Predictive factors for prolonged hospitalisation in acute pyelonephritis patients admitted to the emergency medicine ward

Background: Acute pyelonephritis is a bacterial infection of the upper urinary tract. Patients can be admitted to a variety of wards for treatment. However, at the Prince of Wales Hospital in Hong Kong, they are managed initially in the emergency medicine ward. The aim of the study is to identify the risk factors that are associated with a prolonged hospital length of stay. Methods: This was a retrospective cohort study conducted in Prince of Wales Hospital. The study recruited patients who were admitted to the emergency medicine ward between 1 January 2014 and 31 December 2017. These patients presented with clinical features of pyelonephritis, received antibiotic treatment and had a discharge diagnosis of pyelonephritis. The length of stay was measured and any length of stay over 72 h was considered to be prolonged. Results: There were 271 patients admitted to the emergency medicine ward, and 118 (44%) had a prolonged hospital length of stay. Univariate and multivariate analyses showed that the only statistically significant predictor of prolonged length of stay was a raised C-reactive protein (odds ratio 1.01; 95% confidence 1.01–1.02; p < 0.0001). Out of 271 patients, 261 received antibiotics in the emergency department. All 10 patients (8.5%) who did not receive antibiotics in emergency department had a prolonged length of stay (p = 0.0002). Conclusion: In this series of acute pyelonephritis treated in the emergency medicine ward, raised C-reactive protein levels were predictive for prolonged length of stay. Patients who did not receive antibiotics in the emergency department prior to emergency medicine ward admission had prolonged length of stay.

Clinical experience in management of bloodstream infection in emergency medical ward: A preliminary report

Background: Bloodstream infection is a life-threatening clinical condition posing significant morbidities and mortalities. An “Emergency Critical Care Management Program” has been implemented in the Emergency Medicine Ward at North Lantau Hospital as a pilot critical care service model in the local emergency medicine wards. Patients with blood stream infection are recruited in the program and managed under pre-defined guideline. Objectives: We report our experience in managing patients with blood stream infection in the Emergency Medicine Ward and analyzed their clinical outcomes. Methods: This was a retrospective cohort study including a total of 64 patients with blood stream infection admitted to the Emergency Medicine Ward from 1 March 2015 and 31 March 2018. Patients’ characteristics, microbiology, and risk factors associated with adverse outcomes including in-hospital mortality were analyzed. Results: The most common organism isolated from blood cultures was Escherichia coli (56%). Eight patients were transferred to the tertiary hospital. The overall in-hospital mortality was 7.8% (5/64). From the univariate analysis, advanced age (p < 0.001), higher Sequential Organ Failure Assessment score and quick Sequential Organ Failure Assessment score (p < 0.001), higher Charlson Comorbidity Index (p = 0.003), more organ dysfunction (p < 0.001), pre-existing medical history of chronic liver disease (p = 0.001), dysfunction in respiratory system (p = 0.032), cardiovascular system (p = 0.044) and the central nervous system (p < 0.001), presence of septic shock (p = 0.004), and need for higher level of organ support from the use of inotropes (p < 0.001) and mechanical ventilation (p = 0.024) were associated with in-hospital mortality. In the subgroup analysis, the in-hospital mortality rate for the patients with Sequential Organ Failure Assessment score less than 6 was 1.56% (1/64). Among the five in-hospital mortality cases, four of them were managed in the Emergency Medicine Ward under the End-of-Life Care Program. Decision for withholding and withdrawing life-sustaining therapy was made with the patients’ families. Conclusion: This preliminary report demonstrated that with careful patient selection, adoption of guidelines, and availability of expertise, critical care service can be safely implemented in the emergency medicine ward.

Prone positioning in severe acute hypoxemic respiratory failure in the emergency ward

This paper reports the authors’ preliminary experience with three patients affected by severe acute hypoxemic respiratory failure due to bilateral pneumonia placed in a prone position in Emergency Medicine Ward during application of high flow oxygen nasal cannula.

Ten-year profile of acute poisoning patients presenting to an Accident and Emergency Department requiring intensive care in a regional hospital of Hong Kong

Background: Hong Kong Poison Information Centre publishes annual reports on all poisoning cases received by the Centre in that year since 2006. However, there is little data about acute poisoning cases requiring intensive care unit admissions in Hong Kong. Objective: To report and analyze the 10-year poisoning data of acute poisoning patients presenting to an Accident and Emergency Department requiring intensive care in a regional hospital of Hong Kong. Methods: This was a retrospective study on patients presented from January 2007 to December 2016. These cases were retrieved from Clinical Data Analysis and Reporting System of the Hospital Authority, Hong Kong. Clinical data of these cases were then retrieved from patients’ electronic records. Results: A total of 270 cases were analyzed during the period. There were 152 (56.3%) male patients and 118 (43.7%) female patients. The middle aged group (age 30–39 and age 40–49) constitutes nearly half (48.6%) of all these admissions. Around 50% of them had history of psychiatric illness. Nearly 40% of them were known substance abusers. Majority of the patients (66.7%) were admitted directly from Accident and Emergency Department. The commonest cause was suspected self-harm (56.3%). When ethanol (13%) was excluded, the five commonest types of poisons were benzodiazepine (26.3%), opioids (20.7%), zopiclone (18.5%), carbon monoxide poisoning (13%), and household products (10.7%). Twenty-seven patients (10%) had decontamination done in Accident and Emergency Department or Emergency Medicine Ward. 112 patients (41.5%) were given one or more antidotes in Accident and Emergency Department and Emergency Medicine Ward. Altered mental status was the most frequently found complications (72.2%) in these patients. 76 patients (28.1%) required endotracheal intubation in Accident and Emergency Department. The length of stay in Intensive Care Unit ranged from 1 to 7 days with an average of 2.1 days. There were 25 deaths (9.3%) and 31 patients with major effects (11.5%). Conclusion: An estimate of 9.4% of acute poisoning patients presenting to Accident and Emergency Department might need Intensive Care Unit care at certain stage of their hospital stay. Benzodiazepine, opioids, zopiclone, carbon monoxide poisoning, and ethanol were the top five poisons in our series from 2007 to 2016. The mortality rate (9.3%) was high in our series given that there were more substance abusers.

Study of drug utilization pattern in emergency medicine ward at a tertiary care teaching hospital

Background: The emergency department represents an important platform for conducting drug utilization studies as patients present with a wide spectrum of diseases in acute form. An irrational prescription adversely affects the prognosis and recovery of patients. Hence, the objective of our study was to evaluate the drug utilization pattern and to determine the rationality of prescription using WHO prescribing indicators in emergency medicine ward.Methods: After obtaining Institutional Ethical Committee approval, a prospective observational study was conducted over 2 months. The case records of 150 patients admitted to the emergency medicine ward, with a hospital stay of more than 24hrs were reviewed to analyze the prescription pattern during the initial 48hrs of admission. Case records of patients irrespective of age, sex and diagnosis were included in the study. Descriptive statistics were used to analyze the results (SPSS version 20).Results: A total of 1014 drugs were prescribed from 150 case records with a mean age of 47±18 years. An average of 6.76 drugs was prescribed per prescription; percentage of encounters with at least an antimicrobial was 115 (76.66%). Injections were prescribed in all patients (100%) and only 416 (41.02%) drugs were prescribed by generic name and 657 (64.79%) drugs abided to the WHO essential drug list. Majority of patients received anti-ulcerogenic drugs followed by antimicrobials.Conclusions: There was a tendency of polypharmacy with overuse of PPIs and antimicrobials. There is need to rationalize the drug therapy in terms of increasing prescription of drugs from essential drug list by generic name.