Population Density, Automated External Defibrillator Use, and Survival in Rural Cardiac Arrest

Objective: To determine whether population density is an independent predictor of survival from out-of-hospital cardiac arrest managed by basic life support (BLS) services using automated external defibrillators (AEDs).
Methods: A retrospective, observational study in Kentucky of 34 BLS services covering 22 counties during the years 1992 to 1994 who used AEDs to treat patients who had out-of-hospital cardiac arrests.
Results: Of 311 patients who had out-of-hospital cardiac arrests, 110 (35%) were defibrillated, 46 (15%) were resuscitated to hospital admission, and 19 (6%) survived to hospital discharge. Univariate predictors for survival to hospital discharge were emergency medical services response interval (from call receipt to ambulance arrival) <8 minutes, defibrillation by the AED, initial rhythm of ventricular fibrillation or ventricular tachycardia (VF/VT), and population density >100/square mile (sq mi) for the BLS service area (p < 0.001). A forced logistic regression model of survival to hospital discharge, using these 4 factors plus the presence of a witnessed arrest or bystander CPR, demonstrated that population density >100/sq mi was highly significant (OR 9.4, 95% CI: 1.7 to 51.4, p < 0.01). Stepwise logistic regression models with combinations of these 6 factors found that survival to hospital discharge was best predicted by an initial rhythm of VF/VT (p = 0.004) and population density >100/sq mi (p = 0.011).
Conclusions: Population density is strongly associated with survival from out-of-hospital cardiac arrest. BLS services within areas with population densities ≤100/sq mi sustained little benefit from the addition of AEDs to their treatment of patients who had out-of-hospital cardiac arrests.     

Impact of a government triple zero awareness campaign on emergency department patient characteristics

Objective: To evaluate the impact of a government triple zero community awareness campaign on the characteristics of patients attending an ED. Methods: A study using Emergency Department Information System data was conducted in an adult metropolitan tertiary‐referral teaching hospital in Brisbane. The three outcomes measured in the 3 month post‐campaign period were arrival mode, Australasian Triage Scale and departure status. These measures reflect ambulance usage, clinical urgency and illness severity, respectively. They were compared with those in the 3 month pre‐campaign period. Multivariate logistic regression models were used to investigate the impacts of the campaign on each of the three outcome measures after controlling for age, sex, day and time of arrival, and daily minimum temperature. Results: There were 17 920 visits in the pre‐ and 17 793 visits in the post‐campaign period. After the campaign, fewer patients arrived at the ED by road ambulance (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.80–1.00), although the impact of the campaign on the arrival mode was only close to statistical significance (Wald χ²‐test, P= 0.055); and patients were significantly less likely to have higher clinical urgency (OR 0.86, 95% CI 0.79–0.94), while more likely to be admitted (OR 1.68, 95% CI 1.38–2.05) or complete treatment in the ED (OR 1.46, 95% CI 1.23–1.73) instead of leaving without waiting to be seen. Conclusions: The campaign had no significant impact on the arrival mode of the patients. After the campaign, the illness acuity of the patients decreased, whereas the illness severity of the patients increased.     

Evaluation of the use of automatic external defibrillation in out-of-hospital cardiac arrest in Hong Kong.

A retrospective 6-month audit of out-of-hospital cardiac arrests in Hong Kong following the introduction of automatic external defibrillators is presented. During the 6-month period from 1 July 1995 to 31 December 1995, resuscitation was attempted on 754 patients. Of the 744 patients with cardiac arrest whose records were available, 53.6% had a witnessed arrest. Few cardiac arrest patients (8.9%) received bystander cardiopulmonary resuscitation (CPR) and the majority (80%) of arrests occurred at home. Six hundred and forty-three (86.4%) patients were declared dead on arrival at hospital or in the Accident and Emergency department; 89 (12%) died in hospital and only 12 (1.6%) were discharged alive. The average ambulance response interval (call receipt to arrival of ambulance at scene) was 6.42 min. The average arrest-to-first-shock interval was 23.77 min. Factors predicting survival included initial rhythm and arrest-to-first-shock interval. The survival rate of 1.6% is low by world standards. To improve the survival rates of people with out-of-hospital cardiac arrest, the arrest-to-call interval must be reduced and the frequency of bystander CPR assistance increased. Once these changes are in place, a beneficial effect from the use of pre-hospital defibrillation might be seen.     

