
10 (6.3%)
24 (2.3%)
0.01
Conclusion: The epidemiology of accidental geriatric poisoning in Hong Kong is different from the younger adult counterpart.
Clinical audit on the use of adrenaline in resuscitation to non-traumatic, out-of-hospital cardiac arrest adult patients in NTWC emergency departments
KM Poon, KF Sun, CT Lui and KL Tsui
Department of Accident & Emergency, NTWC, Hong Kong
Background: Out-of-hospital cardiac arrest (OHCA) is a substantial public health issue worldwide. The survival to discharge (STD) rate remains low, ranged from 0.05 % to 1.54% in local studies. There are a substantial proportion of medically futile patients who were not going to be benefited from prolonged resuscitation. Recent large observational studies have shown that the use of adrenaline in OHCA is associated with improved return of spontaneous circulation (ROSC) but not survival to hospital discharge. There was no clear advantage of standard dose adrenaline, high dose adrenaline or number of doses of adrenaline in survival to discharge or neurological outcomes after OHCA. A consensus practice of using up to 3 doses of 1 mg adrenaline intravenous for resuscitation of non-traumatic OHCA adult patients was adopted in Hong Kong.
Objectives: To audit on the use of adrenaline in resuscitation to non-traumatic adult patients with out-of-hospital cardiac arrest according to the consensus practice.
Methodology: It was a retrospective study performed in 2 public hospitals in our cluster. The data was obtained from the hospital cardiac arrest registry (CAR) that included consecutive patients who experienced cardiac arrest. The target population included adult patients (aged 18 or above) with OHCA from 1st Oct 2015 to 30th Sept 2016. Those patients with post mortem changes or death after arrival were excluded. Other exclusion criteria were those trauma patients or those with shockable rhythms.
Results: A total of 684 patients were recruited in the audit. The compliance rate of following the consensus practice of using at most 3 doses of adrenaline was 55.0%. 181 out of 684 patients (26.5%) were found to be medically futile yet received prolonged resuscitation of using more than 3 doses of adrenaline. The difference of survival to discharge between consensus practice group and the control group (using more than 3 doses of adrenaline in resuscitation) was not statistically significant. (P value 0.631).
Conclusion: The compliance of following the consensus practice of using at most 3 doses of adrenaline in resuscitation of patients with OHCA was suboptimal. We were providing prolonged resuscitation to a substantial proportion of medically futile patients.
Community resuscitation course enhance self-efficacy for secondary school students in Hong Kong
SK Ling, H Chan, YF Chan, WL Chan, Heyman Tang and TC Lau
Accident and Emergency Department, Tin Shui Wai Hospital, Hong Kong
Introduction and objective: Out of hospital cardiac arrest (OHCA) cases are significant global public health issues with poor survival outcome. Low bystander CPR issue is one of the recipes for the high mortality rate for OHCA. Low self-efficacy for CPR is one of the common barriers on performing CPR as shown in recent researches. Researches over the globe have been shown there are advantages for providing early training to school students.
Material and Method: The study is a before-and-after interventional study with data taking place in June, 2017. After a one day resuscitation workshop, 43 students are required to fill in an anonymous 10-item questionnaire before the commencement and at the end of the program. The questionnaires for both pre and post tests are identical.
Result: The test score was improved (5.58 vs 8.44 t = 13.173 p = 0) as well as the confidence score (2.07 vs 2.65 t = 3.792 p = 0) in a 4 point Likert scale.
Conclusion: There is a strong evidence that not only the knowledge but also confidence level will increase after the visiting activity, CPR and AED introduction to secondary students. More resuscitation program shall be engaged and encouraged to the community.
The results were investigated by paired-t tests. Statistical analyses were carried out by IBM SPSS Statistics for Windows, Version 22.0. Armonk NY. A p-value of less than 0.05 was regarded as statistically significant.
Test score (Full mark – 9 points).
Pre and post test score result
Mean
Number
Standard deviation
Standard error mean
Pre-test score
5.58
43
1.139
0.174
Post-test score
8.44
43
0.734
0.112
Paired sample test
t = 13.173 p = 0
There is a strong evidence (t = 13.173, p = 0) that the teaching intervention improves the scores. In the data set, it improves on average 2.86 points.
Confidence score (4 points Likert scale).
