Assessment of health literacy in a French emergency department.

BACKGROUND: Health literacy (HL) has become a subject of major interest in public health worldwide. It is known to be linked to self-efficacy in care use and to global health status, and a non-negligible frequency of problematic or inadequate levels of HL in populations worldwide is reported. As this has yet to be evaluated in France, the present study aimed to evaluate the HL level of patients in a French emergency department (ED). METHODS: We conducted a descriptive, cross-sectional observational, single center study in the ED of the Lyon Sud hospital (Hospices civils de Lyon, Lyon, France). The primary endpoint was the HL level of the patients determined according to the score obtained using the 16-item European Health Literacy Survey Questionnaire. The secondary endpoint was the identification of sociodemographic factors associated with the HL level. RESULTS: A total of 189 patients were included for analysis. 10% (95% CI [3%; 17%]) of the patients had an inadequate HL, 38% (95% CI [31%; 45%]) had a problematic HL, and 53% (95% CI [46%; 61%] had an adequate HL. In multivariate analysis, age and perceived health status were independent predictors of the HL level; OR =0.82 (95% CI [0.69; 0.97]; p=0.026) for a 10-year increase in age, and OR =1.84 (95% CI [1.22; 2.82]; p=0.004]). CONCLUSIONS: The HL level of the patients in the ED studied herein was similar to that found in the population of France and other European countries and was influenced by age and perceived health status, which are both associated with care needs. It may be therefore interesting to explore in future studies how taking into consideration HL in the general population may lead to a better self-efficacy in care and optimize the use of the healthcare system.

Impact of the presence of a mediator on patient violent or uncivil behaviours in emergency departments: a cluster randomised crossover trial.

BACKGROUND AND IMPORTANCE: Several studies reported that violent behaviours were committed by patients against healthcare professionals in emergency departments (EDs). The presence of mediators could prevent or resolve situations of tension. OBJECTIVE: To evaluate whether the presence of mediators in EDs would have an impact on violent behaviours committed by patients or their relatives against healthcare professionals. Design, settings and participants A 6-period cluster randomised crossover trial was performed in 4 EDs during 12 months. Patients aged ≥18 and their relatives were included. INTERVENTION: In order to prevent or resolve situations of tension and conflict, four mediators were recruited.Outcome measure and analysis Using a logistic regression mixed model, the rate of ED visits in which at least one act of violence was committed by a patient or their relatives, reported by healthcare professionals, was compared between the intervention group and the control group. RESULTS: A total of 50 429 ED visits were performed in the mediator intervention group and 50 851 in the control group. The mediators reported 1365 interventions; >50% of the interventions were to answer questions about clinical management or waiting time. In the intervention group, 173 acts of violence were committed during 129 ED visits, and there were 145 acts of violence committed during 106 ED visits in the control group. The rate of ED visits in which at least one act of violence was committed, was 0.26% in the intervention group and 0.21% in the control group (OR = 1.23; 95% CI [0.73-2.09]); on a 4-level seriousness scale, 41.6% of the acts of violence were rated level-1 (acts of incivility or rudeness) in the intervention group and 40.0% in the control group. CONCLUSION: The presence of mediators in the ED was not associated with a reduction in violent or uncivil behaviours committed by patients or their relatives. However, the study highlighted that patients had a major need for information regarding their care; improving communication between patients and healthcare professionals might reduce the violence in EDs. TRIAL REGISTRATION: Clinicaltrials.gov (NCT03139110).

Assessing respiratory epidemic potential in French hospitals through collection of close contact data (April-June 2020).

The transmission risk of SARS-CoV-2 within hospitals can exceed that in the general community because of more frequent close proximity interactions (CPIs). However, epidemic risk across wards is still poorly described. We measured CPIs directly using wearable sensors given to all present in a clinical ward over a 36-h period, across 15 wards in three hospitals in April-June 2020. Data were collected from 2114 participants and combined with a simple transmission model describing the arrival of a single index case to the ward to estimate the risk of an outbreak. Estimated epidemic risk ranged four-fold, from 0.12 secondary infections per day in an adult emergency to 0.49 per day in general paediatrics. The risk presented by an index case in a patient varied 20-fold across wards. Using simulation, we assessed the potential impact on outbreak risk of targeting the most connected individuals for prevention. We found that targeting those with the highest cumulative contact hours was most impactful (20% reduction for 5% of the population targeted), and on average resources were better spent targeting patients. This study reveals patterns of interactions between individuals in hospital during a pandemic and opens new routes for research into airborne nosocomial risk.

