Bader Alyahya

Introduction: Emergency department (ED) revisits are considered a significant indicator of the quality of care provided and are used as a benchmark for the performance of individual providers and institutions. The aim of this study is to assess ED revisit rates, reasons, and hospital admission rates among our adult ED patients. Methods: This is a retrospective chart review study conducted in a single‐center tertiary referral hospital in Riyadh, Saudi Arabia. Study participants comprised adult patients who attended the ED, had been discharged, and had an ED revisit within 72 h from April 2019 to January 2020. Results: A total of 573 patients met our inclusion criteria, of whom 53.1% were males. The majority of the patients (74.5%) revisiting the ED were categorized as CTAS Level 3, with gastrointestinal complaints being the most common presentation for revisits (23.6%). During the second visit, 94%, 4%, 0.7%, and 0.3% of the participants were discharged, admitted, discharged against medical advice, and died, respectively. Disease progression was the most common cause of revisits at 96.5%. The factors that showed statistically significant associations with nondischarge disposition in the second visit were CTAS levels in the first and second visits, dementia, functional dependency, and reason for the revisit. Conclusion: Most ED visits within 72 h are due to disease progression rather than system‐ or physician‐related issues, and the majority of these patients are safely discharged after the second visit. Identification of high‐risk patients—such as those with higher CTAS levels, dementia, or functional dependency—may aid emergency physicians in implementing targeted discharge planning and coordinated outpatient follow‐up to reduce unnecessary revisits and optimize use of emergency services. Our findings highlight the importance of structured post–discharge support and underscore the need for tailored interventions in resource‐limited healthcare settings.

Background and Objectives. Blood tests are often indiscriminately requested in the Emergency department (ED) and many EDs have preset orders that are usually performed at triage before clinical assessment to improve the flow of patients through the department. We conducted this study to evaluate the frequency of requests for coagulation profile, the incidence of abnormal coagulation profiles and the unnecessary use of coagulation profile testing in our institution. Methods. This retrospective observational study, conducted in the ED of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, during July and August of 2021(2months) examined coagulation profile requests. Patients demographic data (age and gender), medical and clinical history (presenting complaint, comorbidities, and diagnosis), the use of antiplatelets or anticoagulant agents and laboratory values for PT, APTT, and INR were collected. We calculated the total cost of unnecessary coagulation profile testing based on the independent assessment of two ED consultants. Results. Of 1,754 patients included in the study, 811 (46.2) were males and 943 (53.8) were females, with a mean age of 42.1±18.5years. There were 29 (1.7) patients with liver disease and 21 (1.2) patients had thromboembolic disease. The majority of the patients results were within normal levels of PT (n=1,409, 80.3), APTT (n=1,262, 71.9), and INR (n=1,711, 97.4). Evidence of active bleeding was detected in 29 patients (1.7). Among patients with bleeding only one had an abnormal INR (3.01) and was on warfarin. Forty-six (2.6) patients had elevated INR level. Cohens kappa between the two consultants was recorded at 0.681 (substantial agreement) in their assessment of the appropriateness of coagulation tests requests and both consultants believed that 1,051 tests (59.9) were not indicated and were unnecessary. The expected annual cost saving if the unnecessary tests were removed would be around SAR 1,897,200 (approximately US$ 503,232) which is about SAR 180000 (US$ 48000)/1000 patients. Conclusion. This study showed that coagulation tests are overused in the ED. More than half of coagulation profile tests in our study population were deemed unnecessary and associated with significant cost. Targeted testing based on specific patient presentation and medical history can guide physicians in wisely choosing who needs coagulation studies.

