Variation in accessibility of the population to an Emergency Medical Communication Centre: a multicentre observational study.

BACKGROUND: Access to an Emergency Medical Communication Centre is essential for the population in emergency situations. Handling inbound calls without delay requires managing activity, process and outcome measures of the Emergency Medical Communication Centre to improve the workforce management and the level of service. France is facing political decisions on the evolution of the organisation of Emergency Medical Communication Centres to improve accessibility for the population. First, we aim to describe the variation in activity between Emergency Medical Communication Centres, and second, to explore the correlation between process measures and outcome measures. METHODS: Using telephone activity data extraction, we conducted an observational multicentre study of six French Emergency Medical Communication Centres from 1 July 2016 to 30 June 2017. We described the activity (number of incoming calls, call rate per 1000 inhabitants), process measure (agent occupation rate), and outcome measure (number of calls answered within 20 s) by hourly range and estimated the correlation between them according to the structural equation methods. RESULTS: A total of 52,542 h of activity were analysed, during which 2,544,254 calls were received. The annual Emergency Medical Communication Centre call rate was 285.5 [95% CI: 285.2-285.8] per 1000 inhabitants. The average hourly number of calls ranged from 29 to 61 and the call-handled rate from 75 to 98%. There are variations in activity between Emergency Medical Communication Centres. The mean agent occupation rate was correlated with the quality of service at 20 s (coefficient at - 0.54). The number of incoming calls per agent was correlated with the mean occupation rate (coefficient at 0.67). Correlation coefficients varied according to the centres and existed between different process measures. CONCLUSIONS: The activity dynamics of the six Emergency Medical Communication Centres are not identical. This variability, illustrating the particularity of each centre, must be accurately assessed and should be taken into account in managerial considerations. The call taker occupation rate is the leverage in the workforce management to improve the population accessibility.

Early High-Dose Erythropoietin Therapy After Out-of-Hospital Cardiac Arrest: A Multicenter, Randomized Controlled Trial.

BACKGROUND: Preliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of erythropoietin (Epo) analogs. OBJECTIVES: The authors aimed to evaluate the efficacy of epoetin alfa treatment on the outcome of OHCA patients in a phase 3 trial. METHODS: The authors performed a multicenter, single-blind, randomized controlled trial. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 h apart during the first 48 h (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary endpoints included all-cause mortality rate, distribution of patients in CPC levels at different time points, and side effects. RESULTS: In total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4% of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1% of patients (78 of 242) in the control group (odds ratio: 1.01; 95% confidence interval: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious adverse events were more frequent in Epo-treated patients as compared with controls (22.6% vs. 14.9%; p = 0.03), particularly thrombotic complications (12.4% vs. 5.8%; p = 0.01). CONCLUSIONS: In patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin plus standard therapy did not confer a benefit, and was associated with a higher complication rate. (High Dose of Erythropoietin Analogue After Cardiac Arrest [Epo-ACR-02]; NCT00999583).

Extracorporeal life support in a case of fatal flecainide and betaxolol poisoning allowing successful cardiac allograft.

Use of cardiac allograft for transplantation from donors after acute poisoning is a matter of debate because of potential toxic organ injuries, especially if death results from massive ingestion of cardiotoxic drugs. We report successful allograft cardiac transplantation from a brain-dead patient after severe flecainide and betaxolol self-poisoning requiring extracorporeal life support. Extracorporeal life support was initiated in the emergency department because of a refractory cardiac arrest caused by the cardiotoxicants' ingestion and continued after the onset of brain death to facilitate organ donation of the heart, liver, and kidneys. Forty-five months later, each organ recipient was alive, with normal graft function.

Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment.