Tailoring a specific medical leadership development program for faculty members: the Lyon-Ottawa experience.

The development of leadership skills has been the topic of several position statements over recent decades, and the need of medical leaders for a specific training was emphasized during the COVID-19 crisis, to enable them to adequately collaborate with governments, populations, civic society, organizations, and universities. However, differences persist as to the way such skills are taught, at which step of training, and to whom. From these observations and building on previous experience at the University of Ottawa, a team of medical professors from Lyon (France), Ottawa, and Montreal (Canada) universities decided to develop a specific medical leadership training program dedicated to faculty members taking on leadership responsibilities. This pilot training program was based on a holistic vision of a transformation model for leadership development, the underlying principle of which is that leaders are trained by leaders. All contributors were eminent French and Canadian stakeholders. The model was adapted to French faculty members, following an inner and outer analysis of their specific needs, both contextual and related to their time constraints. This pilot program, which included 10 faculty members from Lyon, was selected to favor interactivity and confidence in older to favor long-term collaborations between them and contribute to institutional changes from the inner; it combined several educational methods mixing interactive plenary sessions and simulation exercises during onescholar year. All the participants completed the program and expressed global satisfaction with it, validating its acceptability by the target. Future work will aim to develop the program, integrate evaluation criteria, and transform it into a graduating training.

[Ethical issues surrounding death in pre-hospital medicine]. / Enjeux et éthique face à la mort en médecine préhospitalière.

Mobile emergency and resuscitation teams are confronted with death on a daily basis. In the home, the management of a death is complex. It raises ethical questions and sometimes destabilizes personal or collective values. Our single-center qualitative survey, conducted over a one-month period (2022), questioned 64/154 caregivers about the moral burden and challenges of such situations. The consequences of operational experience are discussed: time, fatigue, emotions and training. The quality of presence is an alternative to the success or failure of cardiac arrest care at home.

Ethical issues encountered by French intensive care unit caregivers during the first COVID-19 outbreak.

PURPOSE: We aimed to describe the ethical issues encountered by health care workers during the first COVID-19 outbreak in French intensive care units (ICUs), and the factors associated with their emergence. METHODS: This descriptive multicentre survey study was conducted by distributing a questionnaire to 26 French ICUs, from 1 June to 1 October 2020. Physicians, residents, nurses, and orderlies who worked in an ICU during the first COVID-19 outbreak were included. Multiple logistic regression models were performed to identify the factors associated with ethical issues. RESULTS: Among the 4,670 questionnaires sent out, 1,188 responses were received, giving a participation rate of 25.4%. Overall, 953 participants (80.2%) reported experiencing issue(s) while caring for patients during the first COVID-19 outbreak. The most common issues encountered concerned the restriction of family visits in the ICU (91.7%) and the risk of contamination for health care workers (72.3%). Nurses and orderlies faced this latter issue more than physicians (adjusted odds ratio [ORa], 2.98; 95% confidence interval [CI], 1.87 to 4.76; P < 0.001 and ORa, 4.35; 95% CI, 2.08 to 9.12; P < 0.001, respectively). They also faced more the issue "act contrary to the patient's advance directives" (ORa, 4.59; 95% CI, 1.74 to 12.08; P < 0.01 and ORa, 10.65; 95% CI, 3.71 to 30.60; P < 0.001, respectively). A total of 1,132 (86.9%) respondents thought that ethics training should be better integrated into the initial training of health care workers. CONCLUSION: Eight out of ten responding French ICU health care workers experienced ethical issues during the first COVID-19 outbreak. Identifying these issues is a first step towards anticipating and managing such issues, particularly in the context of potential future health crises.