Pre and post test score result
Mean
Number
Standard deviation
Standard error mean
Pre-test score
2.0698
43
0.68604
0.10462
Post-test score
2.6512
43
0.73664
0.11234
Paired sample test
t = 3.792 p = 0
This study also shows a significant (t = 3.792, p = 0) that the confidence level increases on ratio 0.58 on a 4 points Likert scale after the course.
Distribution, accessibility and coverage of automated external defibrillators in public locations in Hong Kong
M Fan,1 KL Fan2 and LP Leung1
1Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
2Accident and Emergency Department, The University of Hong Kong – Shenzhen Hospital, Shenzhen, China
Introduction: The survival rate of out-of-hospital cardiac arrest (OHCA) in Hong Kong (HK) is low. Use of automated external defibrillators (AED) by the public can shorten the time to defibrillation and may improve survival. However, there is limited data on use of AED for OHCA in Hong Kong. This study aimed primarily at describing the distribution and accessibility of AEDs in HK and secondarily at the coverage rate of AED for OHCA using historical data.
Methods: This was an observational descriptive study. Data for the AEDs were from the local AED distributors, the Heart-safe school project, government departments, NGOs and door-to-door search from 1/7/2015 to 31/12/2016. Data for OHCA were from a database maintained by the emergency medical services (EMS) during 1/8/2012 – 31/7/2013. Geographical locations of AEDs and OHCA were converted into Universal Transverse Mercator format. The Python 2.7 and R 3.2.5 were used to execute the GIS analysis and visualization. The distance between cardiac arrest and the closest AED was calculated. The proportion of historical OHCA occurring within 100 m of an AED was calculated as coverage rate. Kruskal-Wallis test, Fisher exact chi square test, and t-test were used where appropriate.
Results: In the study period, 1637 AEDs were located. The number of AEDs per 10,000 population and per km2 were 2.23 and 1.48. 49.4% (n = 809) of the AEDs were placed in schools or educational institutions. 29.3% (n = 479) were installed in recreational facilities supervised by the Government. Only 10.8% of these AEDs were accessible to the public without time restriction. Furthermore, only one third could be used by the public without the need for permission from personnel on-site. From the historical OHCA database, there were 5154 cases. 1.3% had bystander defibrillation. 30-day survival rate was 17.5% and it was much better than the 2.3% as a whole. The time to defibrillation when an AED was used by a bystander was shorter than by the EMS (6.8 min versus 15.2 min, p < 0.001). The coverage rate of an AED within 100 m of cardiac arrest was 15.3%. The coverage rate in different districts of HK varied widely and it did not correlate with the survival rate in each district.
Conclusion: Most AED in HK were placed in schools. Accessibility to the public is far from satisfactory. OHCA with bystander defibrillation had higher survival rate. AED coverage rate was low. More need to be done besides raising the coverage rate.
Door-to-balloon time for ST-elevation acute myocardial infarction in Hong Kong: A case report
SK Ling and Heyman Tang
Accident and Emergency Department, Tin Shui Wai Hospital, Hong Kong
Introduction: STEMI is one of the most challenging cases in the emergency room (ER). Patient suffering from STEMI shall received definite treatment, percutaneous coronary intervention (PCI), within the shortest period of time in order to minimise the total ischemic time for cardiac muscle. Study have been shown that the optimal time between the patient arrive the ER and to device time shall be less than 90 minutes (1), that is the ‘door-to balloon time’. Study from the US also shows that door-to-balloon time closely associated with better in-hospital outcomes (2). In this poster, we will report the first case of STEMI in TSWH in terms of logistic and treatment in multidisciplinary approach. Thus, to discuss the rooms for improvements for the future.
Case report: A 63-year old man with past health history hyper-lipidemia attended the ER by ambulance service at 1559 complaining chest pain since 0700, he had no dizziness, no vomiting and no pain radiation on arrival in the ER. At 1707, the patient arrived the catheter laboratory. PCI was performed with finding of pLAD critical lesion. The balloon time was 1729. The total door-to-balloon time was 90 min. The patient was hospitalised under critical cardiac unit care and discharged without complication after 5 days with follow ups.
