With the increased demand of critical care, emergency physicians often provide a significant proportion of critical care for the critically ill patients apart from their primary roles in resuscitation and initial stabilisation. The dual training pathway of emergency medicine and intensive care medicine enables the Accident and Emergency Departments (AEDs) to be staffed with emergency intensivist to provide care of critically ill patients in the AEDs beyond the initial resuscitation. North Lantau Hospital is a community hospital located in central Tung Chung of Lantau Island. Transporting critically ill patients to the nearest tertiary hospital requires a significant amount of time which poses high risk to them. An “Emergency Critical Care Management” pilot program was created under these circumstances. In this pilot program, up to 2 beds in the Emergency Medicine Ward (EMW) are used for managing critically ill patients. The experience and preliminary outcomes of implementing critical care service in the EMW are shared in this article.

Background: Bloodstream infection is a life-threatening clinical condition posing significant morbidities and mortalities. An “Emergency Critical Care Management Program” has been implemented in the Emergency Medicine Ward at North Lantau Hospital as a pilot critical care service model in the local emergency medicine wards. Patients with blood stream infection are recruited in the program and managed under pre-defined guideline. Objectives: We report our experience in managing patients with blood stream infection in the Emergency Medicine Ward and analyzed their clinical outcomes. Methods: This was a retrospective cohort study including a total of 64 patients with blood stream infection admitted to the Emergency Medicine Ward from 1 March 2015 and 31 March 2018. Patients’ characteristics, microbiology, and risk factors associated with adverse outcomes including in-hospital mortality were analyzed. Results: The most common organism isolated from blood cultures was Escherichia coli (56%). Eight patients were transferred to the tertiary hospital. The overall in-hospital mortality was 7.8% (5/64). From the univariate analysis, advanced age (p < 0.001), higher Sequential Organ Failure Assessment score and quick Sequential Organ Failure Assessment score (p < 0.001), higher Charlson Comorbidity Index (p = 0.003), more organ dysfunction (p < 0.001), pre-existing medical history of chronic liver disease (p = 0.001), dysfunction in respiratory system (p = 0.032), cardiovascular system (p = 0.044) and the central nervous system (p < 0.001), presence of septic shock (p = 0.004), and need for higher level of organ support from the use of inotropes (p < 0.001) and mechanical ventilation (p = 0.024) were associated with in-hospital mortality. In the subgroup analysis, the in-hospital mortality rate for the patients with Sequential Organ Failure Assessment score less than 6 was 1.56% (1/64). Among the five in-hospital mortality cases, four of them were managed in the Emergency Medicine Ward under the End-of-Life Care Program. Decision for withholding and withdrawing life-sustaining therapy was made with the patients’ families. Conclusion: This preliminary report demonstrated that with careful patient selection, adoption of guidelines, and availability of expertise, critical care service can be safely implemented in the emergency medicine ward.

Background: Traveller patients have distinctive clinical characteristics compared to non-traveller patients. Local information about the clinical features of traveller patients is lacking. Objectives: The objective of this study is to evaluate the clinical characteristics of traveller patients presenting to a hospital near the Hong Kong International Airport. Methods: This was a single-centred, retrospective cohort study. Medical records of all traveller patients presenting to the Accident and Emergency Department of North Lantau Hospital in Hong Kong from 1 January 2019 to 31 December 2019 were reviewed. The demographics, triage category, presentation, outcomes and disposal were retrospectively evaluated and compared between traveller and non-traveller patients. Results: There were 528 traveller patients attending the Accident and Emergency Department of North Lantau Hospital during the study period, constituting 0.6% of total annual attendance. About one-third of the traveller patients required admission. The most common discharge diagnoses were gastrointestinal diseases (14.8%), followed by trauma (12.9%) and other neurological diseases (12.9%). Traveller patients had a higher rate of being triaged as critical and emergency categories (p < 0.001), higher admission rate (p < 0.001), higher need for active resuscitation (p < 0.001) and escort (p < 0.001) when compared to non-traveller patients. Around 1.3% of traveller patients presented with out-of-hospital cardiac arrest and were eventually certified dead in Accident and Emergency Department. Conclusion: The traveller population constitutes a small proportion of the patient population, but they can have a significant impact on the Accident and Emergency Departments in high-impact traveller areas. Additional resources such as manpower support and training programmes would be beneficial for Accident and Emergency Departments in high-impact traveller areas.

Background: Sepsis and septic shock are common causes of hospital admission, morbidity, and mortality, posing a significant burden on the health-care systems. Objective: The objective of this study was to report the clinical experience of management and outcomes of sepsis patients in the emergency medical ward of a community hospital. The risk factors associated with adverse outcomes of sepsis patients were also analyzed. Methods: This was a retrospective cohort study of patients with sepsis or septic shock managed in the emergency medical ward of North Lantau Hospital from 1 March 2015 to 31 March 2017. Their characteristics, clinical outcomes, risk factors associated with in-hospital mortality, 28-day mortality, and prolonged hospital stay (>14 days) were analyzed. Results: A total of 68 eligible patients met the inclusion criteria during the study period. The mean age of the patients was 73 (standard deviation, 16.7; range, 34-100) years. The mean Sequential Organ Failure Assessment score of all the cases was 4.5 (standard deviation, 2.4); range, 2-11). The most common source of infection was pneumonia (50%). During the stay in the emergency medical ward, 35 cases (49%) required vasopressor support for management of septic shock, and 12 cases required non-invasive ventilation (NIV) support. Five patients were eventually transferred to tertiary hospital (Princess Margaret Hospital) for further management. There were five in-hospital mortality cases and two 28-day mortality cases. From the univariate analysis, factors associated with in-hospital mortality included Sequential Organ Failure Assessment score >6 (p < 0.000), increasing number of organ dysfunction (p < 0.000), presence of chronic liver disease (p = 0.025), respiratory dysfunction during admission (p = 0.028); factors associated with 28-day mortality were advanced age (p < 0.000), increasing number of organ dysfunction (p = 0.033), presence of congestive heart failure (p = 0.004), and the presence of cancer (p = 0.034); factors associated with prolonged hospital stay were advanced age, presence of chronic obstructive airway disease (p = 0.003), advanced age (p = 0.041), and the use of NIV support (p = 0.001). In multivariate analysis, weak associations between in-hospital mortality and Sequential Organ Failure Assessment score >6 (p = 0.226) and increased number of organ dysfunction (p = 0.108) were demonstrated; there was a trend of prolonged length of stay with increased age (p = 0.139). Conclusion: Our experience and knowledge in managing sepsis patients in the emergency medical ward with implementation of critical care bed services increased significantly. These preliminary results demonstrated that, with appropriate patient selection, sepsis patients can be safely managed in the emergency medical ward. Further study with larger sample size is needed to identify risk factors of adverse outcomes in this group of patients managed in the emergency medical ward.