Use of Emergency Departments by Elder Patients: A Five -year Follow-up Study

Abstract. Objective: Tb compare the use of emergency medical care by elders in the United States in 1995 with that previously described for 1990. Methods: A computerized billing database of 88 EDs in 21 states was retrospectively reviewed for 1995, comparing elder and nonelder patients, estimating national use of emergency medical services by elders, and comparing the 1995 data with previously published results for 1990. Results: From 1990 to 1995, the number of ED visits in the United States increased from 92 million to 100 million. The number of visits made by patients aged 65 years or older increased from 13,639,400 (15%) to 15,666,300 (15.7%), but this increase did not reach statistical significance (p = 0.17). The admission rate for elder ED patients increased from 32% to 46% over the five-year interval (p < 0.01). This represents more than 7 million hospital admissions for elder patients in 1995. The rate of intensive care unit (ICU) admission for elders decreased from 7% to 6% over the five-year interval (p = 0.56), compared with 1.3% for nonelder patients for both years. Thirty percent of elder ED patients arrived by ambulance in 1990, compared with 33% in 1995 (p = 0.02). Based on 1995 data, elders comprised 39% of patients arriving by ambulance [odds ratio (OR) 4.75, 95% confidence interval (CI) = 4.71 to 4.79], 43% of all admissions (OR 6.59, 95% CI = 6.54 to 6.64), and 47% of ICU admissions (OR 5.00, 95% CI = 4.91 to 5.09). The comparable ORs in 1990 were 4.4, 5.6, and 5.5, respectively. Conclusions: From 1990 to 1995, the overall number of ED visits increased. The rate of increase was somewhat greater for elder patients. The use of ambulance services also disproportionately grew among elder patients, as did the rate of hospital admission. The overall rate of ICU admission was stable, but actually fell modestly for elder patients. Of these changes, only the increase in the rate of hospital admission for elders reached statistical significance.     

Impact of Ambulance Transportation on Resource Use in the Emergency Department

OBJECTIVE: To determine how ambulance transportation is associated with resource use in the emergency department (ED). METHODS: A retrospective administrative database review of patient visits to a Montreal tertiary care hospital ED in one year (April 2000-March 2001). Measures of resource use included ED length of stay, admission to the hospital, and whether consultations and radiology/imaging tests (excluding plain-film x-rays) were ordered from the ED. RESULTS: During the study period, 39,674 patients made 59,142 visits to the ED. Ambulance transportation was used for 15.6% of these ED visits. Compared with non-ambulance visits, ambulance visits were more likely to be made by older patients (mean age: 68 vs. 47 years), to be made by females (59% vs. 55%), to have a greater triage urgency score (mean on 1-5 scale, with 1 most urgent: 2.7 vs. 3.9), and to occur after office hours, 5 PM to 9 AM (47% vs. 43%). Ambulance visits were also more likely than non-ambulance visits to result in: a longer length of stay (mean: 13.3 hours [95% CI = 13.0 to 13.6] vs. 5.9 [95% CI = 5.8 to 6.0]), hospital admission (40% vs. 10%) (odds ratio [OR]: 5.94 [95% CI = 5.59 to 6.33]), consultations (56% vs. 20%) (OR: 5.15 [95% = 4.86 to 5.45]), and radiology/imaging tests (20% vs. 12%) (OR: 1.93 [95% CI = 1.81 to 2.07]). In multivariate models that adjusted for the effects of age, gender, triage urgency, and temporal factors, ambulance transportation maintained its association with greater resource use. CONCLUSIONS: This preliminary study indicates that patients arriving at the ED by ambulance use significantly more resources than their walk-in counterparts.     

Patient profile and outcomes of traumatic injury: The impact of mode of arrival to the emergency department

BackgroundTraumatic injuries are of global health concern and significant contributors to Emergency Department (ED) and hospital workload.AimTo compare patterns of traumatic injuries among patient presentations to the ED across different modes of arrival (ambulance, police, or private transport) and to examine the predictors of an ED length of stay (LOS) exceeding 4 hours and hospital admission requirement.MethodsA retrospective observational study using 6 months of health data (8th October 2012–7th April 2013) of ED patient presentations made to one large, regional ED in Queensland, Australia, with a diagnosis code related to trauma.FindingsOver 6 months, 24.2% (n = 6,668) of adult patient presentations were trauma-related; most (60.9%) arrived via privately arranged transport (PAT); 38.7% were brought in by ambulance (BIBA) and 0.4% were brought in by police (BIBP). Demographics, clinical profile and patient outcomes differed based on mode of arrival. One in four patient presentations required hospital admission and 25% had an ED length of stay of >4 hours. Factors influencing hospital admission included older age, night shift, more emergent priority, and being BIBA. An ED length of stay of >4 hours was associated with older age, being BIBA, emergent nature of presentation, and hospital admission.ConclusionThe profile and outcomes of ED patient presentations with traumatic injury differs based on their mode of arrival to the ED. People BIBA were more likely to require hospital admission and have longer ED LOS, compared with those BIBP or PAT, even when controlling for covariates. Our findings may be used to inform nursing resource allocation when considering mode of arrival, especially for older people and people BIBA.     