RéSUMé: OBJECTIF: Notre objectif était de décrire les enjeux éthiques rencontrés par les personnels de santé lors de la première éclosion de COVID-19 dans les unités de soins intensifs (USI) françaises, ainsi que les facteurs associés à leur apparition. MéTHODE: Cette enquête multicentrique descriptive a été réalisée en distribuant un questionnaire à 26 unités de soins intensifs françaises, du 1er juin au 1er octobre 2020. Les médecins, les internes, le personnel infirmier et les aides-soignant·es qui travaillaient dans une unité de soins intensifs pendant la première éclosion de COVID-19 ont été inclus·es. Des modèles de régression logistique multiple ont été réalisés pour identifier les facteurs associés aux questions éthiques. RéSULTATS: Parmi les 4670 questionnaires envoyés, 1188 réponses ont été reçues, soit un taux de participation de 25,4 %. Dans l'ensemble, 953 personnes participantes (80,2 %) ont déclaré avoir éprouvé un ou des problèmes alors qu'elles s'occupaient de patient·es lors de la première éclosion de COVID-19. Les problèmatiques les plus fréquemment rencontrées concernaient la restriction des visites des familles dans les USI (91,7 %) et le risque de contamination pour les personnels de la santé (72,3 %). Le personnel infirmier et les aides-soignant·es étaient davantage confronté·es à ce dernier problème que les médecins (rapport de cotes ajusté [RCa], 2,98; intervalle de confiance [IC] à 95 %, 1,87 à 4,76; P < 0,001 et RCa, 4.35; IC 95 %, 2,08 à 9,12; P < 0,001, respectivement), tout comme ils étaient davantage confrontées à la question d'« agir contrairement aux directives médicales anticipées du/de la patient·e ¼ (RCa, 4,59; IC 95 %, 1,74 à 12,08; P < 0,01 et RCa, 10,65; IC 95 %, 3,71 à 30,60; P < 0,001, respectivement). Au total, 1132 répondant·es (86,9 %) estimaient que la formation en éthique devrait être mieux intégrée à la formation initiale des personnels de santé. CONCLUSION: Huit travailleuses et travailleurs de santé français·es des soins intensifs sur dix ont été confronté·es à des problèmes éthiques lors de la première éclosion de COVID-19. L'identification de ces enjeux est une première étape vers leur anticipation et leur gestion, en particulier dans le contexte d'éventuelles crises sanitaires futures.

Performance of the Fresno-Quebec Rule in identifying patients with concomitant fractures not requiring a radiograph before shoulder dislocation reduction: a multicenter retrospective cohort study.

BACKGROUND AND IMPORTANCE: Although shoulder dislocation diagnosis is often solely based on clinical examination, physicians may order a radiograph to rule out a concomitant shoulder fracture before performing reduction. The Fresno-Québec decision rule aims to identify patients requiring a radiograph before reduction to avoid unnecessary systematic imaging. However, this novel approach needs further validation. OBJECTIVE: To evaluate the performance of the Fresno-Québec rule in identifying patients who do not require a prereduction radiograph and assess the variables associated with a clinically significant fracture. DESIGN, SETTINGS, AND PARTICIPANTS: A multicenter, retrospective cohort study from 2015 to 2021. Data were extracted from three ED university-affiliated tertiary-care centers. Patients aged ≥18 years with a final diagnosis of anterior glenohumeral dislocation were included. OUTCOMES MEASURE AND ANALYSIS: Accuracy metrics [sensitivity (Se), specificity (Sp), positive (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)] of the Fresno-Québec rule were measured. Multivariable logistic regression model was used to identify variables associated with the presence of a concomitant clinically significant fracture. MAIN RESULTS: A total of 2129 patients were included, among whom 9.7% had a concomitant fracture. The performance metrics of the Fresno-Québec rule were as follows: Se 0.96 95% confidence interval (0.92-0.98), Sp 0.36 (0.34-0.38), PPV 0.14 (0.12-0.16), NPV 0.99 (0.98-0.99), PLR 1.49 (1.42-1.55) and NLR 0.12 (0.06-0.23). A total of 678 radiographs could have been avoided, corresponding to a reduction of 35.2%. Age ≥40 years, first dislocation episode [odds ratio (OR) = 3.18 (1.95-5.38); P  < 0.001], the following mechanisms: road collision [OR = 6.26 (2.65-16.1)], low-level fall [OR = 3.49 (1.66-8.28)], high-level fall [OR = 3.95 (1.62-10.4)], and seizure/electric shock [OR = 10.6 (4.09-29.2)] were associated with the presence of a concomitant fracture. CONCLUSION: In this study, the Fresno-Québec rule has excellent Se in identifying concomitant clinically significant fractures in patients with an anterior glenohumeral dislocation. The use of this clinical decision rule may be associated with a reduction of approximately a third of unnecessary prereduction radiographs.

