Standardized Approaches to Syncope Evaluation for Reducing Hospital Admissions and Costs in Overcrowded Emergency Departments

신태건,김준수,조익준,심민섭,박승정 연세대학교의과대학 2013 Yonsei medical journal Vol.54 No.5

Purpose: The evaluation of syncope is often disorganized and ineffective. The objective of this study was to examine whether implementation of a standardized emergency department (ED) protocol improves the quality of syncope evaluation. Materials and Methods: This study was a prospective, non-randomized study conducted at a 1900-bed, tertiary teaching hospital in South Korea. We compared two specific periods, including a 12-month observation period (control group, January-December 2009) and a 10-month intervention period after the implementation of standardized approaches, comprising risk stratification, hospital order sets and establishment of a syncope observational unit (intervention group, March-December 2010). Primary end points were hospital admission rates and medical costs related to syncope evaluation. Results: A total of 244 patients were enrolled in this study (116 patients in the control group and 128 patients in the intervention group). The admission rate decreased by 8.3% in the intervention group (adjusted odds ratio 0.31, 95% confidence interval 0.13-0.70, p=0.005). There was a cost reduction of about 30% during the intervention period [369000 Korean won (KRW), interquartile range (IQR) 240000-602000 KRW], compared with the control period (542000 KRW, IQR 316000-1185000 KRW). The length of stay in the ED was also reduced in the intervention group (median: 4.6 hours vs. 3.4 hours). Conclusion:Standardized approaches to syncope evaluation reduced hospital admissions, medical costs and length of stay in the overcrowded emergency department of a tertiary teaching hospital in South Korea.

응급실 다방문환자의 임상적 특성에 관한 연구 - 응급실 다방문환자의 응급실 과밀화 및 중증도와의 관련성 -

신태건,홍종근,송진우,송형곤 대한응급의학회 2011 대한응급의학회지 Vol.22 No.1

Purpose: Crowding causes dysfunction in the emergency department (ED) and is associated with poor quality of patient care, dissatisfaction of the physicians, and increased financial burden of medical care. Frequent use is often considered a major contributor to ED crowding. The present study sought to verify the relationship between the frequent ED users and ED crowding, and to ascertain the severity of the frequent ED users. Methods: One-year ED visit data from a tertiary teaching hospital located in an urban area were analyzed. Frequent ED users were defined as four or more ED visits per year. Crowding indicators were defined as the length of stay and the percentage of patients staying over 6 hours. Severity indicators were defined as operation within 24 h, admission to intensive care unit, and expiry in the ED. Results: The 2.7% of patients who had four or more ED visits were responsible for 11.9% of visits. The median length of stay of frequent users was significantly longer (6.18 h) than that of infrequent users (3.42 h). The percentage of patients who stayed more than 6 h was significantly larger in the frequent user group than infrequent user group (51.4% vs. 32.9%, respectively; OR=2.158; 95% CI,2.041~2.281). However, the severity of frequent users was lower than that of infrequent users (3.0% vs. 5.3%, respectively;OR=0.553; 95% CI, 0.472~0.648). Conclusion: Frequent users presenting to an ED located in an urban area were more likely to stay longer in the ED,and were less likely to be severe. Active interventions to reduce ED crowding are required.

Improving Survival Rate of Patients with In-Hospital Cardiac Arrest: Five Years of Experience in a Single Center in Korea

신태건,조익준,송형곤,심민섭,송근정 대한의학회 2012 Journal of Korean medical science Vol.27 No.2

The aim of this study was to describe the cause of the recent improvement in the outcomes of patients who experienced in-hospital cardiac arrest. We retrospectively analyzed the inhospital arrest registry of a tertiary care university hospital in Korea between 2005 and 2009. Major changes to the in-hospital resuscitation policies occurred during the study period, which included the requirement of extensive education of basic life support and advanced cardiac life support, the reformation of cardiopulmonary resuscitation (CPR)team with trained physicians, and the activation of a medical emergency team. A total of 958 patients with in-hospital cardiac arrest were enrolled. A significant annual trend in inhospital survival improvement (odds ratio = 0.77, 95% confidence interval 0.65-0.90) was observed in a multivariate model. The adjusted trend analysis of the return of spontaneous circulation, six-month survival, and survival with minimal neurologic impairment upon discharge and six-months afterward revealed similar results to the original analysis. These trends in outcome improvement throughout the study were apparent in non-ICU (Intensive Care Unit) areas. We report that the in-hospital survival of cardiac arrest patients gradually improved. Multidisciplinary hospital-based efforts that reinforce the Chain of Survival concept may have contributed to this improvement.