Discussion: In this case, the door-to-needle target time was achieved with 90 minutes. There are a few challenge points to note in this STEMI case, Firstly, the communication between the TSWH ER and PCI catheter laboratory in Tuen Mun Hospital (TMH) is quite difficult. As this is the first STEMI case in TSWH ER, the TSWH telephone operator is not quite sure which the party to be called. Moreover, as TSWH is quite new to the TMH CCU, more information are required from the receiving parties in order to confirm the intervention. Secondly, time are spent on deciding who is responsible for escorting the patient. Manpower is tight as the time approaches to the closing hour of the ER, overtime working maybe required for escorting the patient, Also, escorting doctor need to hand over his cases to other senior doctors before escort.
Conclusion: Our team aims to use all our endeavours to minimise the door-to-balloon time without sacrificing safety for our patients. With the collaborations with different health care disciplines including emergency physicians, nurses, cardiologists, radiological technologist and emergency medical service, it is possible to minimise the door-to-balloon time together with safety for all patients.
1559
Registration in ER/TSWH
1601
Categorised 3 (Urgent) by triage nurse
1606
ECG performed and showed ST-elevation on V2 and V3
1608
Patient was upgraded to Category 2 (Emergency) and sent to resuscitation room
1635
Case doctor decide to transfer patient to TMH for PCI
1653
Patient was discharged from TSWH. Transferred to TMH
1707
Patient arrived TMH cardiac catheter lab.
1729
Balloon time
Enhance service of emergency nurse practitioner in Accident and Emergency Department of Yan Chai Hospital
FC Lung, TK Yeung and Chau KY Daisy
Accident and Emergency Department, Yan Chai Hospital, Hong Kong
Introduction: Emergency Nurse Practitioners (ENPs) have provided service in the Accident and Emergency Department of Yan Chai Hospital (YCH) since 2013. They primarily treat a wide range of minor injuries and illnesses. They assess, diagnose, investigate and treat patients under medical supervision in order to deliver the service.
Scope of ENP service: ENPs will perform assessment independently and hence discuss their clinical examination findings as well as treatment plan with designated senior medical officers for the following patients: wounds (e.g. abrasion and laceration), burns and scalds, human or animal bites, insect bites or stings, soft tissue infections, minor injuries and illnesses of upper limbs (e.g. hands, wrists, arms, elbows, and shoulders), minor injuries and illnesses of lower limbs (e.g. foot, ankles, knees and hips), and ENT conditions.
Objectives:
(1) To shorten the waiting time for consultation;
(2) To shorten patients’ length of stay; and
(3) To improve patient’s satisfaction level.
Results: Total 1,901 cases have been consulted by ENPs from February 2013 to June 2017. From February 2013 to December, 2014, 545 cases were consulted and the average shortening of waiting time and length of stay are 41.3 minutes and 47.3 minutes respectively. In 2015, 501 cases were consulted and the average shortening of waiting time and length of stay are 65.5 minutes and 73.5 minutes respectively. In 2016, 655 cases were consulted and the average shortening of waiting time and length of stay are 48.3 minutes and 66.5 minutes respectively. From January to June, 2017, 200 cases were consulted and the average shortening of waiting time and length of stay are 45.5 minutes and 71.4 minutes respectively.
Overall patient’s satisfaction result: From May 2014 to September 2016, patient satisfaction surveys were conducted and a total of 114 questionnaires were collected. Overall results were satisfaction.
Enhancement of logistic flow for ambulance cases in triage cubicles to meet the triage pledge and augment patient safety in A&E/TSWH
SK Ling, KM Chan, YF Chan, CY Chan, WL Chan and Heyman Tang
Accident and Emergency Department, Tin Shui Wai Hospital, Hong Kong
Introduction: Triaging patients are the first step of the A&E workflow and are vital for determining the waiting time of each patient. The A&E/TSWH have a total attendance of over 170 every day (8 hours service), approximately 30 cases arrived by using ambulance service daily. There are three entrances for patients to visit the A&E/TSWH. The main entrance and side entrance from the hospital lobby are near to the registration counter and the main triage station; they allow ‘walk in’ cases to attend the A&E. Nurses might miss out cases that are transferred to A&E from ambulance crew and lead to delayed triage process, consultation and treatment for urgent cases. Ultimately, it may affect the patient safety in receiving timely treatment and meeting the standard triage pledge time.
Objectives:
1.) To enhance the logistic flow of patients from ambulances to triage areas in A&E/TSWH.
2.) To augment patient safety by timely triage and treatment.
To meet the standard triage service time pledge for every case.