Assessing patient partnership among emergency departments in France: a cross-sectional study.

OBJECTIVES: This study aims to describe the use of patient partnership, as defined by the Montreal Model, in emergency departments (EDs) in France and report the perception of patient partnership from both the practitioner and patient perspectives. METHODS: This cross-sectional study was conducted between July 2020 and October 2020. First, a survey was sent to 146 heads of EDs in both teaching hospitals and non-teaching hospitals in France to assess the current practices in terms of patient partnership in service organization, research, and teaching. The perceived barriers and facilitators of the implementation of such an approach were also recorded. Then, semi-structured telephone interviews were carried out with patients involved in a service re-organization project. RESULTS: A total of 48 answers (response rate 32.9%) to the survey were received; 33.3% of respondents involved patients in projects relating to service re-organization, 20.8% involved patients in teaching projects, and 4.2% in research projects. Overall, 60.4% of the respondents were willing to involve patients in re-organization or teaching projects. The main barriers mentioned for establishing patient partnership were difficulties regarding patient recruitment and lack of time. The main advantages mentioned were the improvement in patient/caregiver relationship and new ideas to improve healthcare. When interviewed, patients mentioned the desire to improve healthcare and the necessity to involve people with different profiles and backgrounds. A too important personal commitment was the most frequently raised barrier to their engagement. All the patients recognized their positive role, and more generally, the positive role of patient engagement in service re-organization. CONCLUSION: Although this preliminary study indicates a rather positive perception of patient partnership among heads of EDs in France and partner patients, this approach is still not widely applied in practice.

Soluble TREM-1 plasma concentration predicts poor outcome in COVID-19 patients.

BACKGROUND: The immuno-receptor Triggering Expressed on Myeloid cells-1 (TREM-1) is activated during bacterial infectious diseases, where it amplifies the inflammatory response. Small studies suggest that TREM-1 could be involved in viral infections, including COVID-19. We here aim to decipher whether plasma concentration of the soluble form of TREM-1 (sTREM-1) could predict the outcome of hospitalized COVID-19 patients. METHODS: We conducted a multicentre prospective observational study in 3 university hospitals in France. Consecutive hospitalized patients with confirmed infection with SARS-CoV-2 were enrolled. Plasma concentration of sTREM-1 was measured on admission and then at days 4, 6, 8, 14, 21, and 28 in patients admitted into an ICU (ICU cohort: ICUC) or 3 times a week for patients hospitalized in a medical ward (Conventional Cohort: ConvC). Clinical and biological data were prospectively recorded and patients were followed-up for 90 days. For medical ward patients, the outcome was deemed complicated in case of requirement of increased oxygen supply > 5 L/min, transfer to an ICU, or death. For Intensive Care Unit (ICU) patients, complicated outcome was defined by death in the ICU. RESULTS: Plasma concentration of sTREM-1 at inclusion was higher in ICU patients (n = 269) than in medical ward patients (n = 562) (224 pg/mL (IQR 144-320) vs 147 pg/mL (76-249), p < 0.0001), and higher in patients with a complicated outcome in both cohorts: 178 (94-300) vs 135 pg/mL (70-220), p < 0.0001 in the ward patients, and 342 (288-532) vs 206 pg/mL (134-291), p < 0.0001 in the ICU patients. Elevated sTREM-1 baseline concentration was an independent predictor of complicated outcomes (Hazard Ratio (HR) = 1.5 (1.1-2.1), p = 0.02 in ward patients; HR = 3.8 (1.8-8.0), p = 0.0003 in ICU patients). An sTREM-1 plasma concentration of 224 pg/mL had a sensitivity of 42%, and a specificity of 76% in the ConvC for complicated outcome. In the ICUC, a 287 pg/mL cutoff had a sensitivity of 78%, and a specificity of 74% for death. The sTREM-1 concentrations increased over time in the ConvC patients with a complicated outcome (p = 0.017), but not in the ICUC patients. CONCLUSIONS: In COVID-19 patients, plasma concentration of sTREM-1 is an independent predictor of the outcome, although its positive and negative likelihood ratio are not good enough to guide clinical decision as a standalone marker.