Delays in presentation with acute coronary syndrome in people with coronary artery disease in Australia and New Zealand

Objectives: To report time from the onset of symptoms to hospital presentation in Australian and New Zealand patients with subsequently confirmed acute coronary syndrome, and to identify factors associated with prehospital delay time in these patients. Methods: Patients with coronary artery disease enrolled in a randomized clinical trial testing an intervention to reduce delay in responding to acute coronary syndrome symptoms had been followed for 24 months. In cases of admission to the ED for possible acute coronary syndrome, medical records were reviewed to determine the diagnosis, prehospital delay time, mode of transport to the hospital and aspirin use before admission. Clinical and demographic data were taken from the trial database. Results: Patients (n= 140) had an average (SD) age of 67.3 (11.5) years; 36% were female. Two‐thirds of patients went to hospital by ambulance and 89.3% had a final diagnosis of unstable angina. The median time from onset of symptoms to arrival at the ED was 2 h and 25 min (interquartile range 1:25–4:59); 12.1% arrived ≤ 1 h and 66% within 4 h. Multiple linear regression analysis showed that use of ambulance (Beta = 0.247, P= 0.012) and younger age (Beta = 0.198, P= 0.043) were independent predictors of shorter delay times. Conclusion: The time from the onset of symptoms to hospital presentation was too long for maximal benefit from treatment in most patients. Further efforts are needed to reduce treatment‐seeking delay in response to symptoms of acute coronary syndrome.     

Cognitive status and ambulation in geriatric rehabilitation: walking without thinking?

OBJECTIVE: To assess the relation between cognitive and ambulatory abilities in geriatric rehabilitation inpatients. STUDY DESIGN: Survey study of geriatric cohorts. SETTING: Inpatient university hospital rehabilitation unit. PATIENTS: One hundred fifty urban geriatric rehabilitation patients with orthopedic, neurologic, or medical diagnoses. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM), Mattis Dementia Rating Scale, Neurobehavioral Cognitive Status Examination. RESULTS: Both cognitive measures predicted admission and discharge total FIM scores, continence status, and activities of daily living (ADL) scores. Neither measure could predict admission or discharge FIM ambulation scores better than demographic variables. CONCLUSION: While cognitive status affects the overall rehabilitation course and ultimate functional status of the geriatric patient, it does not predict walking or stair climbing ability.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Risk factors for 72-hour admission to the ED

This study's purpose was to identify risk factors for return and admission within 72 hours of discharge from the emergency department (ED). During a 2-year period, 104,584 patients were seen and discharged in the ED, and 493 (0.47%) patients returned within 72 hours requiring admission. Risk factors compared were age, sex, race, insurance status, and initial diagnosis. Initial visits were also characterized by weekday, means of arrival, time of arrival and discharge, and time between visits. Older patients, especially over 65 years, and patients with insurance for the elderly (Medicare) were at higher risk. The highest risk initial diagnosis categories were mental disorder (1.2%), genitourinary system (0.93%), and symptom-based diagnoses (0.76%). Also, a high proportion of patients arrived by ambulance. Patients at increased risk of early admission can be identified and should be the first target for prospective prevention strategies that seek to minimize high-risk early returns to the ED.     

Utility of clinical characteristics in identifying depression in geriatric ED patients.

