Variability of intensive care admission decisions for the very elderly.

UNLABELLED: Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83-91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear. TRIAL REGISTRATION: ClinicalTrials.gov NCT00912600.

Accuracy of C-reactive protein, procalcitonin, and mid-regional pro-atrial natriuretic peptide to guide site of care of community-acquired pneumonia.

BACKGROUND: The use at bedside of C-reactive protein (CRP), procalcitonin (PCT) or mid-regional pro-atrial natriuretic peptide (ANP) has been advocated to help management of patients with community-acquired pneumonia (CAP) in emergency medicine. OBJECTIVE: To assess the effectiveness of CRP, PCT, and ANP measures in assisting emergency physicians deciding hospital admission for CAP with low risk of complication. DESIGN: Multicenter, prospective, observational study with blind evaluation. SETTING: Emergency departments of 12 French hospitals. PATIENTS: Five hundred forty-nine consecutive, immunocompetent adult patients with mild CAP. MEASUREMENTS: Centralized and blind measure of baseline CRP, PCT, and ANP; sensitivity, specificity, and positive and negative likelihood ratios for determining hospital admission. Gold standard for admission was defined by experts' advice combined with admission requirement or death at 28 days. Optimal threshold values were determined by receiver operating characteristic (ROC) curves, and area under curve (AUC) of the three biomarkers was compared. RESULTS: According to gold standard, 310 (56%) patients required admission and 239 (44%) needed to be discharged. PCT and ANP levels increased with Pneumonia Severity Index risk categories. ANP (AUC 0.76 [95% CI 0.72-0.80]) more accurately predicted admission requirement than did PCT (AUC 0.65 [95% CI 0.61-0.70]) or CRP (AUC 0.59 [95% CI 0.54-0.64]) (both p values <0.01). We determined that 135 pmol/L was a threshold for ANP level to discriminate admission requirement (positive likelihood ratio 7.45 [95% CI 4.22-8.16]). CONCLUSIONS: In a selected population of CAP with low risk of complication, a single ANP measurement was more accurate than CRP and PCT to predict appropriate admission. These results should be confirmed by additional studies.

Offline exhaled nitric oxide in emergency department and subsequent acute asthma control.

BACKGROUND: Few studies have evaluated exhaled NO measurement during acute asthma. OBJECTIVES: To evaluate exhaled NO fraction (FE(NO)) and peak expiratory flow (PEF) time-courses during acute asthma treatment (beta 2-agonist plus systemic steroid) and to assess whether FE(NO) time-course predicts subsequent asthma control. METHODS: Sixty-five asthmatic patients (mean +/- SD, 34 +/- 10 years) were prospectively enrolled in three Emergency Departments. RESULTS: Sixteen patients were excluded (failure of offline FE(NO) measurement at 100 mL/s [FE(NO 0.1)], n = 4, and early discharge). The 49 remaining patients performed FE(NO 0.1) and PEF on admission, at the 2nd (H2) and 6th hour (H6). Follow-up using an Asthma Control Diary was obtained in 27 of 49 patients, whether they were hospitalized (n = 9) or discharged (n = 18). All but 2 patients had elevated FE(NO) on admission (median [interquartile], 49 [26-78] ppb). Unlike PEF, mean FE(NO 0.1) of our sample was not significantly modified by treatment. No significant relationship was evidenced between exhaled NO and PEF variations. The variation of FE(NO 0.1) [H0 minus H6] was different in patients who were hospitalized (decrease of 8 +/- 20 ppb) versus discharged (increase of 5 +/- 20 ppb, p = 0.04). This variation of FE(NO 0.1) was correlated with the Diary score (control of subsequent week), an initial increase in FE(NO 0.1) being associated with better asthma control. Nevertheless, neither exhaled NO nor PEFR were good predictors of asthma control. CONCLUSIONS: An increase in FE(NO) is observed in almost all patients with acute asthma, and its subsequent increase within 6 hours is associated with a better degree of asthma control in the subsequent week.

Multidetector-row computed tomography in suspected pulmonary embolism.

BACKGROUND: Single-detector-row computed tomography (CT) has a low sensitivity for pulmonary embolism and must be combined with venous-compression ultrasonography of the lower limbs. We evaluated whether the use of D-dimer measurement and multidetector-row CT, without lower-limb ultrasonography, might safely rule out pulmonary embolism. METHODS: We included 756 consecutive patients with clinically suspected pulmonary embolism from the emergency departments of three teaching hospitals and managed their cases according to a standardized sequential diagnostic strategy. All patients were followed for three months. RESULTS: Pulmonary embolism was detected in 194 of the 756 patients (26 percent). Among the 82 patients with a high clinical probability of pulmonary embolism, multidetector-row CT showed pulmonary embolism in 78, and 1 patient had proximal deep venous thrombosis and a CT scan that was negative for pulmonary embolism. Of the 674 patients without a high probability of pulmonary embolism, 232 (34 percent) had a negative D-dimer assay and an uneventful follow-up; CT showed pulmonary embolism in 109 patients. CT and ultrasonography were negative in 318 patients, of whom 3 had a definite thromboembolic event and 2 died of possible pulmonary embolism during follow-up (three-month risk of thromboembolism, 1.7 percent; 95 percent confidence interval, 0.7 to 3.9). Two patients had proximal deep venous thrombosis and a negative CT scan (risk, 0.6 percent; 95 percent confidence interval, 0.2 to 2.2). The overall three-month risk of thromboembolism in patients without pulmonary embolism would have been 1.5 percent (95 percent confidence interval, 0.8 to 3.0) if the D-dimer assay and multidetector-row CT had been the only tests used to rule out pulmonary embolism and ultrasonography had not been performed. CONCLUSIONS: Our data indicate the potential clinical use of a diagnostic strategy for ruling out pulmonary embolism on the basis of D-dimer testing and multidetector-row CT without lower-limb ultrasonography. A larger outcome study is needed before this approach can be adopted.

[Emergency admission of eighty year-old and older patients. Characteristics and health care channels]. / Patients âgés de 80 ans et plus admis en urgence. Caractéristiques et filières de soins.

OBJECTIVES AND METHODS: The primary objective of this study was to describe characteristics and health channels of all octogenarians admitted during a 12 weeks period from two emergency units (EU) (A and B). To do so, an investigator collected data from each EU from the patients and medical teams. The secondary objective was to compare health channels between the two EU. In contrast with EU B, EU A had developed a formal cooperation with Geriatrics units. For comparison between the EU, the chi 2 and Student's t tests were used. For description of health channels, we used the following definitions: transfer: the patient was admitted after his admission to an EU in another hospital and inadequate orientation: patients in whom the diagnosis exceeded the specialty department to which they had been admitted. RESULTS: A mean of 3.4 elderly patients/day aged 80 years and more were admitted in emergency. Most patients had initially been admitted to the EU. Length of stay in the EU was > 2 days in 26.5% of cases. To be able to cope with this flow of patients, the EU had organised health channels depending on local capacity and without the influence of the formal cooperation: in EU A, the transfer rate was of 51%; in EU B, transfers were less frequent (18%, p < 0.0001) but the proportion of inadequate orientation was of 39.4% vs. 22.7% in EU A (p = 0.02). The rate of admission to a geriatric unit was identical (13%). CONCLUSIONS: Health channels of elderly patients admitted in emergency exhibit dysfunctions: frequent transfers, prolonged length of stay in an EU, inadequation. A formal cooperation between the EU and Geriatrics units is not sufficient to lastingly improve health care channels.