The impact of shift work on pain recognition, a robust ability among intensive care nurses.

BACKGROUND: Pain empathy is essential for high-quality of care. The cognitive ability to identify and understand the pain in others remains underexplored in the context of hospital shift work. This study aimed to observe the early subliminal ability to detect pain in other faces and to investigate pain intensity evaluations during day and night shifts. METHODS: Twenty-one nurses (31 ± 7 years, 20 women) from cardio-paediatric intensive care participated in this study. Eighteen nurses completed all testing in the morning and evening hours, before and after the 12-hour day and night shift. In the first test, the nurses had to decide if facial stimuli presented subliminally showed pain or not. During the second test, they consciously determined the intensity of the painful faces on a numerical scale. Sleep, sleepiness and empathy were also measured. RESULTS: Recognition accuracy and pain sensitivity remained stable over time, only sensitivity increased following the work shift (F(1,15) = 7.10, p = 0.018). Intensity ratings remained stable. Sleepiness at the end of the night shift was negatively correlated with accuracy (ρ = -0.51, p = 0.018) and positively correlated with prior night shifts (ρ = -0.50, p = 0.022). CONCLUSION: The judgement of facial pain expressions seems robust across shift types, only individual factors such as sleepiness interfere with pain recognition. Pain sensitivity may be enhanced during working hours. SIGNIFICANCE STATEMENT: Some professions need to know how to assess pain 24/7 and a lack of sleep can disrupt the cognitive processes necessary for this assessment. Night shifts provoke a bias in pain management, and sleep deprivation, a decrease in pain evaluation. By conducting a repeated measure study in the field that applied a different paradigm (subliminal recognition of facial cues) we add evidence to the understanding of pain recognition and the impact of sleep deprivation on the early processing of pain in others.

Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis.

BACKGROUND: Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE: To measure any resulting change in CTPA use for suspected PE. DESIGN: Retrospective analysis. SETTING: 26 European EDs in 6 countries. PATIENTS: Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS: The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS: 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION: Data were limited to 7 days every 2 months. CONCLUSION: Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE: None specific for this study.

Incidence of Underlying Abnormal Findings on Routine Magnetic Resonance Imaging for Bell Palsy.

Importance: There is no consensus on the benefits of routine magnetic resonance imaging (MRI) of the facial nerve in patients with suspected idiopathic peripheral facial palsy (PFP) (ie, Bell palsy [BP]). Objectives: To estimate the proportion of adult patients in whom MRI led to correction of an initial clinical diagnosis of BP; to determine the proportion of patients with confirmed BP who had MRI evidence of facial nerve neuritis without secondary lesions; and to identify factors associated with secondary (nonidiopathic) PFP at initial presentation and 1 month later. Design, Setting, and Participants: This retrospective multicenter cohort study analyzed the clinical and radiological data of 120 patients initially diagnosed with suspected BP from January 1, 2018, to April 30, 2022, at the emergency department of 3 tertiary referral centers in France. Interventions: All patients screened for clinically suspected BP underwent an MRI of the entire facial nerve with a double-blind reading of all images. Main Outcomes and Measures: The proportion of patients in whom MRI led to a correction of the initial diagnosis of BP (any condition other than BP, including potentially life-threating conditions) and results of contrast enhancement of the facial nerve were described. Results: Among the 120 patients initially diagnosed with suspected BP, 64 (53.3%) were men, and the mean (SD) age was 51 (18) years. Magnetic resonance imaging of the facial nerve led to a correction of the diagnosis in 8 patients (6.7%); among them, potentially life-threatening conditions that required changes in treatment were identified in 3 (37.5%). The MRI confirmed the diagnosis of BP in 112 patients (93.3%), among whom 106 (94.6%) showed evidence of facial nerve neuritis on the affected side (hypersignal on gadolinium-enhanced T1-weighted images). This was the only objective sign confirming the idiopathic nature of PFP. Conclusions and Relevance: These preliminary results suggest the added value of the routine use of facial nerve MRI in suspected cases of BP. Multicentered international prospective studies should be organized to confirm these results.