Background: Acetaminophen overdose is a common clinical condition, often leading to liver toxicity. Current treatments involve the three-infusion N-Acetylcysteine (NAC) regimen (FDA-labeled), which may be complex, time-consuming, and need to be changed. An alternative uses two infusions instead, which offers possible advantages regarding simplicity and administration errors. This study sought to compare the respective efficacies and safety outcomes when treating acute acetaminophen overdose among children and adolescents. Methods: At Montreal Children’s Hospital, a retrospective study was conducted comparing pre-2003 FDA-labelled three-infusion NAC therapy with a two-infusion regimen. Information was collected regarding patient demographics, NAC administration details, errors, rates of hepatotoxicity, and adverse reactions, and the statistical test Chi-square test was employed to obtain the results. Results: A total of 126 patients met the inclusion criteria. Of these patients, 65 received a two-infusion regimen, and 61 patients received the FDA-labeled regimen. The two-infusion group experienced significantly fewer administration errors (4 errors vs. 23 errors; p < 0.001), while the rates of hepatotoxicity between them were similar. There were no instances of liver transplantation or mortality due to either regimen. Adverse reactions occurred equally frequently between both regimens with no discernible difference—the meantime to administer NAC was 9 h for the two-infusion regimen and 8.5 h for FDA-labeled regimen groups, respectively. Three cases of hepatitis were successfully treated with timely NAC therapy, and no liver transplantation or mortality occurred. Adverse reactions, including anaphylactoid reactions, were observed in both groups but were resolved when temporarily stopped and restarted at a slower infusion rate. Conclusions: The two-infusion NAC regimen proved similar efficacy at protecting liver damage and improving patient outcomes compared to its FDA-labeled three-stage counterpart, with significantly fewer administration errors for this version of NAC treatment, suggesting potential advantages in terms of safety and simplicity. Future research should investigate larger cohorts and more variables to validate these results further and optimize the management of acetaminophen overdose cases; further investigation should focus on dosing strategies, personalized approaches, and long-term patient care in this context.

Background. The simultaneous measurement of serum amylase and lipase levels in the diagnosis of pancreatitis was deemed unnecessary in several studies. We aim at evaluating the prevalence of the simultaneous co-ordering of serum amylase and lipase. Methods. This retrospective chart review was conducted at King Saud University Medical City in Riyadh, Saudi Arabia, between January 2021 and January 2022. We examined requests for serum amylase or serum lipase levels that had been sought for suspected pancreatitis within the electronic health system (EHS). Results. A total of 9,617 requests for serum amylase and serum lipase levels for 5,536 patients were made in a year; 6,873 (71.5) were made for serum lipase alone; 1,672 (17.4) were made for co-ordered serum lipase and amylase; 322 (3.3) were made for amylase alone; and 750 (7.8) were made for repeated amylase testing. Four hundred and thirteen tests (4.3) yielded a diagnosis of pancreatitis. The estimated cost reduction when serum amylase was removed if serum lipase was co-ordered was 108,680 SAR (approximately US$28,960). Conclusion. Serum amylase and lipase were co-ordered for about 17.4 of pancreatitis diagnostic tests, all of which were unnecessary. Eliminating serum amylase testing for any patient who receives a test of their lipase levels would exert a significant impact on institutional costs and savings.

PURPOSE: The purpose of this study is to evaluate the visual response of methanol-induced optic neuropathy to management with erythropoietin (EPO) along with conventional therapy. METHODS: This retrospective case series examines the ophthalmological data of patients diagnosed with methanol-induced optic neuropathy between 2020 and 2021 at two centers, Riyadh, Saudi Arabia. Patients’ characteristics and the results of initial and final ophthalmological examinations were documented and compared between patients who received EPO in addition to conventional management and those who received only conventional management. RESULTS: A total of nine cases were reviewed, of which eight (88.9%) were males and one was female (11.1%). The mean age was 37.7 years. At presentation, funduscopic examination revealed optic disc edema in four eyes (two patients), and 14 eyes had normal appearance (seven patients). Among the nine patients who received conventional management, 5 (55.6%) additionally received intravenous EPO during the treatment course. There was no clinically or statistically significant difference in terms of visual outcome between the two groups. The mean visual acuity at the final presentation was 1.32 ± 0.79 logarithm of the minimum angle of resolution (LogMAR) in the EPO group and 1.36 ± 0.85 LogMAR in the non-EPO group. Optical coherence tomography indicated that the EPO group had an average retinal nerve fiber layer thickness of 48.13μm (±6.2), at the final assessment. CONCLUSION: Managing the visual impairments in individuals with methanol-induced optic neuropathy using intravenous EPO resulted in similar final visual outcomes compared to conventional management.