INTRODUCTION: Rapid intravascular access is a prerequisite component of emergency care and resuscitation. Peripheral intravenous (IV) access is the first-choice for most of the medical or trauma patients, but may be delayed in emergency conditions because of various difficulties. Elsewhere, intraosseous (IO) access may now be easily performed with a new semi-automatic battery-powered IO-insertion device (EZ-IO. The aim of this study was to compare the overall time to establish IO infusion with the EZ-IO device and the equivalent time for peripheral IV infusion, performed by emergency personnel in standard (No-CBRN) and in chemical, biological, radiological, and nuclear (CBRN) protective equipment. METHODS: Nine nurses and 16 physicians randomly performed 4 procedures on a training manikin: IV and IO access under No-CBRN conditions and IV and IO under CBRN conditions. The time for each infusion attempt included all the steps essential for a simulated safe clinical use of infusion. RESULTS: Under No-CBRN conditions, the time to establish IO infusion was shorter than the equivalent IV time (50+/-9 vs 70+/-30s). Similarly, under CBRN conditions, the time for IO infusion was shorter than for IV infusion (65+/-17 vs 104+/-30s). The mean time saved by IO infusion over IV infusion was respectively 20+/-24s (P<0.001) and 39+/-20s (P<0.001) under No-CBRN and CBRN conditions. CONCLUSION: The time to establish IO infusion was significantly shorter than that for peripheral IV infusion, under both No-CBRN and CBRN conditions. Further clinical studies are required to confirm that IO access would effectively save time over IV access in real pre-hospital emergency settings.

Early high-dose erythropoietin therapy and hypothermia after out-of-hospital cardiac arrest: a matched control study.

AIM: To test the possible neuroprotective effect of early high-dose erythropoietin-alpha (Epo-alpha) after out-of-hospital cardiac arrest (OHCA). METHODS: A matched control study. Following resuscitation with mild hypothermia after OHCA, participants received a first dose of Epo-alpha followed by four additional injections within 48 h (40,000 IU intravenously each injection). Plasma Epo-alpha levels were measured at different time points. Outcome and adverse events were assessed up to day 28 and were compared with those of matched-paired controls. RESULTS: In all 18 participants received Epo-alpha and were compared with 40 matched controls. Pharmacokinetic variables were similar to those previously reported for healthy people or for persons treated with usual dosages of Epo. At day 28, survival rates among the Epo-treated group and the controls (55% versus 47.5%, p=0.17) and rates of full neurological recovery (55% versus 37.5%) did not differ significantly. Incidences of thrombocytosis in the Epo-treated group and controls were 15% and 5%, respectively; an arterial vascular thrombosis was observed in one case (5%) from the Epo-treated cohort. CONCLUSIONS: Among victims of OHCA treated with Epo-alpha and hypothermia, we observed a high survival rate, with no minor cerebral sequels but potential haematological side effects. Future studies of Epo should pay particular attention to these findings.

Referent d-dimer enzyme-linked immunosorbent assay testing is of limited value in the exclusion of thromboembolic disease: result of a practical study in an ED.

OBJECTIVE: The aim of this study was to assess in clinical practice the accuracy of a referent d-dimer enzyme-linked immunosorbent assay for the exclusion of venous thromboembolic disease (VTED). PATIENTS AND METHODS: An observational prospective study took place in an emergency department; 205 consecutive outpatients suspected of having VTED were included. Blood samples were collected at admission for VIDAS DD measurement. Venous thromboembolic disease was confirmed by standard clinical imaging. All patients were followed up at 3 months. RESULTS: Venous thromboembolic disease was confirmed in 57 patients (28%). The sensitivity and negative predictive value of a DD assay lower than 500 ng/mL were 78% (95% confidence interval = 67%-87%) and 84% (95% confidence interval = 73%-90%), respectively. Twelve patients had a false-negative DD with one or more of the following: (a) symptoms reported for more than 15 days (n = 2), (b) prior anticoagulation (n = 3), (c) distal VTED (n = 5), or (d) high clinical probability (n = 3). CONCLUSION: In our cohort of patients, DD was less accurate than previously reported, with an upper estimate of the sensitivity of only 87%.