We will determine if clinical characteristics can be useful in identifying depression in geriatric Emergency Department (ED) patients. We have provided a cross-sectional observational study of geriatric patients presenting to an urban university-affiliated public hospital. A brief self-rated depression scale (SRDS) was used to identify depression. Clinical characteristics, examined retrospectively, included chief complaint, chronic illnesses, mode and time of arrival and discharge disposition. Relative prevalence of depression was calculated for these clinical characteristics. 70 (27%; 95% CI, 22% to 32%) of 259 patients were found to be depressed by the SRDS. Patients with nonspecific chief complaints were more commonly depressed than patients with system-specific chief complaints, but not significantly (relative prevalence 1.6; 95% CI, 1.0 to 2.4; p = 0.19). The relative prevalence of depression also did not vary significantly when analyzed by specific chronic illness (P = 0.42) except cardiac disease (1.6; 95% CI, 1.1 to 2.4), PM or night arrival (1.3; 95% CI, 0.8 to 2.3; p = 0.17), ambulance use (1.1; 95% CI, 0.7 to 1.7; p = 0.88), or need for medical admission (1.0; 95% CI, 0.7 to 1.5; p = 0.97). Depression is common in geriatric ED patients. Clinical characteristics fail to identify elderly ED patients who are likely to be depressed. Use of a brief SRDS can aid in recognition of depression in this group.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Effectiveness of ambulance paramedics versus ambulance technicians in managing out of hospital cardiac arrest.

OBJECTIVE: To determine the effectiveness of extended trained ambulance personnel (paramedics) for the management of out of hospital cardiac arrest. METHODS: A retrospective cohort study of patients who suffered a cardiac arrest between 1 January 1992 and 31 July 1994, and who were transported to their local accident and emergency (A&E) department. Data were collected on basic demography, operational time intervals, and ambulance crew status. Further clinical data were collected, and outcome measures included status on arrival at A&E, status on leaving A&E (hospital admission), and status on leaving hospital. The data were analysed using univariate and multivariate techniques. RESULTS: Univariate analysis showed the likelihood of arriving in A&E with a return of spontaneous circulation was more than doubled among patients attended by a paramedic crew compared with those attended by technicians (relative risk = 2.48, 95% confidence interval 1.34 to 4.60). The likelihood of successful hospital admission was also significantly increased (RR = 1.92, 95% CI 1.13 to 3.27); however, beyond this point, further survival benefits appeared to be much smaller. Similar findings were revealed using multivariate analysis. Second level modelling revealed further possible differences between paramedic and technician crews according to type of incident. Patients successfully admitted to hospital who died before discharge remained severely disabled between admission and death. CONCLUSIONS: There are marked short term survival advantages after cardiac arrest associated with paramedic care, but these probably diminish rapidly over time.     

Out-of-hospital airway management and cardiac arrest outcomes: a propensity score matched analysis

Objective

It is unclear whether advanced airway management during ambulance transport is associated with improved out-of-hospital cardiac arrest (OHCA) outcomes compared with bag-valve mask ventilation (BVM). This study aimed to determine whether EMT-intermediate ETI or LMA is associated with improved OHCA outcomes in Korea.

Methods

We used a Korean national OHCA cohort database composed of hospital and ambulance data. We included all EMS-treated by level 1 EMTs (EMT-intermediate level) and OHCA with presumed cardiac etiology for the period January 2006–December 2008. We excluded cases not receiving continued resuscitation in the emergency department (ED), treated by level 2 EMT, as well as those without available hospital outcome data. The primary exposure was airway management technique during ambulance transport (endotracheal tube (ETI), laryngeal mask airway (LMA) or bag-valve-mask ventilation with an oropharyngeal airway). The primary outcomes were survival to admission and survival to hospital discharge. We compared outcomes between each airway management group using multivariable logistic regression, adjusting for sex, age, witnessed, prehospital defibrillation, bystander cardiopulmonary resuscitation (CPR), call to ambulance arrival time to the scene, call to ambulance arrival time to ED, initial ECG, metropolitan (defined as population > 1 million), and level of ED (higher versus lower level). We repeated the analysis using propensity-score matched subsets.

Results

Of 54,496 patients with OHCA, we included 5278 (9.7%). Overall survival to admission and to discharge was 20.2% and 6.9%, respectively. ETI and LMA were performed in 250 (4.7%) and 391 (7.4%), respectively. In the full multivariable models using total patients, adjusted survival to admission and discharge were similar for ETI and BVM: OR 0.91 (0.66–1.27) and 1.00 (0.60–1.66), respectively. Adjusted survival to admission and discharge were significantly lower in LMA than BVM: OR 0.72 (0.54–0.95) and 0.52 (0.32–0.85), respectively. In the full multivariable models using propensity matched samples, adjusted survival to admission and discharge were similar for ETI and BVM; OR 1.32 (0.81–2.16) and 1.44 (0.66–3.15), respectively. Adjusted survival to admission was similar for LMA and BVM: OR 0.72 (0.50–1.02). However, survival to discharge was significantly lower for LMA than BVM: OR 0.45 (0.25–0.82).

