Purpose:This study aimed to evaluate the impact of the Hip Fracture Fast-Track (HFFT) protocol, designed specifically for older patients at our hospital, which commenced on January 1, 2022, on the management of emergency department (ED) pain in older adults with hip fractures. Patients and Methods:Retrospective pre- and post-study data from electronic health records (EHR) at our hospital, using the International Classification of Diseases (ICD)-10 codes S72.0, S72.1, S72.8, and S72.9, were utilized. The study included patients aged 65 years or older who presented to the ED with low-energy, non-pathologic isolated hip fractures or proximal femur fractures. The pre-HFFT period included patients from January 1, 2020, to December 31, 2021, and the post-HFFT period included patients from January 1, 2022, to October 31, 2023. Data were compared for the proportion of patients undergoing pain evaluation in the ED, before discharge, time to first analgesia, number of patients receiving pain relief in the ED, and the use of fascia iliaca compartment blocks (FICBs) and pericapsular nerve group blocks (PENGBs). Results:The final analysis involved 258 patients, with 116 in the pre-protocol group and 142 in the post-protocol group. The rate of analgesic use increased significantly in the post-HFFT group (78 [67.24%] vs 111 [78.17%], P = 0.049). The rate of pain score screening at triage increased from 51.72% before the HFFT protocol to 86.62% post-HFFT protocol (p < 0.001). Compared with the pre-HFFT protocol, the post-HFFT protocol exhibited a higher rate of FICB (0% vs 14.08%, p < 0.001) and PENGB (0% vs 5.63%, p = 0.009) administration. Conclusion:The HFFT protocol's implementation was associated with improved ED pain evaluation and analgesic administration in older adults with hip fractures. These findings indicate that tailored protocols, such as the HFFT, hold promise for enhancing emergency care for this vulnerable population.

Introduction: Under-triage increases patients’ risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system. Methods: In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients’ ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed. Results: 1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18–30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07–2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29–2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01–2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22–0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10–0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18–30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16–8.00; p = 0.023). Conclusions: Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

Objective To evaluate the association of 25-hydroxyvitamin D (25(OH)D) level on sepsis severity and risk of hospitalisation in emergency department (ED) septic patients when categorised as vitamin D insufficiency according to the level of 25(OH)D<30 ng/mL. Design Cross-sectional observational study. Setting A 900-bed academic tertiary hospital with an ED residency training programme in Bangkok, Thailand. Participants An observational study of 101 ED septic patients aged ≥18 years was conducted between March 2015 and September 2015. Outcome measures The level of 25(OH)D was analysed and correlated with sepsis severity assessed by Acute Physiology Age Chronic Health Evaluation-II (APACHE-II) and Mortality in ED Sepsis (MEDS) scores, and the risk of hospitalisation. Results One hundred and one patients were enrolled, with an average age of 68±18 years, 56% female, APACHE-II score of 14±6, MEDS score of 8±5 and 25(OH)D level was 19±11 ng/mL. The prevalence of vitamin D insufficiency in our ED septic patients was 87% and the admission rate was 88%. A significant association between 25(OH)D level and sepsis severity scores was found, which was measured by APACHE-II and MEDS scores (−0.29; 95% CI −0.41 to −0.17, p<0.001 and −0.15; 95% CI −0.25 to −0.06, p=0.002, respectively). However, vitamin D insufficiency could not determine hospitalisation (OR=1.42; 95% CI 0.27 to 7.34; p=0.68 and OR=1.65; 95% CI 0.07 to 41.7; p=0.76 when adjusted by baseline covariates). Conclusions The vitamin D insufficiency of septic patients in our ED was high and had a significant negative association with sepsis severity. However, vitamin D insufficiency status cannot predict the hospitalisation of septic patients who were admitted to the ED. Further research is needed to investigate the role of vitamin D supplementation in the ED in affecting sepsis severity. Trial registration number TCTR20151127001.