Methods: The call bell was set up and the new triage workflow was announced and shared among colleagues. Feedbacks were also collected after the establishment of the workflow.
Result: Patients are diverted to different locations according to their complains and history, Negative pressure room for patients with suspected airborne infectious illnesses - Patient with suspected or confirmed infectious diseases can be isolated in the negative pressure room to reduce the time of contact from the public zone, thus reduce the chance of spreading among patients and staff. Resuscitation rooms for critical cases – critical cases will be directed to the resuscitation rooms for treatments and investigations. The waiting time for triaging will be well shortened. ‘Padded’ rooms for disturbed patients – disturbed or psychological high risks patients are directed to ‘padded’ rooms for further assessment. This can not only protect patients’ privacy but also enhance patients’ safety. The risks of disturbing other patients are reduced as well. Trolley triage station or main triage station for relative stable cases – This can ease the manpower of the A&E and be allocated to different locations after triaging.
Conclusion: The implementation of the call bell enhanced the logistic flow communication between nurses and ambulance crew. Thus, augmented the patient safety and committed the service pledge in A&E/TSWH. To keep the enhancement works sustainable, continuous review, top management support and effective leadership are of paramount importance to success.
Enhancement of wound care in accident and emergency accident by implementation of Fast Track Wound Clinic
TL Yau, CS Chung, HK Ngan, P Mo, YK Ho, YY Yuen, MY Wong and YK Chan
Accident and Emergency Department, Yan Chai Hospital, Hong Kong
In the scope of services, the management and care of acute traumatic wounds are entitled total workload of Accident and Emergency Department (A&E). The optimal wound care for initial wound closure is within 6 to 10 hours of injury. During the peak demand from seasonal or diurnal variation in A&E, the time of managing of acute wound may excess the optimal time. With the introduction of Fast Track Wound Clinic in A&E, semi-urgent, single system with uncomplicated wound conditions can be managed in timely manner. The purpose of Fast Track Wound Clinic is to create a second flow of patients in parallel to the regular flow, for semi-urgency patient without adverse consequences for critical, emergency and urgent patients. The Fast Track Clinic was commenced since 27 March 2017.
Objectives:
To attain functional closure and laceration repair within 6 to 10 hours after injury
To decrease risk of infection, minimize the scar formation and improve healing
To reduce patients’ anxiety and pain level
To reduce the waiting time, treatment time and Length of Stay (LOS)
Inclusion Criteria:
Semi-urgent, single system with uncomplicated wound conditions
Onset of acute wound injury within 8 hours
Require early surgical intervention such as suturing, application of steri-strip and tissue glue
Burn and scald wound except sunburn or erythematous only
Outcomes:
A retrospective review was conducted.
751 A&E attendants were recruited to Fast Track Wound Clinic from 27 March 2017 to June 2017.
The average of length of waiting time of Fast Track Wound Clinic was 40.25 minutes while other semi-urgent category was 109.91 minutes since 27 March 2017 to June 2017. The average of waiting time was shorten 69.7 minutes.
The comparison of average of LOS before and after implementation of Fast Track Wound Clinic between May to June 2016 and 2017 were 223 minutes and 150.64 minutes respectively. The average of LOS in A&E was reduced 72.4 minutes.
Experience of frailty care model in a local emergency department in Hong Kong
SC Leung Patrick, HF Ho and CK Wong Gordon
Accident and Emergency Department, Queen Elizabeth Hospital, Hong Kong
Introduction: With aging population in Hong Kong, attendance of geriatric patients to public hospitals is increasing. Emergency department, as the gatekeeper of the hospital, and in-patient wards are overwhelmed. In order to provide timely and quality care to the low acuity group of geriatric patients who need hospitalization, a new model, named frailty unit, was set up in our emergency medicine ward (EMW).
Method: The frailty unit was opened in EMW of Queen Elizabeth hospital on 14 December 2015. Those patients who meet the inclusion criteria will be admitted; Age > 60 with any of the followings 1) acute deconditioning due to acute medical illness. 2) Increasing fall with balance deficiency. 3) Post discharge community service required due to medical illness and inadequate social support. Exclusion criteria are 1) unstable vital signs. 2) Medical emergencies such as stroke or acute coronary syndrome. 3) Social needs or placement problem alone. All patients admitted to the frailty unit will go through a designated 3-day clinical treatment pathway. On the day of admission, the doctor will formulate a management plan and the nurse will perform a comprehensive assessment with the patient assessment form. Our physiotherapist and occupational therapist will provide assessment on physical and mental status. They will advise appropriateness of ambulatory care at home or other institutions upon discharge. The community nurse and the case manager will be engaged for discharge arrangement and follow up plan. Bed manager will be responsible for arrangement of rehabilitation bed. The patient’s condition will be optimized and reviewed in the frailty round in consecutive days. Those who improved will be discharged home while those who need further management will be transferred to convalescent hospital for rehabilitation.