Outcome of patients admitted with oxygen mismatch and myocardial injury or infarction in emergency departments.

AIMS: To describe the outcomes and associated factors in a population of patients admitted to emergency departments with at least one condition of oxygen supply/demand imbalance, regardless of the troponin result or restrictive criteria for type 2 myocardial infarction. METHODS: We constituted a retrospective cohort of 824 patients. Medical records of patients having undergone a troponin assay were reviewed for selection and classification, and data including in-hospital stay and readmissions were collected. The reported outcomes are in-hospital mortality, 3-year mortality, and major adverse cardiovascular events. RESULTS: Patients with myocardial infarction or injury, either chronic or acute, were older, with more history of hypertension and chronic heart or renal failure but not for other cardiovascular risk factors and medical history. Acute myocardial injury and type 2 myocardial infarction were significantly associated with in-hospital mortality [odds ratio (OR) 3.71 95% confidence interval (CI) 1.90-7.33 and OR 3.15 95% CI 1.59-6.28, respectively]. However, the long-term mortality does not differ in comparison with patients presenting chronic myocardial injury or nonelevated troponin, ranging from 26.9 to 34.3%. Patients with chronic myocardial injury and type 2 myocardial infarction had more long-term major cardiovascular events (39.3 and 38.8%), but only for acute heart failure, and none was associated with this outcome after adjustment. CONCLUSION: Among patients admitted to emergency departments with an oxygen supply/demand imbalance, acute myocardial injury and type 2 myocardial infarction are strongly associated with in-hospital mortality. However, they are not associated with higher long-term mortality or major cardiovascular events after discharge, which tend to occur in elderly people with comorbidities.

Evaluation of a training program for emergency medical service physician dispatchers to reduce emergency departments visits.

BACKGROUND: Emergency Departments (ED) have seen an increasing number of older patients who are mostly referred following a call to the Emergency Medical Services (EMS). Long waiting times in settings, which are not designed to meet older patients' needs, may increase the risk of hospital-acquired complications. Unnecessary visits should therefore be avoided as much as possible. The objective of the study was to evaluate whether a program to provide geriatric knowledge and tools to the dispatching physicians of the EMS could decrease ED referrals of older patients. METHODS: Design: Before-and-after study with two 6-month periods before and after intervention. PARTICIPANTS: All calls received by a dispatching physician of the Rhône EMS from 8 am to 6 pm concerning patients aged 75 years or above during the study period. INTERVENTION: A program consisting of training dispatching physicians in the specific care of older patients and the developing, with a multidisciplinary team, of specific tools for dispatching physicians. OUTCOME: Proportion of ED referrals of patients aged 75 years or above after a call to the EMS. RESULTS: A total of 2671 calls to the Rhône EMS were included corresponding to 1307 and 1364 patients in the pre-and post-intervention phases, respectively. There was no significant difference in the proportion of referrals to the ED between the pre-intervention (61.7%) and the post-intervention (62.8%) phases (p = 0.57). Contact of the patients with their General Practitioner (GP) in the month preceding the call was associated with a 22% reduced probability of being referred to an ED. CONCLUSIONS: No beneficial effect of the intervention was demonstrated. This strategy of intervention is probably not effective enough in such time-constraint environment. Other strategies with a specific parallel dispatching of geriatric calls by geriatricians should be tested to avoid these unnecessary ED referrals. TRIAL REGISTRATION: ClinicalTrials NCT02712450.

Management and Outcome of COVID-19 Positive and Negative Patients in French Emergency Departments During the First COVID-19 Outbreak: A Prospective Controlled Cohort Study.

INTRODUCTION: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs. METHODS: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6-May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status. RESULTS: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P <0.001), and they required mechanical ventilation (89, 11.9% vs 37, 1.9%; P <0.001) and high-flow nasal cannula oxygen therapy (135, 18.1% vs 41, 2.2%; P < 0.001) more frequently. The in-hospital mortality was significantly higher among COVID-19 positive patients (139, 18.3% vs 149, 7.7%; P <0.001). CONCLUSION: Emergency departments were on the frontline during the COVID-19 pandemic and had to manage potential COVID-19 patients. Understanding what happened in the ED during this first outbreak is crucial to underline the importance of flexible organizations that can quickly adapt the bed capacities to the incoming flow of COVID-19 positive patients.