Purpose: This study aimed to determine the validity of ultrasonographic measurement of the rectus femoris muscle (RFM) thickness as a screening tool for low appendicular muscle mass (ASM) to diagnose sarcopenia and to determine the cut-off point of RFM thickness in the Thai population.Patients and methods: We enrolled 857 community-dwelling adults aged 60 years and older who were diagnosed with sarcopenia using the Asian Working Group for Sarcopenia-2019 algorithm. The RFM thickness was measured using ultrasonography and compared with bioelectrical impedance analysis (BIA) data. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated, and the area under the receiver operating curve (AUROC) was used to determine the accuracy of the test.Results: A total of 857 participants were included in the study. Overall, when the cut-off values of RFM thickness of <1.1 cm were used for male and <1 cm for female, the highest sensitivity for sarcopenia diagnosis was 90.9% and specificity was 92.2%. The PPV was 76.6, and the NPV was the highest at 97.3. The highest sensitivity for the diagnosis of severe sarcopenia was 92.5% and specificity was 97.4%. The AUROC of the cut-off point of RFM thickness for the diagnosis of sarcopenia was 0.92 (95% confidence interval [CI], 0.89-0.94); for severe sarcopenia, it was 0.95 (95% CI, 0.92-0.98).Conclusion: Measuring RFM thickness using ultrasonography is a feasible and reliable screening test for sarcopenia, and the cut-off values of <1.1 cm for male and <1 cm for female showed the highest accuracy for confirming low ASM in the Thai population.

Background The Bangkok falls study aimed to identify fall-associated factors, including home healthcare hazards, nutritional status, hydration status, sarcopenia, frailty, locomotive syndrome, and health status of urban older adults in a middle-income country. Methods This was a population-based cohort study that enrolled adults who lived in Bangkok, Thailand. Our study recruited older adults aged ≥ 60 years old, able to walk, and expected to live in the community for at least 2 years. The study had three phases included; phase 1: subject identification and terminology clarification. Phase 2: we collected data at community sites on baseline characteristic and fall risk identification. Examinations and laboratory investigations were scheduled for one month later. Phase 3: telephone follow up for falls rate, functional status and death at 3, 6, 12 months. Results A total 1,001(51.84%) people were enrolled for our study. The average age of our study was 69.9 years old (SD, 6.8), and two-thirds were female. Using “Stopping Elderly Accidents, Death and Injuries” (STEADI) screening fall risk, our study found that 37.7% had scores ≥ 4, which means that there is a risk of fall. In addition, the risk of falls increased among older adults aged 75–84 years (49.5%) and older adults aged ≥ 85 years (67.7%) ( P -value < 0.001). Conclusion This study demonstrated the feasibility of conducting a population-based cohort study among urban older adults in a middle-income country using the local community healthcare system. Our study have a tendency to provide data source for fall risk factors and disability in older adults.

AimThe prevalence of hypertonic dehydration (HD) among community‐dwelling and hospitalized populations has been evaluated. However, to our knowledge, no study had previously focused on older patients admitted to the emergency department (ED). The present study aimed to evaluate the prevalence, risk factors and short‐term outcomes of HD among Thai older patients admitted to the ED.MethodsThis was a prospective cross‐sectional study at one urban ED in Thailand. Patients aged ≥65 years who were admitted to the ED were enrolled into the study. Data including clinical hydration status, Charlson Comorbidity Index (CCI) score, activities of daily living score, current use of medications, laboratory examination results and serum osmolarity level were collected. HD was defined as a serum osmolarity level of >300 mOsm/kg. The short‐term outcomes were a 30‐day ED revisit, hospital readmission and mortality rates.ResultsIn total, 80 (21.6%) of 370 patients presented with HD. A CCI score of ≥5 was found associated with HD among older patients (adjusted odds ratio: 1.82; 95% confidence interval: 1.03–3.21). The ED revisit rates were 18.1% in the dehydrated group and 10.9% in the non‐dehydrated group. The hospital readmission rates were 8.3% in the dehydrated group and 10.6% in the non‐dehydrated group. Furthermore, the 30‐day mortality rates were 6.9% and 5.3% in the dehydrated and non‐dehydrated groups, respectively.ConclusionsOne‐fifth of older patients admitted to the ED presented with HD. A CCI score of ≥5 was considered a risk factor of HD. Moreover, further studies should focus on the long‐term outcomes of HD and risk reduction. Geriatr Gerontol Int 2021; 21: 485–491.