Result: From 14 December 2015 to 28 February 2017, 461 patients were admitted to the frailty unit. Female to male ratio is 1.4:1. The top 5 diagnosis of admission is fall, dizziness, low back pain, deconditioning and lower limb weakness. 300 (65.1%) can be discharged, 94 (20.4%) transferred to convalescent hospital and 67 (14.5%) transferred to other specialty bed. The average length of stay is 2.2 days. The overall mortality rate per 1000 discharge is 0 and unplanned readmission within 28 days after discharge is 10.6%.
Conclusion: The frailty care model at emergency department is feasible. It can help to expedite care and discharge of low acuity geriatric patients who need hospitalization and relieve congestion of hospital while providing quality care.
Hepatotoxicity after receiving therapeutic dose of paracetamol in geriatric patients
MT Lau, CK Chan and ML Tse
Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong
Introduction: Paracetamol is a commonly used analgesic for mild to moderate pain in geriatric patients. It has a well-established safety profile and can be used in patients with multiple co-morbidities. Accidental poisoning and adverse drug reactions are seldom reported in normal healthy adults. Here we describe 3 cases of geriatric patients with liver injury after administration of maximum recommended daily dose of paracetamol for adults.
Case presentation: These 3 patients aged 77 to 96 years old were administered paracetamol 1 gram four times per day for duration of 5–6 days during in-patient stay. Two patients received paracetamol for painful hip problems, while one patient received paracetamol for post-operative pain. They all have normal baseline liver functions on admission. They were subsequently found to develop deranged liver function, and elevated serum paracetamol concentrations suggestive of delayed clearance. Chronic supratherapeutic paracetamol poisoning were diagnosed, and all patients were treated with intravenous N-acetylcysteine. Two of them recovered. One developed asystolic cardiac arrest of unknown cause, with successful resuscitation. The patients were all underweight with body weight ranges from 31 to 41 kg. The reported paracetamol doses were 129 mg/kg/day, 100 mg/kg/day, and 98 mg/kg/day.
Discussion: This case series demonstrated that the recommended ceiling dose of paracetamol can be toxic to susceptible geriatric patients. Risk factors identified included low body weight, malnutrition, pre-existing comorbidities, institutional care and regular paracetamol intake for more than a few days. Other possible risk factors should include use of cytochrome P450 inducers and pre-existing liver disease. As there are a big number of geriatric patients taking regular paracetamol and low grade liver injuries can only be detected clinically with liver function testing, this case series likely reflected only the very tip of a big iceberg. Practically, one reasonable approach is to extrapolate the experience in paediatrics that limits the ceiling dose of paracetamol to <4 g/day or <90 mg/kg/day, whichever is lower. In the long term, research should be conducted to establish a safer dosing regimen for the geriatric population. Pharmacokinetic studies should be conducted particularly among the at-risk sub-groups. The relevance of the toxic dose and toxic blood concentrations of paracetamol established largely from younger adults should also be prudently re-examined in the geriatric population.
Intentional poisoning in geriatric patients in Hong Kong
KK Lau
Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong
Objectives: To identify the commonest poisons among geriatric patients in intentional poisoning situations and compare the epidemiological pattern of poisons with that of younger adults.
Design: Retrospective observational study
Study method: Electronic records from the Hong Kong Poison Information Centre database were searched. Geriatric patients aged 70 and above with intentional poisoning from 1 January 2016 to 31 December 2016 were included in the study group. Adults aged 18 to 69 with intentional poisoning within the same study period were included in the control group.
Result: The study group of 123 geriatric patients and the control group of 1928 younger adults were selected in this study. The commonest agents involved in intentional poisoning in geriatric patients were sedatives & hypnotics (32.5%), analgesics (18.7%), cardiovascular drugs (17.9%), household products (16.3%), pesticides (12.2%), psychiatric drugs (12.2%), alcohol (8.1%) and abusive opioids (5.7%). In comparison with the younger adults, intentional poisoning in geriatric patients had statistically significant difference in the categories of cardiovascular drugs, household products, pesticides and alcohol.
