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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 25-29

Clinical profile and outcome of the patients presenting to the resuscitation room of the emergency department in a Tertiary Care Hospital of South India


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission22-Jul-2019
Date of Acceptance08-Aug-2019
Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Gina Maryann Chandy
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_23_19

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  Abstract 

Background: The sickest patients who visit the emergency department (ED) are triaged as priority one based on guidelines. To improve the quality of Emergency medicine (EM) care, a better understanding of patients is needed; hence, this study was done on priority one patients of the ED. Materials and Methods: This retrospective study included all priority one patients during a 4-month period (February, May, September, and December), over 1 year (2017). Demographic details, vital signs at the time of presentation, and details of disposition were noted. Results: Among 2333 priority one patients, majority (89.3%) had non trauma-related diseases, while only 10.7% had trauma as the cause of disease. Males were predominant (64%) and females accounted for 36%. Adults were more than half (59.16%), followed by the geriatric age group. Bradycardia was noted in 6.4% (149) patients, while 52.1% (1212) had tachycardia and 29.7% of the population presented with hypotension. Breathlessness was the most common complaint (44.6%); trauma specialty departments were referred to include neurosurgery (43.1%) and orthopedics (27.5%). Broader specialties such as general medicine and general surgery had majority of their spectrum-related cases referred to them, 44.9% (n = 716) and 39.3% (n = 50), respectively. More than a quarter of patients (27.2%) were discharged from the ED, one-third (68.1%) of the patients were discharged from the hospital overall, and 7.4% succumbed to death. Conclusion: The patient demographics and other characteristics identified by this study help us to guide and shape Indian EM training programs, infrastructure, and faculty development, to more accurately reflect the burden of acute disease in India.

Keywords: Acute care, emergency department, emergency department utilization, priority one, resuscitation room


How to cite this article:
Rufus Y B, Abhilash KP, Swadeepa R J, Koshy SA, Chandy GM. Clinical profile and outcome of the patients presenting to the resuscitation room of the emergency department in a Tertiary Care Hospital of South India. Curr Med Issues 2019;17:25-9

How to cite this URL:
Rufus Y B, Abhilash KP, Swadeepa R J, Koshy SA, Chandy GM. Clinical profile and outcome of the patients presenting to the resuscitation room of the emergency department in a Tertiary Care Hospital of South India. Curr Med Issues [serial online] 2019 [cited 2019 Sep 17];17:25-9. Available from: http://www.cmijournal.org/text.asp?2019/17/2/25/265821


  Introduction Top


Patients with different ailments present to the emergency department (ED); few of them have severe life-threatening diseases; this presents a challenging task to the ED personnel to identify the sickest patients and to initiate the treatment at the earliest. The ED provides immediate care and also access to specialist care at the time of need, and this could be a boon for the emergent conditions. The ED plays a pivotal role by acting as a crucial interface between the emergency medical services and the hospital facility. Emergency facilities have to be utilized to the maximum, and this can be obtained by proper prioritization, and hence, the triage plays a vital role in prioritizing the patients based on their severity of symptoms and vital signs.[1] In the current-day scenario, prioritizing the patients is the key element in efficiently delivering the limited resources to the neediest first; this holds good not only during dealing with natural disasters where there is a humongous influx of patients but also during epidemics, pandemics, and regular emergency care departments.[2] Triage refers to the methods used to assess patients' severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment.[3] The resuscitation area also known as “Resus” is a specialized area, dedicated to the immediate care of patients who have compromised airway, breathing, and circulation and victims of cardiac arrest situations related to any cause. The resuscitation room consists of trolleys with all resuscitative equipment (emergency drugs, monitors, defibrillators, airway, intubation, and surgical equipment) available at an arm's distance to deliver the immediate required care. As road traffic accidents, acute cardiac events such as myocardial infarctions, and cerebrovascular accidents (CVAs) are the most commonly cited causes of death and disability in India, to effectively manage these emergencies, the ED should have a well-trained staff and a robust infrastructure.[4] Many of the severe surgical emergency patients arrive at hospitals unconscious, in hemodynamic derangements, with respiratory obstructions or other urgent problems that must be addressed immediately; drugs such as antibiotics and inotropes should be administered as early as required; untreated sepsis increases the risk of mortality; once the patients are hemodynamically stabilized, surgical treatment can be considered.[5],[6]

This article describes a tertiary, peri-urban hospital's ED priority one patient population in terms of demographics, nature of the disease, their chief complaints, primary specialty units they are handed over to, and their disposition in terms of ED outcome and final outcome.