Introduction: Point-of-care ultrasonography (POCUS) is increasingly utilized in emergency departments (EDs) throughout Thailand.Although emergency medicine (EM) residents are trained in POCUS, Thai medical students receive limited training.An introductory POCUS course was implemented for medical students to prepare them for internships.Objective: This study described the perception and use of POCUS by graduates of an introductory POCUS course.Materials and Methods: Medical students who completed the POCUS course were surveyed during their intern year from 2012 to 2015.The survey collected demographic characteristics.The Likert Scale was used to assess POCUS practice patterns and perceptions of the course.Results: There were 230 respondents (98% response rate).All thought that POCUS was important.Furthermore, 96% of respondents felt that the POCUS course meaningfully impacted their ability to deliver care.POCUS use was greatest for obstetrics/gynecology and trauma cases.Over half of respondents (55.2%) felt very confident with using extended-Focused Assessment with Sonography in Trauma.Most respondents (81.8%) were positively impacted by the course, and 61.7% were satisfied with the scope of the course.Recommendations for improvement included increasing the course length, the content, and the hands-on time for POCUS practice. Conclusion:Graduates positively perceived the course and felt it dramatically impacted their clinical practice as novice physicians.An introductory POCUS course should be incorporated into the medical school curriculum to prepare graduates for practice.Future goals include increasing the scope of POCUS practice to help guide interns and residents in emergency patient care such as lung ultrasound in COVID-19 or pneumonia patients and studying the impact this course has on patient outcomes.

A 33-year-old man presented with a 4-day history of acute diarrhea and fever. His physical examination revealed tachycardia, tenderness over the right upper abdomen, and petechial rash along the extremities. A complete blood count (CBC) demonstrated a WBC count of 4.97×103/mm3 and platelet count of 14×103/mm3. Liver function test results showed mild elevations of aspartate and alanine aminotransferases (367 IU/L and 126 IU/L, respectively), with albumin level of 3.6 mg/dL. Point-of-care abdominal ultrasonography showed a reticular and thickened gallbladder wall (Figures 1 and 2). Bilateral pleural effusion and ascites were also detected.Figure 2Sagittal view of the gallbladder. Note the multiple hypoechoic layers and heterogeneous wall appearance.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Severe dengue fever (so-called dengue hemorrhagic fever). Dengue NS1 antigen result was positive. He made a full recovery after 5 days of hospitalization and supportive care. Thickened and reticular gallbladder wall is found in the majority of dengue hemorrhagic fever cases. In the leakage phase, plasma leaks in between gallbladder wall collagen fibers and becomes visible on ultrasonographic imaging as a reticular pattern.1Oliveira G.A. Machado R.C. Horvat J.V. et al.Transient reticular gallbladder wall thickening in severe dengue fever: a reliable sign of plasma leakage.Pediatr Radiol. 2010; 40: 270-274Crossref Scopus (15) Google Scholar Leakage also manifests as ascites and pleural effusion, and the presence of these signs can be associated with more severe disease of dengue fever.2Colbert J.A. Gordon A. Roxelin R. et al.Ultrasound measurement of gallbladder wall thickening as a diagnostic test and prognostic indicator for severe dengue in pediatric patients.Pediatr Infect Dis J. 2007; 26: 850-852Crossref PubMed Scopus (54) Google Scholar,3Michels M. Sumardi U. de Mast Q. et al.The predictive value of serial daily bedside ultrasonography for severe dengue in Indonesian adults.PLoS Negl Trop Dis. 2013; 13: e2277Crossref Scopus (32) Google Scholar

Background: Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury. Objective: We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia. Case report: A 20-year-old man presented with bilateral lower extremity weakness and numbness 3 h prior to presentation. 3 days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flowor AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma. Conclusion: Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome. (C) 2019 Elsevier Inc. All rights reserved.