Conclusions

In Korea, EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM. Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilation.     

Acute coronary syndromes: cardiac rehabilitation programmes and quality of life

AIMS: This paper reports a study examining the quality of life of clients following hospital admission with acute coronary syndrome in Hong Kong and their use of cardiac rehabilitation. BACKGROUND: Coronary heart disease is a major source of mortality and morbidity in Hong Kong. Western studies have suggested that participation in cardiac rehabilitation improves the quality of life of clients with coronary heart disease yet the use of cardiac rehabilitation has been reported to be low. Better understanding is needed of the psychosocial status of these clients in Hong Kong and their use of cardiac rehabilitation services. METHODS: A prospective, pretest-post-test study was carried out, with data collected over a period of 6 months with convenience sample of 182 participants. Baseline data were obtained within one week after hospital admission for individuals experiencing ACS. The second phase of data collection commenced at 6 months after hospital discharge. Total period of data collection took over 12 months between 2002 and 2003. The Chinese version of the SF-36 was used to assess quality of life, and demographic data and the extent to which clients participated in the cardiac rehabilitation programme were assessed. RESULTS: Only 25% of the participants attended at least one session of the cardiac rehabilitation programme. Significant improvement occurred in all clients' perceived quality of life 6 months following initial hospital admission. No significant group differences in perceived quality of life were found according to whether or not clients used the cardiac rehabilitation services. CONCLUSION: Improvement in perceived health-related quality of life was evident over a 6-month period. Yet our findings suggested that participation in the cardiac rehabilitation programme did not have any apparent effects in subjects' perceived quality of life. Further studies using both generic and disease-specific health-related quality of life instruments, as well as the inclusion of control group, are recommended. Continual improvement in cardiac rehabilitation programmes, and consideration of alternative modes of delivery other than the traditional attendance at hospital outpatient services, are also recommended.     

Survival rate and factors associated with 1-month survival of witnessed out-of-hospital cardiac arrest of cardiac origin with ventricular fibrillation and pulseless ventricular tachycardia: the Utstein Osaka project

OBJECTIVE: We reassessed 1-month survival of patients with witnessed out-of-hospital cardiac arrest (OHCA) of cardiac origin with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in Osaka, Japan, and identified factors associated with 1-month survival using updated data from 1998 to 2004 collected based on the Utstein Style. METHODS: Using the Utstein Osaka Project database, we analyzed 1028 cases which met the following criteria: (1) patient age 18 years or older; (2) presumed cardiac origin based on the definition of the Utstein Style; (3) witnessed by citizens; (4) VF or pulseless VT at the time of arrival of the ambulance. The main outcome measure was survival at 1 month after collapse. Variables to develop a predictive model for 1-month survival were selected by stepwise logistic regression. RESULTS: Survival at 1 month was 19.6%. Factors retained in the final logistic regression were age, sex, type of witness, and time interval from (a) ambulance call receipt to cardiopulmonary resuscitation (CPR) by the ambulance crew; (b) ambulance call to defibrillation; (c) CPR by the ambulance crew to hospital arrival. Area under the receiver-operating characteristic curve for the model developed with the six variables was 0.738 and Hosmer-Lemshow goodness-of-fit p-value was 0.94. CONCLUSION: We successfully developed a model to estimate the probability of 1-month survival using variables easy to collect in the early phase of resuscitation, and this model would help physicians and family members predict the likelihood of 1-month survival of OHCA patients on admission.     

Safety and delay time in prehospital thrombolysis of acute myocardial infarction in urban and rural areas in Sweden

Sixteen hospitals in Sweden, including those in urban and more sparsely populated areas, and the associated ambulance organizations were enrolled in a prospective evaluation of the feasibility of treating patients with a ST-elevation infarction with a thrombolytic agent (reteplase) before hospital admission. A physician staffed the ambulances in 1% of cases, a nurse in 67%, and a staff nurse in 32% of cases. In all, 64 patients in urban areas and 90 patients in rural areas were included. The occurrence of complications before hospital admission was low and similar in the 2 groups. The median interval between the onset of symptoms and the start of thrombolysis was 1 hour 44 minutes in urban areas versus 2 hours 14 minutes in rural areas (P = 0.03). The median arrival time (interval between onset of symptoms and arrival of the ambulance) tended to be shorter in urban areas (1 hr 10 min vs 1 hr 33 min; not significant) and the median interval between the arrival of the ambulance and the start of thrombolysis was shorter in urban areas (27 min vs 36 min; P < 0.0001). When comparing urban areas with the least-populated rural areas, differences in various delay times became even more marked. Patients in urban areas had a higher ejection fraction and fewer symptoms of heart failure after 30 days and a lower 1-year mortality.     