심폐소생술을 시행 받은 심정지 환자에서 경피적 체외심폐보조장치의 임상 경험

신태건,최진호,송형곤,정연권,조익준 대한응급의학회 2008 대한응급의학회지 Vol.19 No.6

Purpose: Percutaneous cardiopulmonary support (PCPS) provides hemodynamic stability under various clinical settings, including cardiopulmonary arrest. We compared a single center's experience with performing PCPS during cardiopulmonary resuscitation (CPR) and post-resuscitation care to evaluate the prognostic factors for survival. Methods: We retrospectively reviewed 83 patients with cardiopulmonary arrest who received PCPS during or within 6 hours of CPR from January, 2004, to December, 2007. Venoarterial bypass systems were used in all cases with femoral cannulation. Results: The mean duration of CPR was 37.2±26.4 min and the mean time interval from CPR to PCPS insertion was 73.1±107.9 min. The mean duration of PCPS was 73.4±110.6 h. Of the 83 patients, 48 underwent PCPS during CPR before recovery of spontaneous circulation and 35 received PCPS during post-resuscitation care for hemodynamic support. Forty-eight patients (57.8%) were successfully weaned off of the PCPS and 34 patients (41.0%) were discharged from the hospital. Among the survivors, 29 patients (34.9%) had no neurological deficits. In multivariate regression analysis, the duration of CPR and defibrillation of pulseless ventricular tachycardia or fibrillation before PCPS were significant prognostic factors for survival (p=0.007 and p=0.015, respectively). In subgroup analysis of the 48 patients who received PCPS before resuscitation with conventional CPR, the duration of CPR that was equal to the time interval from CPR to PCPS insertion was also a significant factor for survival (p=0.011) with a survival rate of 27.1%. Conclusion: The duration of CPR is very important for survival. Application of PCPS in CPR can shorten the duration of CPR and maintain hemodynamic stability. Therefore, PCPS is a good resuscitative tool in CPR and post-resuscitation care with an acceptable survival rate and outcome when conventional measures fail.

Korean Shock Society septic shock registry: a preliminary repor

신태건,황승연,강구현,김원영,류승목,김규석,조유환,정성필,주영선,범진호,최성혁,윤영훈,권운용,임태호,한갑수,최한성,서길준 대한응급의학회 2017 Clinical and Experimental Emergency Medicine Vol.4 No.3

Objective To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). Methods This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. Results A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. Conclusion This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.

Modified Cardiovascular Sequential Organ Failure Assessment Score in Sepsis: External Validation in Intensive Care Unit Patients

신태건,( Byuk Sung Ko ),( Tae Ho Lim ),( Seung Mok Ryoo ),( Won Young Kim ),( Eunah Han ),( Sung Phil Chung ),( Hyunglan Chang ),( Kyuseok Kim ),( Chang June Yune ),( Hui Jai Lee ),( Sung-hyuk Choi ),( J 대한응급의학회 2023 대한응급의학회 학술대회초록집 Vol.2023 No.2

병원 전 심정지 환자의 동반자에 대한 면담 설문을 통한 심폐소생술에 대한 태도 연구

오석남,신태건,홍종근,송근정,심민섭 대한응급의학회 2010 대한응급의학회지 Vol.21 No.5

Purpose: The purpose of this study was to provide an appropriate direction for cardiopulmonary resuscitation (CPR) education for laypersons by analyzing the status of CPR training, bystander CPR, and the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Methods: Data were obtained prospectively by interviews of bystanders who arrived with an OHCA patient between Jan 1, 2009 and Mar 31, 2010. Variables analyzed included CPR education, bystander CPR, and prognosis of OHCA patients. Multivariate logistic regression analysis was performed to identify independent factors for bystander CPR. Results: Nineteen (33.9%) of 56 bystanders (male: 48.2%,age: 48.98±16.87) conducted CPR on an individual having an OHCA. Fourteen (25.0%) of the 56 had CPR education. Of the 14, 8 (57.1%) performed CPR. Among those who did not have any CPR training (p<0.05) 11 (26.2%) conducted it. In a multivariate regression analysis, younger age was a significant predictor for bystander CPR. Previous CPR training and male also appeared to be potential factors although their predictive value was not statistically significant. Conclusion: The rates of CPR training experience and bystander CPR were relatively low in this study. Younger age, male and previous CPR training were associated with the rate of bystander CPR, which is known as a critical factor influencing survival of OHCA patients. In order to increase survival of OHCA patients by raising the bystander CPR rate, systemic CPR education for laypersons should be established.

Diagnostic Accuracy of Plasma Renin and Renin Activity in Predicting Mortality and Renal Outcomes in Septic Shock Patients with Hypoperfusion or Hypotension

이건탁,신태건,박종은,황승연,정치량,김민하,김다슬,정다운,강형구,오재훈,임태호,고벽성,채보라,김원영 대한응급의학회 2023 대한응급의학회 학술대회초록집 Vol.2023 No.2

중증 기저질환이 병원 내 심정지 환자의 예후에 미치는 영향

김신념,신태건,심민섭,조익준,송형곤 대한응급의학회 2010 대한응급의학회지 Vol.21 No.6

Purpose: The purpose of our study was to evaluate the relevance of a patient’s critical comorbidities to his survival rate, along with factors that influence the prognosis of patients who went through in-hospital cardiac arrest. We also investigated the association between the physical burden of the patients’ comorbidities and the prognosis of inhospital arrest patients using the Deyo-Charlson score. Methods: We retrospectively reviewed data for 1,094patients with in-hospital cardiopulmonary arrest between January 2003 and June 2009 according to the Utstein-style guidelines. Severe comorbidities included congestive heart disease, chronic renal failure, severe liver disease, pulmonary disease, and hematologic or metastatic solid malignancy. Multivariate Cox regression analysis and logistic regression models were used to assess the hazard ratio and survival factors. Results: The hazard ratio of patients with severe liver disease or hematologic or metastatic solid cancer were 1.42(95% CI, 1.14-1.76, p=0.002) and 1.60 (95% CI, 1.36-1.88,p<0.001), respectively. Shorter CPR duration and subsequent intervention were significant prognostic factors in patients with severe comorbidities. The Deyo-Charlson score was one of the independent prognostic factors in the overall study population. Conclusion: The six month survival rate of patients with a history of severe liver disease or hematologic or solid metastatic cancer that underwent in-hospital cardiac arrest is low.

Prediction of vasopressor requirement among hypotensive patients with suspected infection: usefulness of diastolic shock index and lactate

김다슬,신태건,박종은 대한응급의학회 2022 대한응급의학회 학술대회초록집 Vol.2022 No.2