This study aimed to determine the prevalence of infectious diseases and risk factors for one-year mortality in elderly emergency department (ED) patients. A retrospective cohort study of patients aged 65 and over who visited the ED of one urban teaching hospital in Bangkok, Thailand and who were diagnosed with infectious diseases between 1 January 2016 and 30 June 2016. There were 463 elderly patients who visited ED with infectious diseases, accounting for 14.5% (463/3,196) of all elderly patients’ visits. The most common diseases diagnosed by emergency physicians (EPs) were pneumonia [151 (32.6%) patients] followed by pyelonephritis [107 (23.1%) patients] and intestinal infection [53 (11.4%) patients]. Moreover, 286 (61.8%) patients were admitted during the study period. The in-hospital mortality rate was 22.7%. 181 (39.1%) patients died within 1 year. Our multivariate analysis showed that age 85 years and older [odds ratio (OR) = 1.89; 95% confidence interval (CI): 1.36–2.63], Charlson Co-morbidity Index score ≥ 5 (OR = 3.51; 95% CI2.14–5.77), lactate ≥4 mmol/l (OR = 2.66;95% CI 1.32–5.38), quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2 (OR = 5.46; 95% CI 2.94–10.12), and platelet count < 100,000 cells/mm3 (OR = 3.19; 95% CI 1.15–8.83) were associated with 1-year mortality. In one middle-income country, infectious diseases account for 14.5% of elderly ED patients. Almost two-thirds of patients presenting to ED with infection are admitted to hospital. One-third of elderly ED patients with infection died within 1 year. Age ≥ 85 years, Charlson Co-morbidity Index score ≥ 5, lactate ≥4 mmol/l, qSOFA score ≥ 2, and platelet count < 100,000 cells/mm3 predicted 1-year mortality rate.

Background In disaster situations, the elderly are considered to be a particularly vulnerable population. Preparedness is the key to reduce post-disaster damage. There is limited research in middle-income countries on how well elderly emergency department (ED) patients are prepared for disaster situations. The objective of this study was to determine the attitudes and behavior of elderly ED patients toward disaster preparedness. Methods This study was a cross-sectional face-to-face survey at one urban teaching hospital in Bangkok, Thailand between August 1st and September 30th, 2016. Patients aged 60 and older who presented to the ED were included to this study. We excluded patients who had severe dementia [defined as Short Portable Mental State Questionnaires (SPMSQ) > 8], were unable to speak Thai, had severe trauma and/or needed immediate resuscitation. The survey instruction was adapted from previous disaster surveys. This study was approved by the Vajira Institutional Review Board (IRB). Results A total of 243 patients were enrolled. Most of them were female [154 patients (63.4%)]. The median age was 72 [Interquartile range (IQR) 66-81] years and the most common underlying diseases were hypertension [148 patients (60.9%)] and diabetes [108 patients (44.4%)]. The majority of patients [172 patients (72.4%)] reported that they had had some teaching about disaster knowledge from a healthcare provider and had experienced a disaster [138 patients (56.8%)]. While 175/197 (81.8%) patients who had underlying diseases reported that they had a medication supply for disaster situations, only 61 (25.1%) patients had an emergency toolbox for disasters. Most patients (159, 65.4%) did not know the emergency telephone number, and 133 (54.7%) patients reported transportation limitations. Conclusions While most Thai elderly ED patients reported having a medication supply for disaster situations, many lacked comprehensive plans for a disaster situation. Work needs to be done to improve the quality of preparedness in disaster situations among elderly patients. Future research should focus on preparedness knowledge regarding evacuation, and shelter/residence for older patients.

BACKGROUND:We sought to determine the prevalence of delirium in a Thai emergency department (ED). The secondary objective was to identify risk factors and short-term outcomes in delirious elderly ED patients.METHODS:This was a prospective cross-sectional study in the ED of an urban tertiary care hospital. Patients aged ≥65 years who presented to the ED were included. We excluded patients who had severe dementia, were not responsive to verbal stimuli, had severe trauma and were blind, deaf, aphasic or unable to speak Thai. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit. We collected 30-day mortality rate, hospital length of stay and revisit rate as short-term outcomes.RESULTS:We had a final sample size of 232 patients; 27 (12%) were delirious in the ED, of which 16 (59%) were not recognised to be delirious by the emergency physician. Multivariable logistic regression analysis showed dementia (adjusted OR (AOR) 13.1; 95% CI 2.9 to 59.6), auditory impairment (AOR 4.8; 95% CI 1.6 to 13.8) and ED diagnosis of metabolic derangement (AOR 6.5; 95% CI 1.6 to 26.8) were associated with delirium in the ED. Delirium was associated with a higher mortality rate than those without delirium (15% vs 2%, p=0.004).CONCLUSIONS:In one middle-income country, elderly ED patients were delirious >10% of the time. Delirium was underdiagnosed and was associated with an increased 30-day mortality rate. Delirium screening needs to be improved, potentially focusing on high-risk patients.