Aim: To evaluate the effect of triage rapid initial assessment by doctor (TRIAD) on waiting time and processing time of an emergency department (ED) without extra staff. Method: A senior emergency doctor was put into triage instead of a consultation cubicle for seven shifts of 9 hours each. All the patients were assessed and necessary interventions started at the time of triage. Waiting time and processing time of various categories of patients were compared with a control group that was sampled during the week before the trial period. Results: In total, there were 1310 cases in the trial period and 1355 controls. Over a quarter (27%) of the patients received triage doctor interventions. The average waiting time was reduced by 38% and the average processing time by 23%. Patients without triage intervention also had a 24% shorter waiting time because of overall improvement in efficiency. Trauma patients and patients needing radiography particularly benefited from the new system. The waiting time and processing time of category 4 and 5 patients improved significantly as a result of more efficient processing of more urgent cases. Conclusion: The waiting time and processing time of the ED were greatly reduced by TRIAD without extra manpower. E mergency departments (EDs) in Hong Kong have for decades been frustrated by the problems of overcrowding and long waiting times. Health providers attribute long waiting times to public misuse of the emergency service. Schemes aimed at educating the public about this have been carried out but have not improved the situation; regardless of health providers' viewpoints, patients still perceive their problems to be emergencies. The situation in Hong Kong is further complicated by the lack of comprehensive and systematic primary healthcare, and consequently the ED has become a common entry point to the public healthcare system.We have adopted the Manchester triage system for many years. This system aims to identify potential life threatening emergencies from vital sign parameters and a brief history. Using this method, about 75% of the patients are triaged as category 4 (semi-urgent) or 5 (non-urgent). It is these groups of patients that have the longest waiting times and highest levels of patient dissatisfaction and complaints. We have taken triage as the starting point of our patient care whereas patients usually regard the time of consultation by a doctor as the endpoint of waiting. Our triage system focuses on vital signs and life threatening emergencies. This categorisation can be misleadingly reassuring as early signs may be absent in spite of acute problems. For example a patient may have stable vital signs and be triaged as category 4 (semi-urgent) in spite of a bleeding wound, severely painful renal colic, parental anxiety for a feverish child, or an expanding aortic aneurysm presenting as backache.Because of financial constraints on the public healthcare system, the problem cannot simply be tackled by increasing staffing levels in the ED. We believe that triage is a break...

Objective: To compare the haemodynamic effect of low dose midazolam and etomidate as induction agent in emergency department rapid sequence intubation. Methods: A prospective observational study in two phases. In phase one, midazolam 2-4 mg was used as induction agent and in phase two, etomidate 0.2-0.3 mg/kg was used. The haemodynamic data were recorded before and after intubation for comparison. Changes in mean systolic blood pressure were analysed with SPSS software. Results: A 10% decrease in mean systolic blood pressure was observed in the midazolam group (p = 0.001) while there was no significant change in the etomidate group. Some 19.5% of patients had hypotension after being given midazolam while only 3.6% with etomidate (p = 0.002). Patients older than 70 tended to have more hypotension episodes but the difference was not statistically significant. Conclusions: Midazolam, even in low dose, was more likely than etomidate to cause significant hypotension when used as an induction agent for rapid sequence intubation. Etomidate is a better alternative. R apid sequence intubation (RSI) is a procedure commonly performed by doctors working in the emergency department in many parts of the world. It had been shown that the procedure could significantly reduce intubation related complications especially trauma to the airway and aspiration when compared with intubation without sedation and paralysis. 1 2 However, by reviewing the recent publications we discovered a change in the pattern of complications. Accompanying the drastic decrease of airway trauma and aspiration, hypotension has become the most commonly encountered complication.3-5 After reviewing local data, we have found the same problem. 6 The issue has not been properly investigated in previous studies and some might believe that acutely ill patients were haemodynamically compromised and prone to develop hypotension. The occurrence of hypotension is associated with significant mortality and morbidity in critically ill patients 7-8 and we should not overlook its potential hazards. Midazolam was the most commonly used induction agent for many years locally and we suspected that it was probably responsible for hypotension. Other common induction agents, for example, thiopentone and propofol are known to cause hypotension as well. We therefore investigated whether etomidate is a better choice than midazolam as an induction agent in terms of haemodynamic stability. We were unable to find any studies directly comparing these two drugs as induction agent in RSI in our review of the literature. METHODSThis was a prospective observational study carried out in an emergency department of an urban district hospital. All noncardiac arrest patients that needed emergency intubation in the emergency department were eligible to be recruited in the study and patients with either midazolam or etomidate as induction agent for RSI were included. The study period was divided into two phases. Phase one lasted for 11 months during which midazolam was the most commonly used ind...

To determine whether the minimum clinically significant difference (MCSD) in visual analogue scale (VAS) pain score varies with age, gender, education level and cause of pain (trauma versus non-trauma) in Chinese patients. Methods: This was a prospective descriptive study of local Chinese patients 15 years of age or older who presented with pain to the accident & emergency department. On presentation, patients were asked to indicate their current pain severity with a single mark through a standard 100-mm visual analogue scale. Then they would be offered an analgesic for pain-relief. After 30-45 minutes, the patients were asked to give a verbal categorical rating of their pain as 'a lot better', 'a little better', 'much the same', 'a little worse', or 'much worse' and to mark the level of pain on a VAS of the same type as used previously. The MCSD in VAS pain score was defined as the mean difference between the current and preceding scores when the subject reported 'a little worse' or 'a little better' in pain. Data were compared based on gender, age, education level, and traumatic versus non-traumatic causes of pain. Results: 186 patients were enrolled in the study, yielding 77 evaluable comparisons where pain was rated as 'a little better' or 'a little worse'. Overall, the MCSD in VAS pain score in the group was 17 mm (95%CI 13.6 mm to 20.6 mm). There were statistically significant differences between the MCSD in VAS pain score between genders and causes of pain (trauma versus non-trauma). Conclusions: The MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non-trauma cases.

No abstract

Objective To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement. Method This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications. Results A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates. Conclusion Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.