Changes over time in anxiety, depression, and stress symptoms among healthcare workers in French emergency departments during the first COVID-19 outbreak.

STUDY OBJECTIVE: Assess the changes in anxiety, depression, and stress levels over time and identify risk factors among healthcare workers in French emergency departments (EDs) during the first COVID-19 outbreak. METHOD: A prospective, multicenter study was conducted in 4 EDs and an emergency medical service (SAMU). During 3 months, participants completed fortnightly questionnaires to assess anxiety, depression, and stress using the Hospital Anxiety and Depression and the Chamoux-Simard scale. The changes in anxiety, depression, and stress levels over time were modelled by a linear mixed model including a period effect and a continuous time effect within periods. RESULTS: A total of 211 respondents (43.5 %) completed the survey at inclusion. There was a decrease in mean anxiety (from 7.33 to 5.05, p < 0.001), mean depression (from 4.16 to 3.05, p = 0.009), mean stress at work (from 41.2 to 30.2, p = 0.008), and mean stress at home (from 33.0 to 26.0, p = 0.031) at the beginning of each period. The mean anxiety level was higher for administrative staff (+0.53) and lower for paramedics (-0.61, p = 0.047) compared to physicians. The anxiety level increased with the number of day and night shifts (0.13/day, p < 0.001, 0.12/night, p = 0.025) as did stress at work (1.6/day, p < 0.001, 1.1/night, p = 0.007). Reassigned healthcare workers were at higher risk of stress particularly compared to SAMU workers (stress at work: p = 0.015, at home: p = 0.021, in life in general: p = 0.018). CONCLUSION: Although anxiety, depression, and stress decreased over time, anxiety was higher among physicians and administrative staff. Reassignment and working hours were identified as potential risk factors for mental health distress in EDs.

Diagnostic accuracy of fluorescence flow-cytometry technology using Sysmex XN-31 for imported malaria in a non-endemic setting.

Malaria diagnosis based on microscopy is impaired by the gradual disappearance of experienced microscopists in non-endemic areas. Aside from the conventional diagnostic methods, fluorescence flow cytometry technology using Sysmex XN-31, an automated haematology analyser, has been registered to support malaria diagnosis. The aim of this prospective, monocentric, non-interventional study was to evaluate the diagnostic accuracy of the XN-31 for the initial diagnosis or follow-up of imported malaria cases compared to the reference malaria tests including microscopy, loop mediated isothermal amplification, and rapid diagnostic tests. Over a one-year period, 357 blood samples were analysed, including 248 negative and 109 positive malaria samples. Compared to microscopy, XN-31 showed sensitivity of 100% (95% CI: 97.13-100) and specificity of 98.39% (95% CI: 95.56-100) for the initial diagnosis of imported malaria cases. Moreover, it provided accurate species identification asfalciparumor non-falciparumand parasitaemia determination in a very short time compared to other methods. We also demonstrated that XN-31 was a reliable method for patient follow-up on days 3, 7, and 28. Malaria diagnosis can be improved in non-endemic areas by the use of dedicated haematology analysers coupled with standard microscopy or other methods in development, such as artificial intelligence for blood slide reading. Given that XN-31 provided an accurate diagnosis in 1 min, it may reduce the time interval before treatment and thus improve the outcome of patient who have malaria.

