Profile of Medico-legal Cases Coming to Emergency ward of B. P. Koirala Institute of Health Sciences

Background: Medico-legal case usually presents as an emergency case in any hospital. Profiling of these cases provides with evidence on the burden of the medico-legal cases and identifying ways to better manage these cases in the emergency ward of hospitals. Objective: To study the profile of medico-legal cases coming to the emergency ward of B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. Material & Methods: We conducted a retrospective review of all medico-legal cases presenting in the emergency ward of BPKIHS from April 2015 to March 2016. The cases were profiled for socio-demography, injury and diagnosis from the medico-legal register at the emergency ward of BPKIHS. Results: Medico-legal cases comprise almost 10% of all cases at the emergency ward of BPKIHS. A total of 3,715 cases were included in this study. Half (50.0%) of the cases fell in to the category of 25-59 years. Males were almost twice (62.7%) in number, compared to females (37.3%). The top three diagnoses among medico-legal cases are road traffic accidents (41.81%), physical assault (21.13%) and poisoning (20.08%). Other diagnoses were burns, fall injury, sexual assault, self inflicted injury, hanging, gunshot injury, stab injury, machinery injury, drug overdose, blast injury, brought dead, trauma by animal, electrical injury, snake bite and human bite. Conclusions: There are significant numbers and wide varieties of medico-legal cases that present in the emergency ward of BPKIHS. Given the large number of cases presenting at BPKIHS, there is a potential for future research on medico-legal cases for academic and policy purpose.

Abstract 108: Pulselessness Despite Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children: Prevalence, Predictors of Survival, and Implications for Hospital Profiling

Background: Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, it is unknown how often these children progress to pulseless in-hospital cardiac arrest (IHCA) despite CPR, and whether survival differs from primary pulseless IHCA. Methods: In Get With The Guidelines-Resuscitation (2000-2016), we identified all pediatric patients (age>30 days, <18 years) receiving CPR, and assessed the prevalence and predictors of survival among those progressing from bradycardia to pulselessness after initiation of CPR using multilevel Poisson regression that accounted for the pulseless rhythm. Results: Overall, 5592 pediatric patients were treated with CPR, of whom over half (2799) were for bradycardia with poor perfusion and the remaining 2793 were primary pulseless IHCAs. Among those with bradycardia, 869 (31%, or 16% of entire cohort) progressed to pulselessness after a median of 3 min of CPR (IQR 1- 9). Survival to discharge was 70% for bradycardia without pulselessness, 30% with bradycardia progressing to pulselessness, and 38% with primary pulseless IHCA (P<.001). Children who became pulseless while receiving CPR for bradycardia had a 19% lower likelihood (RR 0.81 [0.70 - 0.93]) of surviving to hospital discharge than those initially pulseless. Among children who progressed to pulselessness while receiving CPR for bradycardia, longer time to pulselessness was an independent predictor of lower survival (ref: <2 min, for 2-5 min: RR 0.54 [0.41 - 0.70]; for >5 min: RR 0.41 [0.32 - 0.53], Figure ). Conclusions: Among non-neonatal pediatric patients in whom CPR is initiated, half have bradycardia with poor perfusion, and nearly one-third of these progress to IHCA despite CPR. Survival was lower for pediatric patients who subsequently became pulseless as compared to those who were initially pulseless. These findings have implications for care delivery and profiling hospital performance for pediatric IHCA.

Abstract TMP61: Outcomes After Ischemic Stroke Among “America’s Best Hospitals”

Background: The ranking of “America’s Best Hospitals” by the US News & World Report is a popular hospital-profiling system, but it is not known whether the 50 top hospitals for Neurology and Neurosurgery have lower 30-day risk-standardized mortality (RSMR) and readmission rates (RSRRs) after stroke compared with other hospitals, or whether outcomes are comparable among these 50 top hospitals. Methods: The 50 top hospitals for adult Neurology and Neurosurgery were identified from the 2015-16 US News & World Report rankings. CMS Hospital Compare provided RSMRs and RSRRs within 30 days of ischemic stroke for hospitals with ≥25 stroke cases/year. We fit a mixed model to assess differences in RSMRs and RSRRs between top-ranked vs other hospitals, adjusted for hospital characteristics and weighted by hospital volume. Among the 50 top-ranked hospitals, we explored whether ranking order was associated with outcomes. Results: Among 2718 hospitals, the 50 top-ranked vs other hospitals had lower mean 30-day mortality (RSMR 14.8% vs 15.3%, p<.01) but higher readmission (RSRR 14.5% vs 13.4%, p<.01). These patterns persisted in adjusted analyses; top hospitals had lower mortality by 0.98% (95% CI -1.36%, -0.60%) and higher readmission by 0.66% (0.41%, 0.92%). Among top hospitals, there was considerable variability in risk-standardized outcomes, ranging from 9.5-19.3% for mortality and 10.8-17.5% for readmission. RSMRs were lower than the national average for 14% of top hospitals while RSRRs were lower for only 2% and higher for 14% (figure). Hospital rank was not significantly associated with either mortality (RSMR 0.04% increase with each rank, 95% CI 0.0%, 0.08%) or readmission (RSRR -0.01%; 95% CI -0.04%, 0.02%) among the 50 top-ranked hospitals. Conclusions: Admission to a top-ranked hospital for Neurology or Neurosurgery was associated with lower 30-day risk-standardized mortality but higher readmission. There was considerable heterogeneity among the top 50 hospitals.