Psychosocial outcomes of Hong Kong Chinese diagnosed with acute coronary syndromes: a prospective repeated measures study

BACKGROUND: Western studies have suggested that emotional stress and distress impacted on the morbidity and mortality in people following acute coronary events. Symptoms of anxiety and depression have been associated with re-infarction and death, prolonged recovery and disability and depression may precipitate the client's low self-esteem. This study examined perceived anxiety, depression and self-esteem of Hong Kong Chinese clients diagnosed with acute coronary syndrome (ACS) over a 6-month period following hospital admission. OBJECTIVES: To examine: DESIGN: A prospective, repeated measures design with measures taken on two occasions over a 6-month period; (1) within the 1st week of hospital admission following the onset of ACS and (2) at 6 months follow up. SETTING AND PARTICIPANTS: Convenient sample of 182 voluntary consented clients admitted with ACS to a major public hospital in Hong Kong who could communicate in Chinese, complete questionnaires, cognitive intact, and were haemodynamically stable and free from acute chest pain at the time of interview. METHODS: Baseline data were obtained within 1 week after hospital admission. The follow-up data was collected 6 months after hospital discharge. The Chinese version of the Hospital Anxiety and Depression Scale (HADS), State Self-esteem Scale (SSES), and Rosenberg's Self-Esteem Scale (RSES) were used to assess anxiety and depression, state self-esteem, and trait self-esteem, respectively. RESULTS: Findings suggested gender differences in clients' perception in anxiety, depression and self-esteem. Improvements in clients' perception of these variables were evident over the 6-month period following their acute coronary events. CONCLUSION: The study confirmed the western notion that psychosocial problems are common among coronary clients and this also applies to Hong Kong Chinese diagnosed with ACS. Further studies to explore effective interventions to address these psychosocial issues are recommended.     

A geriatric day hospital in Hong Kong: An analysis of activities and costs

A survey of the activities of a geriatric day hospital in Hong Kong was carried out. It revealed that alternative modalities of hospital-based treatment were impractical and difficult to organize. Most patients and their carers were satisfied with the day hospital service, and the main area for improvement was in transportation. Costs of day hospital treatment were also calculated, and were found to be cheaper than an equivalent period of in-patient rehabilitation or out-patient therapy.     

Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest

BACKGROUND: Patients suffering in-hospital cardiac arrest (IHCA) often have abnormal clinical observations documented prior to the arrest. This study assesses whether these patients have a less favourable outcome following IHCA. METHODS: A multiple logistic regression analysis of retrospectively collected hospital chart data and prospectively collected Utstein style resuscitation data. Patients were defined as having abnormal clinical observations if they had one of the following documented 8 h before the arrest: systolic arterial blood pressure below 90 or over 200, pulse rate below 40 or over 140 beats per min or oxygen saturation below 90% with or without supplemental oxygen. Pre-arrest variables included were: age, sex and functional status, co-morbidities, reason for hospital admission, days in the hospital before the arrest, witnessed or un-witnessed arrest, arrest occurring outside regular working hours, monitored or non-monitored ward, whether basic life support was performed before the arrival of the resuscitation team, delay to arrival of resuscitation team and initial rhythm. RESULTS: Survival to hospital discharge of patients with clinically abnormal observations was 9% and among those without 18% (p=0.037). Independent pre-arrest predictors of survival were: un-witnessed arrest (odds ratio [OR] 0.1, confidence interval (CI) 0.01-0.8), initial rhythm other than ventricular fibrillation or ventricular tachycardia (OR 0.13, CI 0.05-0.3), delay to arrival of the resuscitation team exceeding 2 min (median) (OR 0.4, CI 0.15-0.9) and the presence of documented clinical abnormal observations prior to the arrest (OR 0.3, CI 0.09-0.95). CONCLUSIONS: Patients with documented clinically abnormal observations before IHCA have a worse outcome than those without, despite prompt resuscitation. Efforts should be made to identify these patients in time, thereby possibly avoiding the arrest. This can also be used when assessing the prognosis in IHCA.