Title: Précision diagnostique de la technique de cytométrie de flux en fluorescence utilisant le Sysmex XN-31 pour le paludisme d'importation en zone non endémique. Abstract: Le diagnostic du paludisme basé sur la microscopie est rendu difficile par la disparition progressive des microscopistes expérimentés en zone non-endémique. À côté des méthodes conventionnelles, la technique de cytométrie de flux en fluorescence utilisant le Sysmex XN-31, un automate d'analyse hématologique, a été enregistrée pour participer au diagnostic du paludisme. L'objectif de cette étude prospective, monocentrique et non-interventionelle était d'évaluer la précision diagnostique du XN-31 pour le diagnostic initial et le suivi des cas de paludisme d'importation en comparaison des tests de référence dont la microscopie, l'amplification isothermale en boucle, et des tests de diagnostic rapide. Durant une période d'un an, 357 échantillons de sang ont été analysés, dont 248 négatifs et 109 positifs pour le paludisme. En comparaison de la microscopie, le XN-31 a montré une sensibilité de 100 % (95 % CI : 97.13-100) et une spécificité de 98.39 % (95 % CI : 95.56-100) pour le diagnostic initial des cas de paludisme d'importation. De plus, l'identification des espècesfalciparumet non-falciparumainsi que la parasitémie ont été précises dans un temps très court en comparaison des autres méthodes. Nous avons aussi démontré que le XN-31 était une méthode fiable pour le suivi des patients à J3, J7 et J28. Le diagnostic du paludisme peut être amélioré en zone non-endémique par l'utilisation d'automates d'hématologie spécialisés, associés à la microscopie standard ou d'autres méthodes en développement telle que l'intelligence artificielle appliquée à la lecture des lames de sang. Dans la mesure où le XN-31 produit un diagnostic précis en une minute, cela peut réduire le délai avant le traitement et donc améliorer l'issue pour les patients souffrant de paludisme.

Temporal Trend of Transient Ischemic Attack Management over a 10-Year Period: Data from the Rhône County, France.

BACKGROUND: Timely recognition and management of transient ischemic attack (TIA) offer the greatest opportunity to prevent subsequent stroke. But variability of TIA management quality exists across hospitals. Under the impetus of national plans, measures were adopted to improve TIA management, including a structured local pathway. Our objective was to compare TIA management between two periods over 10 years, before and after the implementation of these measures. METHODS: A before-and-after study was conducted with two identical population-based cohort studies in 2006-2007 (AVC69) and 2015-2016 (STROKE69) including all patients with TIA diagnosis over a 7-month period in six public and private hospitals in the Rhône county in France. The primary outcome was the adequate TIA management defined as brain and vessel imaging within 24 h of admission and the prescription of antithrombotic treatment at discharge. RESULTS: We identified 109 patients TIA patients in 2006-2007, and 458 over the same period in 2015-2016. A higher proportion of patients were adequately managed in 2015-2016 compared to 2006-2007 (14/96 [15%] in 2006-2007 vs. 306/452 [68%] in 2015-2016, p < 0.001). This difference was mainly driven by a marked increase of vessel imaging performed within 24 h of admission, most often by computed tomography angiography. Furthermore, patients called more often emergency medical dispatch before admission, were admitted with a shorter delay after symptom onset, and were more likely discharged to home in 2015-2016 compared to 2006-2007. CONCLUSION: Our study demonstrated an increasing rate of adequate TIA management, mainly driven by a marked increase of vessel imaging within 24 h of admission, over a 10-year period in the Rhône county in France.

Clinical characteristics and outcome of elderly patients admitted in emergency department with an oxygen mismatch and type 2 myocardial infarction or myocardial injury.

BACKGROUND: Aging is a risk factor for type 2 myocardial infarction or myocardial injury, but few data are available on the elderly. We aimed to determine the factors associated with these pathologies and mortality in the elderly population and its age classes. METHODS: A retrospective cohort of all patients with oxygen mismatch (anemia, hypoxia, tachycardia, hypo/hypertension) for whom a troponin drawn was performed at admission in 2 emergency departments. Medical records were reviewed and classified as having type 2 myocardial infarction, acute or chronic myocardial injury, or no myocardial injury. RESULTS: Of the 824 patients who presented with oxygen mismatch, 675 (81.9%) were older than 65 years. Age over 85 years was a risk factor for acute non-ischemic myocardial injury (odds ratio, 95% confidence interval 2.23, 1.34-3.73). Non-ischemic myocardial injury was associated with hypoxemia, tachycardia, and acute renal failure in those older than 85 years, but only with acute infection in the 75-84-year-old group. Type 2 myocardial infarction was associated only with acute renal failure in the oldest group and, in the 75-84-year-old group, with acute heart failure and shock. Patients older than 85 years with acute myocardial injury, with or without infarction, had a higher in-hospital mortality, but subsequently, mortality depends more on the comorbidities than on age. CONCLUSION: Factors associated with type 2 myocardial infarction and acute non-ischemic myocardial injury in elderly admitted with oxygen mismatch vary notably between age classes. They are associated with in-hospital mortality but not with subsequent mortality when other cormorbities are taken into account.