Number of geriatric cases
Number of younger adult cases
Odds ratio (95% CI)
P value (Chi square)
Sedative & hypnotics
40 (32.5%)
717 (37.2%)
0.81 (0.55–1.20)
0.298
Analgesics
23 (18.7%)
324 (16.8%)
1.14 (0.71–1.82)
0.587
Cardiovascular drugs
22 (17.9%)
78 (4.0%)
5.17 (3.09–8.64)
<0.0005
Household products
20 (16.3%)
93 (4.8%)
3.83 (2.27–6.46)
<0.0005
Pesticides
15 (12.2%)
39 (2.0%)
6.73 (3.60–12.58)
<0.0005
Psychiatric drugs
15 (12.2%)
280 (14.5%)
0.82 (0.47–1.42)
0.476
Alcohol
10 (8.1%)
359 (18.6%)
0.39 (0.20–0.75)
0.003
Abusive opioids
7 (5.7%)
137 (7.1%)
0.79 (0.36–1.73)
0.552
Conclusion: The epidemiology of intentional poisoning in geriatric patients was different from that of the younger adults in Hong Kong.
Is the Modified Early Warning Score (MEWS) a useful tool to facilitate triage decision in an Accident & Emergency Department?
KY Poon1,2, Janice HH Yeung1,3 and William YW Chan2,4
1Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong
2Accident and Emergency Department, Tuen Mun Hospital, Hong Kong
3Accident & Emergency Department, Prince of Wales Hospital, Hong Kong
4Hong Kong Government Flying Service, Hong Kong
Introduction: There is no study to prove the utility of modified Early Warning Score (MEWS) act as a predictive triage instrument in Hong Kong Accident and Emergency Department (AED). The study objective is to find the relationship between MEWS and 5-level triage category and the outcome of the changed category level by MEWS. It investigates the MEWS is a useful tool to facilitate nurses to make triage decision in limited resource environment setting.
Methods: An observational study adopted a retrospective design that conducted in a public AED in Hong Kong between mid of February to March. During this period, the triage nurses categorized the patient as usual according to their clinical judgment with patients’ chief complain and vital sign measured based on Hong Kong Accident and Emergency Triage Guideline (HKAETG). In the same day after the end of shift duty, the investigator collected the data from AED card and ambulance record to calculate the MEWS. It categorized the patients and based on total MEWS. The primary outcome was the 5-level triage category by triage nurses and MEWS. Then, it compared the changed category cases and their outcome.
Results: Total 500 patients were included (52.4% male, 47.6% female). The mean age was 60.33 ± 20.45. There was 31.2% missing recorded respiratory rate (RR) in AED card, their RR referred from ambulance record only. Majority of patient suffered from respiratory (20%), gastrointestinal (15.8%) and cardiac problem (12.6%). Most of them admitted to hospital (77.8%) and discharged (19.6%). Only 1.4% and 1.2% were admission to intensive care unit (ICU) as well as death in AED separately. Commonly, their disposals were associated with MEWS and category level. The MEWS with category level triage or the category level by nurses’ clinical judgment or calculated by MEWS were strong relationship. The correlation coefficients were −0.84 and 0.849. There was 78.2% no change category level after calculated by MEWS. However, 9.6 % and 12.2 % cases needed to be up-graded and downgraded. In upgraded cases, there were two cases admitted to ICU. Other cases were hospital admissions (94.7%) who were complaint of respiratory problem mainly (22.9%). In downgrade cases, 9.8 % discharged, 8.3% admitted to gynecological ward and one case to mental hospital.
Conclusion: Respiratory problem was the main chief complains of the patients. RR was a crucial parameter in identify patient deterioration. It should promote RR measured in triage station for making more accurate triage decision. MEWS have strong relationship with the category level. It could assist nurses in making triage decision but MEWS could not replace nurses to categorized patient. MEWS only could act as an assist tools for nurses triage in more data reference and baseline to predict the patients outcome. MEWS was not suitable in all cases such as pregnancy woman and mental cases. MEWS was a simple scoring system facilitates nurses in making triage decision.