  Materials and Methods Top


We conducted a retrospective, observational study on patients presenting to the resuscitation room of Department of Emergency Medicine, Christian Medical College and Hospital, Vellore, which is a 45-bedded department in South India with an average of 250 admissions daily. The department caters to all adult emergency cases (>15 years) as well as pediatric trauma cases. All other pediatric emergency cases are taken care by a dedicated pediatric ED. All the patients who were registered as priority one were included in the study. Data of the patients were noted into the pro forma sheet. All patients presenting to the resuscitation room of our ED during the months of February (2017), May (2017), September (2017), and December (2017) were included in the study; 1 month from each climatic season was selected to include all the seasonal diseases and to avoid bias. Data of 2504 patients were collected, of which only 2333 patients' data were included. The remaining 177 patients were either brought dead on arrival to the ED or had significant data missing. Data of the patients were obtained from the electronic hospital records; details of history and physical examination findings of all patients were recorded on a standard data collection sheet. Patients were profiled in terms of age, gender, nature of the disease and the chief complaints they presented with, vital signs at the time of presentation, details of which primary specialty they were handed over to, and their plan regarding admission or disposition of patients.

Triage priority level one was defined as follows:

  • Patients whose airway, breathing, and circulation was compromised with the Glasgow Coma Scale (GCS) of <8
  • Patients who had hypoxia oxygen saturation <80 and having respiratory rate >40 or <12 breaths/min
  • Hemodynamically unstable trauma and nontrauma patients with SBP <90 mmHg
  • Active seizures, CVA within 4 h, active chest pain, and hypertensive emergency.


All patients were initially managed and stabilized by the ED team; patients, who required cross consultation, were handed over to the respective specialty departments for further management. If a patient required consultation from more than one specialty, the primary unit was decided by the ED team based on the expertise required from the concerned specialties. Patients who improved remarkably and those who did not meet the admission criteria were discharged either by the ED team or by the other specialty units after a short observation period, and those who required admission were admitted to the respective wards and intensive care units (ICUs) as per the care required; inhospital outcome of all the admitted patients was noted.

Statistical analysis was performed using the SPSS software (SPSS Inc., 2007, version 16.0 Chicago, IL, USA). Frequencies of each variable were entered, and the proportions of each variable to the total were recorded; mean and standard deviation was calculated. This study was approved by the Institutional Review Board, and patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.


  Results Top


Among 2333 patients who were triaged to the resuscitation room as priority one during the study period, majority (89.3%) had nontrauma-related conditions, while only 10.7% had trauma as the cause of the disease [Figure 1]. Among patients who presented with nontraumatic ailments, a vast proportion (92.6%) had medical issues, while 7.4% had surgical problems. Males (64%) were predominant than females (36%). Adults were more than half (59.16%) of the study cohort followed by the geriatric age group (39.65%), and the pediatric population was a mere 1.2%. While 41.5% had a normal pulse rate, 6.4% (149) had bradycardia and 52.1% (1212) had tachycardia. The baseline characteristics of the patients along with the vital signs and chief complaints are mentioned in [Table 1]. Three-fourths of the study population (75%) had normal GCS; breathing difficulty was the most common presenting complaint. Breathlessness along with chest pain was present in 7.7%, abdominal pain with breathlessness was present in 2.15%, and altered sensorium with breathlessness was noted in 4.8% of the individuals. ED team alone managed 16.2% (380) of the total cases, of which 88.2% (335) were medical, 7.1% (27) were surgical, and 4.73% (18) were trauma cases. Trauma specialty departments were referred to include neurosurgery (43.1%) and orthopedics (27.5%). Broader specialties such as general medicine and general surgery had majority of their spectrum-related cases referred to them. Cases that were handed over to different primary specialty departments are shown in [Table 2]. More than a quarter (27.2%) patients were discharged from the ED in stable condition, while less than a quarter (22.4%) patients were either referred to other centers in view of the shortage of beds in wards and ICUs or left against medical advice [Figure 2]. An overwhelming 68.1% of the patients were discharged from the ED and inhospital combined and 7.4% succumbed to death. The inhospital outcome is shown in [Figure 3].
Figure 1: Flowchart of patients presenting to the resuscitation room of the emergency department

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Table 1: Demographic details, vitals, and chief complaints of priority one patients (n = 2333)

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Table 2: Cases handed over to different primary specialties

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Figure 2: Emergency department outcome of priority one patients (n = 2333)

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Figure 3: Inhospital outcome of priority one patients (n = 1127)