Purpose: To assess the views of emergency medicine physicians (EMPs) on the practice of providing unnecessary medical management in the emergency department. Methods: All EMPs in Saudi Arabia were approached to participate in this cross-sectional study. A self-administered online survey that collected the participants’ demographic information and opinions regarding the unnecessary management provided by EMPs in Saudi Arabia was conducted between December 2020 and February 2021. SPSS 22.0 was used to analyze the data. Results: A total of 181 EMPs returned the questionnaire. More than 80% of the participants believed that EMPs order unnecessary tests or procedures at least a few times per week. The major reasons for ordering unnecessary medical tests or procedures were “concern about malpractice issues” (60.8%), “not having enough time with a patient for meaningful discussion” (47%), and “just to be safe” (46.4%). More than 55% of the respondents also believed that EMPs are in the best position to address the problem of unnecessary testing. Conclusion: Most of the EMPs who participated in this study recognized that ordering unnecessary tests is a serious problem that happens on a daily basis. Many factors and reasons were described by the participants, and multiple possible solutions were suggested to help overcome the issue. Evaluating physicians’ perspectives on the issue is a key step in addressing the problem and implementing appropriate interventions.

Introduction Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. Methods and analysis PASSEM study is an international prospective external validation cohort study. For 9 months, each participating centre will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalisation. We will collect patients’ demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., >72 hours), and 30-as well as 90-days all-cause mortality. The study started in December 2021 and planned to enrol 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. Ethics and dissemination The Aseer Regional Committee for Research Ethics in the General Directorate of Health Affairs-Aseer Region has approved this study. Informed consent is not required for this study due to its complete observational nature and absence of interventions or invasive procedures. We will publish study’s results in peer-reviewed journals and may present them at scientific conferences. Study registration number ClinicalTrials.gov identifier: NCT05172479

Purpose: This study aimed to investigate the perceptions and habits of different emergency department (ED) workers (nurses, residents, and attending physicians) and their pre- or post-shift routines. The study also examined the effect of night shifts on personal life, social life, and health. Patients and Methods: An anonymous, online, cross-sectional, multiple-choice, self-rating (5-point Likert scale) survey was administered to the participants. All analyses were performed using the SPSS version 22.0. Ethical approval was obtained from the Institutional Review Board (IRB) of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. Results: Thirty-three nurses, 51 residents, and 39 attending physicians participated in the survey (response rates of 21%, 100%, and 100%, respectively). A significant difference was noted in the need to use physical sleeping aids between the three groups (P < 0.003), with more nurses using humidifiers as a sleeping aid (21.2%) than residents or attending physicians. However, there was no difference in the use of pharmacological aids between the three groups. All groups utilized coffee as the preferred stimulant, especially residents (76.5%, P < 0.032). Nurses and attending physicians wake up 2 hours before their shift, while residents prefer 3 hours (P < 0.001). Attending physicians reported the highest accident rates post-night shifts of 17.9% (P < 0.001). Residents reported satisfaction while working night shifts and were least in agreement with night shifts reducing life span. Attending physicians were more in agreement with the increasing risk of drug/alcohol misuse and the incidence of depression in relation to night shifts. Conclusion: Participants shared many commonalities, yet residents were less likely to use sleeping aids and enjoy night shifts more than the other groups. All groups consumed coffee for stimulation. Attending physicians reported the highest accident rates post night shifts.

Background: Tizanidine, an α-2 adrenoceptor agonist, is widely prescribed for the management of spasticity in adults. Case reports on pediatric tizanidine overdose are limited. Here, we report a case of pediatric tizanidine toxicity that was reversed with naloxone. Case presentation: A 3-year-old male presented to the emergency department with lethargy, bradycardia, and bradypnea after accidental ingestion of multiple tizanidine tablets. Improvements in the level of consciousness and respiratory and heart rates were observed after two intravenous administrations of naloxone at a dose of 0.05 and 0.1 mg/kg, respectively. Conclusions: This case report provides further evidence regarding the use of naloxone as a viable antidote for centrally acting α-2 receptor agonists and presents additional epidemiologic data on childhood tizanidine poisoning.