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  Discussion Top


Our study comprised priority one, critically ill patients who presented to us with different disease spectrums. Emergency medicine is already set to be the fastest growing specialty, to efficiently deliver the best of its services; it needs well-trained personnel who have the knowledge of the acute patient burden and the resources available so that the sickest patient gets the immediate and prompt care. Thorough literature searches for comparable papers showing a systematic sample of ED priority one patient epidemiology in India did not reveal any similar studies. This article provides baseline documentation on ED resuscitation room patients' clinical profile. However, a study done on all patients visiting ED at a tertiary hospital in Kerala reveals few similarities and contrasts.[7] Similar to the above-mentioned study, males were higher in number than females, but the pediatric population in our study was very low due to the fact that only pediatric trauma cases visit our ED, thanks to the dedicated pediatric emergency unit which handles all pediatric nontrauma cases. There is a stark contrast with regard to the chief complaint, as the most common presenting complaint here is breathlessness which accounted for 44.6% (1041) followed by chest pain 20% (466) of the population. General medicine, genera surgery and neurosurgery were the specialties to which maximum number of cases were handed over to. Broader specialties such as general medicine and general surgery had the lions' share in their respective spectrums. Nontrauma-related causes (89.2%) for diseases were far more compared to the trauma-related causes (11.1%); a study done in the UK showed 0.63% of trauma patient load was treated in the resuscitation room, while an Indian study done at our hospital in the past revealed that a significant proportion of trauma patients (12.8%) n = 251 were managed as priority one cases; these data are similar to the findings of our study (11.1%).[8],[9] The proportion of patients who are discharged in stable condition from the ED, 30.3%, are comparable to the proportion of patients who are being admitted to wards, 27.2%, but the proportion of deaths was slightly higher (2%) compared to the study done in Kerala (0.7%); this could be due to the fact that a vast diversity of sicker patients are referred to our center in terminal stages. Percentage of discharges as the final outcome was more than doubled compared to the discharges from ED. Overall percentage of deaths as a final outcome has more than tripled compared to the deaths in ED.

Our study highlights the burden of priority one patients in the ED of India. Many primary and secondary health centers lack a triage facility, trained personnel, and necessary equipment to deal with such sick patients. Unlike in our hospital, specialists in trauma and nontrauma care are not available in most rural hospitals, and hence, many patients need to be referred to higher centers after initial stabilization.

A limitation of our study was that it was conducted at a single medical center, and hence, the patient population may be biased by patient selection and referral pattern. Nonetheless, the study provides the baseline documentation regarding patients presenting to the resuscitation room.


  Conclusion Top


Our study shows that medical emergencies are more common than the nontrauma surgical and trauma-related emergencies. A well-equipped ED and proper training of emergency physicians and paramedical team in recognizing the sick patients and delivering a prompt and early care are paramount in saving the lives of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Christ M, Grossmann F, Winter D, Bingisser R, Platz E. Modern triage in the emergency department. Dtsch Arztebl Int 2010;107:892-8.  Back to cited text no. 1
    
2.
Aacharya RP, Gastmans C, Denier Y. Emergency department triage: An ethical analysis. BMC Emerg Med 2011;11:16.  Back to cited text no. 2
    
3.
Fernandes CM, Tanabe P, Gilboy N, Johnson LA, McNair RS, Rosenau AM, et al. Five-level triage: A report from the ACEP/ENA five-level triage task force. J Emerg Nurs 2005;31:39-50.  Back to cited text no. 3
    
4.
Arora P, Bhavnani A, Kole T, Curry C. Academic emergency medicine in India and international collaboration. Emerg Med Australas 2013;25:294-6.  Back to cited text no. 4
    
5.
McCord C, Ozgediz D, Beard JH, Debas HT. General Surgical Emergencies. Essential Surgery: Disease Control Priorities. 3rd ed. Washington (DC): The International Bank for Reconstruction and Development / The World Bank 2015.  Back to cited text no. 5
    
6.
Birenbaum DS, Kalra S. Whats new in emergencies, trauma and shock? Shock, sonography and survival in emergency care! J Emerg Trauma Shock 2015;8:1-2.  Back to cited text no. 6
    
7.
Clark EG, Watson J, Leemann A, Breaud AH, Feeley FG, Wolff J, et al. Acute care needs in an Indian emergency department: A retrospective analysis. World J Emerg Med 2016;7:191-5.  Back to cited text no. 7
    
8.
O'Byrne GA, Bodiwala GG. Use of the resuscitation room for trauma. Arch Emerg Med 1987;4:83-90.  Back to cited text no. 8
    
9.
Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.  Back to cited text no. 9
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